Lit Matters #1: Which thrombolytic should I use for stroke patients, or does it matter?

Acute ischemic stroke thrombolysis appears equivalent with tenecteplase and alteplase in patients treated within 4.5 hours. The practical difference is workflow: tenecteplase is a single weight-based bolus, while alteplase requires a bolus plus infusion, and the decision still hinges on patient selection and bleeding risk.

Stroke Thrombolytic Choice

• Noninferiority signal: In mild to moderate acute ischemic stroke, tenecteplase matched alteplase for excellent 90-day functional outcome, supporting either agent as a reasonable IV thrombolytic choice.
• Administration advantage: Tenecteplase has a clear bedside workflow edge because it is given as a one-time weight-based bolus, unlike alteplase’s bolus-then-infusion regimen.
• Study population specifics: The trial enrolled patients within 4.5 hours of symptom onset with NIHSS 1-25, with a median NIHSS of 6, making the results especially relevant to lower-severity stroke presentations.
• Bleeding comparison: Safety looked similar between agents, with symptomatic intracranial hemorrhage occurring in 9 patients in each group and overall intracranial bleeding rates staying close.
• Selection still matters: The key bedside issue is not just TNK versus tPA but who should get thrombolysis at all, especially given a number needed to harm around 12. We get into that risk-benefit framing in the episode.