What is the dose of alteplase for ischemic stroke?

Alteplase (tPA) is dosed at 0.9 mg/kg (maximum 90 mg) for ischemic stroke. 10% is given as an IV bolus over 1 minute, and the remaining 90% infused over 60 minutes.

What is the dose of tenecteplase for ischemic stroke?

Tenecteplase (TNK) is dosed as a single IV bolus at 0.25 mg/kg (maximum 25 mg). Per AHA/ASA 2026 guidelines, tenecteplase is considered equivalent to alteplase (both COR 1) for acute ischemic stroke thrombolysis.

What are absolute contraindications to IV tPA in stroke?

Absolute contraindications include: significant head trauma or prior stroke in last 3 months, intracranial neoplasm/AVM/aneurysm, recent intracranial surgery, active internal bleeding, BP >185/110 despite treatment, platelet count 1.7, or current use of direct thrombin/Xa inhibitors with elevated drug levels.

What is the time window for IV tPA in stroke?

Standard window is 0–3 hours from symptom onset (or last known well). Extended window is 3–4.5 hours with additional exclusions (age >80, NIHSS >25, prior stroke + diabetes, anticoagulation use). Beyond 4.5 hours, perfusion-guided tPA is possible in selected patients (EXTEND trial, 4.5–9 hours).

IV tPA Protocol — Alteplase & Tenecteplase

1.Thrombolytic Agents

Alteplase (tPA): 0.9 mg/kg (max 90 mg). Bolus 10% IV push over 1 min; remaining 90% over 60 min.[+]

Tenecteplase (TNK): 0.25 mg/kg (max 25 mg) single IV bolus. Equivalent first-line alternative to alteplase (AHA/ASA 2026, Class I); single-bolus delivery simplifies transfer for thrombectomy.[+]

2.Blood Pressure Management

Pre-treatment: BP must be <185/110 mmHg. Labetalol 10–20 mg IV push (may repeat) or Nicardipine infusion 5–15 mg/hr.[+]

If BP remains refractory despite aggressive treatment, do not give tPA. Treating above 185/110 increases sICH risk.

Post-treatment (24h): Maintain <180/105 mmHg. Monitor q15min × 2h, then q30min × 6h, then q1h × 16h.[+]

3.Inclusion Criteria

Clinical diagnosis of ischemic stroke with disabling deficit; LKW <4.5 h; age ≥18.

4.Key Exclusions (Do Not Give)

Hemorrhage: Any ICH or SAH on CT.[+]

Coagulopathy: Platelets <100,000, INR >1.7, PTT >40 s.[+]

Anticoagulants: Therapeutic LMWH within 24h. DOAC within 48h unless normal thrombin time/anti-Xa confirmed.[+]

Head history: Severe head trauma or stroke within 3 months. Major intracranial/intraspinal surgery within 3 months.[+]

Bleeding risk: GI malignancy or bleed within 21 days; aortic arch dissection; active internal bleeding. CT hypodensity >1/3 MCA territory.[+]

5.Relative Exclusions

Minor or rapidly improving symptoms — treat if disabling. Major surgery or trauma <14 days. Seizure at onset — treat if imaging confirms stroke. Pregnancy. Recent MI (<3 months).[+]

6.Wake-Up / Unknown Onset

Eligible if: MRI DWI+ and FLAIR− suggests onset <4.5 h; or CTP favorable penumbral profile per WAKE-UP / EXTEND.[+]

7.Tenecteplase vs Alteplase — When to Choose

Per 2026 AHA/ASA guidelines, tenecteplase and alteplase are equivalent first-line choices (COR 1, LOE A). Select based on clinical context.[+]

Choose Tenecteplase (TNK) when:

Transferring for thrombectomy (drip-and-ship): single bolus means no IV pump during transport. Also preferred when rapid administration is needed or nursing resources are limited.[+]

Supported by the ORIGINAL trial (JAMA 2024), which confirmed noninferiority across 1,465 patients — mRS 0–1 at 90 days 72.7% vs 70.3%, identical sICH rates (1.2% each). Simpler single-bolus administration eliminates the 60-minute infusion pump.[+]

Choose Alteplase when:

Extended window (>4.5 h) perfusion-selected patients: alteplase has more trial data (EXTEND, WAKE-UP). Also use alteplase when institutional protocol or formulary requires it.[+]

Do not use TNK at doses >0.25 mg/kg — higher doses (0.4 mg/kg) showed increased hemorrhage in early trials. The approved stroke dose is 0.25 mg/kg IV bolus only.