Tenecteplase for acute ischemic stroke: from an alteplase alternative toward workflow-oriented thrombolysis

Tenecteplase has emerged as a practical, evidence-supported thrombolytic alternative for acute ischemic stroke, challenging the long-standing predominance of alteplase. Greater fibrin specificity, resistance to plasminogen activator inhibitor-1, a longer half-life, and single-bolus administration provide a strong pharmacologic rationale for its use in time-sensitive stroke care. Accumulating evidence from randomized trials and meta-analyses suggests that tenecteplase 0.25 mg/kg is a reasonable alternative to alteplase for eligible patients treated within 4.5 hours, with particular practical advantages for those with large vessel occlusion who may require transfer for endovascular thrombectomy. Recent trials have broadened the discussion to include imaging-selected treatment beyond the conventional time window and adjunctive intra-arterial administration after thrombectomy. However, implementation varies across regions, and regulatory approval, reimbursement, safety concerns, and limited real-world data from Asia continue to shape clinical adoption. This review examines the pharmacologic rationale, clinical trial evidence, evolving guidelines, workflow implications, and unresolved questions surrounding tenecteplase for acute ischemic stroke, focusing on its potential role in Asian stroke systems.