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What this edition changes
- Tenecteplase equals alteplase. 0.25 mg/kg as a single bolus (max 25 mg) or alteplase 0.9 mg/kg within 4.5 hours — both Class 1.
- Up to 9 hours. Thrombolysis at 4.5–9 hours, or within 9 hours of the midpoint of sleep, when automated perfusion imaging shows salvageable penumbra (Class 2a).
- Disabling, not a number. Treat a disabling deficit at any NIHSS; a mild non-disabling deficit gets dual antiplatelet therapy, not thrombolysis.
- Thrombectomy widened. Large cores (ASPECTS 3–5) and basilar occlusion with NIHSS ≥ 10, within 24 hours (Class 1).
- Don't over-lower blood pressure. Systolic below 140 after successful thrombectomy is harmful.
- Faster systems. Mobile stroke units are Class 1, and CTA is not delayed for creatinine.
The lecture also corrects several points from the earlier edition: the NINDS trial window (3 hours, not 4.5), the origin of the NIHSS, and the old NIHSS 4–25 rule for thrombolysis.
Inside
A three-question pre-test (answers at the end) · Recognition and EMS · the emergency department and NIHSS · creatinine and CTA · imaging (CT, CTA/MRA, MRI and perfusion) · the history of thrombolysis · alteplase and tenecteplase: mechanism, dosing, risks and contraindications · who benefits, including the extended window · the acute stroke pathway · managing bleeding after thrombolysis · AHA vs ESO, thrombolysis and thrombectomy · AI, rehabilitation and telestroke.
Main sources
- Prabhakaran S, et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke (AHA/ASA). Stroke 2026. doi:10.1161/STR.0000000000000513
- Berge E, et al. ESO guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J 2021;6:I–LXII.
- Alamowitch S, et al. ESO expedited recommendation on tenecteplase for acute ischaemic stroke. Eur Stroke J 2023;8:8–54.
- 2025 update to the ESO guideline on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage. Eur Stroke J 2026.
- ESO–ESMINT guideline on the acute management of basilar artery occlusion, 2024.
Teaching material, not a protocol. Check doses and thresholds against local guidance. This edition was fact-checked and updated with AI assistance; the clinical content is the author's responsibility. Our AI policy.
