Alteplase and tenecteplase are tissue plasminogen activators that bind to fibrin within a thrombus to initiate fibrinolysis. Alteplase is approved in the treatment of myocardial infarction, pulmonary embolism, and acute ischaemic stroke; while tenecteplase is only registered for thrombolytic treatment during the early phase of myocardial infarction.

A recently published Australian trial compares the use of these two medications for the management of patients with ischaemic stroke who are eligible to undergo thrombectomy. The primary outcome of >50% reperfusion of the ischaemic territory or the absence of a retrievable thrombus occurred in 22% of tenecteplase-treated patients and 10% of those treated with alteplase. Tenecteplase was also associated with a better functional outcome at 90 days, although the incidence of recovery to independent function was not significantly different.

Tenecteplase has a longer half-life than alteplase which allows administration as a single bolus rather than a 60-minute infusion. This may offer practical benefits in cases where the patient requires transport within or between hospitals.

The main adverse effect of these agents is bleeding. This can range from superficial bleeding observed at access sites through to major internal bleeding. Their use is, therefore, contraindicated in patients with a high risk of haemorrhage. No significant difference in the incidence of intracerebral haemorrhage was observed between the two groups in this study.

While the results of this phase 2 trial are promising, larger studies are required to confirm the non-inferiority of tenecteplase in this setting.


  1. Actilyse® (alteplase) Australian approved product information. North Ryde: Boehringer Ingelheim Pty Limited. Approved July 2015.
  2. Campbell BCV, Mitchell PJ, Churilov L, Yassi N, Kleinig TJ, Dowling RJ, et al. Tenecteplase versus alteplase before thrombectomy for ischemic stroke. N Engl J Med. 2018; 378(17): 1573- 82.
  3. Metalyse® (tenecteplase) Australian approved product information. North Ryde: Boehringer Ingelheim Pty Limited. Approved January 2016.

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