Intravenous thrombolysis constitutes the systemic reperfusion treatment for patients with acute ischemic stroke (AIS) and alteplase is the only approved thrombolytic agent. Although no randomized controlled trial (RCT) has shown the superiority of tenecteplase over alteplase in AIS, tenecteplase is increasingly used off-label in Stroke Units [1]. Tenecteplase appears as an attractive treatment for clinicians since studies have suggested that this drug has a more favorable pharmacokinetic profile than alteplase [2] without inferiority in terms of clinical efficiency and safety [3]. Moreover, the ease of use of tenecteplase may allow a significant reduction of imaging-to-thrombolysis time [4] and may facilitate ambulance transfer when mechanical thrombectomy (MT) is required for patients managed in a drip-and-ship paradigm [5].

The present work originates from the French Neurovascular Society that constituted a working group among its membership. Relevant data published until 30th October 2021 on tenecteplase in AIS were reviewed. The review included RCTs [6], [7], [8], [9], [10], [11], [12] comparing tenecteplase and alteplase, recent meta-analyses [3], [13], [14], [15], [16], [17] and real-life experience data of tenecteplase use [1], [4], [5], [18], [19], [20], [21]. Ongoing RCTs that assessed tenecteplase in AIS have also been listed on clinicaltrial.gov and anzctr.org.au.

We wanted to make an as reliable as possible description of available data. First, we selected common issues about the use of tenecteplase in AIS and tried to answer the subsequent questions: What dosage of tenecteplase should be used in daily practice? How effective is tenecteplase for cerebral artery recanalization? What is the clinical effectiveness of tenecteplase? What is the therapeutic safety of tenecteplase? What are the benefits associated with tenecteplase ease of use? Second, expert consensus agreements on tenecteplase use in AIS were identified. In October 2021, the working group was asked to review and revise the manuscript. In November 2021, the current version of the manuscript was approved.

The definite purpose of the present literature analysis was to provide an up-to-date set of expert consensus statements for the use of tenecteplase in patients with AIS.