This review helps pharmacists understand how imaging-based patient selection and tenecteplase have widened thrombolysis eligibility and where the extended-window evidence still falls short.
Bottom Line
Imaging-based selection now extends intravenous thrombolysis to 9 hours and wake-up stroke, and tenecteplase has become an equal first-line agent to alteplase within 4.5 hours, but adding a late-window lytic on top of thrombectomy in perfusion-selected large-vessel occlusion has not improved functional outcomes.
COR 1
tenecteplase equal to alteplase <4.5h
COR 2a
extended-window thrombolysis 4.5-9h
OR 1.13
TIMELESS late-window disability, ns
NNT ~9
WAKE-UP favorable 90-day outcome
State of Play
Acute ischemic stroke (AIS) reperfusion has shifted from a strict clock-based model toward tissue-based, imaging-selected eligibility, allowing thrombolysis in wake-up and late-presenting patients. Tenecteplase has moved from an alternative to an equal first-line thrombolytic within 4.5 hours, largely on the strength of workflow advantages and noninferiority data. The central unresolved tension is whether a late-window lytic adds anything for patients already headed to endovascular thrombectomy.
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Full Analysis: Subscribers Only
The complete evidence synthesis, practice recommendations, and open questions.
What Changed
How It Fits the Guidelines
Effect chart & evidence comparison
Evidence at a Glance
Practice Considerations
Open Questions
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Not medical advice. PharmD Signal provides educational synthesis of published pharmacy and medical literature for practicing pharmacists. It is not a treatment recommendation for any individual patient; clinical decisions remain the responsibility of the treating clinician exercising independent professional judgment.