Powers et al 2019 Guidelines for Management of AIS e371 3.6. Other IV Fibrinolytics and Sonothrombolysis 3.6. Other IV Fibrinolytics and Sonothrombolysis COR LOE New, Revised, or Unchanged It may be reasonable to choose tenecteplase (single IV bolus of 0.25-mg/kg, maximum 25 mg) over IV alteplase in patients without contraindications for IV fibrinolysis who are also eligible to undergo mechanical thrombectomy. IIb B-R New recommendation. IV tenecteplase (0.25 mg/kg bolus, maximum 25 mg) was compared with IV alteplase (usual dose of 0.9 mg/kg over 60 minutes, maximum 90 mg) in the EXTEND-IA TNK trial (Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke).178 This multicenter trial randomized 202 patients without previous severe disability and with documented occlusion of the internal carotid artery, proximal MCA (M1 or M2 segments), or basilar arteries presenting within 4.5 hours of symptom onset to receive 1 of these 2 fibrinolytic agents. Primary end point was reperfusion of >50% of the involved ischemic territory or an absence of retrievable thrombus at the time of the initial angiographic assessment. The trial was designed to test for noninferiority and, if noninferiority proven, for superiority. Secondary outcomes included the mRS score at 90 days. Median NIHSS score was 17. The primary end point was achieved by 22% of patients treated with tenecteplase versus 10% of those treated with alteplase (P=0.002 for noninferiority and 0.03 for superiority). In an analysis of secondary end points, tenecteplase resulted in better functional outcomes at 90 days on the basis of the ordinal shift analysis of the mRS score (common OR [cOR], 1.7 [95% CI, 1.0 2.8]; P=0.04) but less robustly for the proportion who achieved an mRS score of 0 to 1 (P=0.23) or 0 to 2 (P=0.06). sICH rates were 1% in both groups. See Table XLIII in online Data Supplement 1. 