Fibrinolytic agents and the pharmacology of stroke thrombolysis

At a glance

• Fibrinolytics convert plasminogen to plasmin, which breaks down fibrin in the clot. The benefit is restoring flow to the ischaemic penumbra before it infarcts; the main harm is bleeding, especially intracranial.
• Tenecteplase 0.25 mg/kg (maximum 25 mg) as a single bolus is now standard in Australian stroke services and is TGA-registered for stroke within 4.5 hours. Alteplase 0.9 mg/kg is the historical comparator.
• Benefit is strongly time dependent: about 1.9 million neurons are lost each minute of a large vessel occlusion.