This report presents the successful experience with tenecteplase (Nektelisa, AO Generium, Russia) for ischemic stroke (IS) therapy at the Regional Vascular Center of the Komi Republican Clinical Hospital (Syktyvkar, Russia). Since October 2025, ten patients with IS have received intravenous thrombolysis with Nektelisa; all of them demonstrated marked neurological improvement (NIHSS dynamics of 4 points or more) within the first day, with no fatal outcomes and an acceptable safety profile. In addition, we demonstrate the first clinical case in the Russian Federation of successful tenecteplase use for wake-up stroke (WUS) based on DWI/FLAIR mismatch criteria on MRI. Current clinical guidelines support intravenous thrombolysis (IVT) with alteplase for WUS based on MRI DWI/FLAIR mismatch; however, global data on tenecteplase application using these criteria are limited, and such cases have not been previously described in Russia. We present successful IVT with tenecteplase (25 mg as a single bolus) in a 75-year-old woman with severe IS (NIHSS = 18) 8.5 hours after the time last known well. A significant regression of neurological symptoms was observed within the first hour; the NIHSS score decreased to 7 points 10 hours post-thrombolysis. A control CT scan at 24 hours ruled out intracranial hemorrhage, and no therapy-related complications were recorded. At discharge on day 15 (NIHSS = 4), the modified Rankin Scale (mRS) score was 3, indicating a significant regression of functional deficit. Thus, this case demonstrates that tenecteplase administration for wake-up stroke beyond the 4.5- hour window, based on DWI/FLAIR mismatch criteria, is safe and effective. This first successful experience with tenecteplase in the Russian Federation provides an important basis for broader implementation of Nektelisa into clinical practice, including for complex patient categories with an extended therapeutic window, provided strict adherence to proven selection criteria is maintained.

Makim S. Cherepianskii is a neurologist with 20 years of clinical experience and the highest qualification category in neurology and public health management. He graduated from Kirov State Medical Academy (2005) and completed his internship in neurology in 2006. From 2010 to 2021 he headed the neurological department for acute cerebrovascular diseases at the Komi Republican Clinical Hospital (KRKB), Syktyvkar, Russia, and since 2021 he has served as Deputy Chief Physician and Head of the Regional Vascular Center of KRKB. Since 2012 he has been Chief Freelance Neurologist of the Ministry of Health of the Komi Republic. He is a member of the Russian Society of Neurologists and other professional medical associations. His scientific interests include acute stroke care, intravenous thrombolysis, and organization of regional stroke services. He has authored more than 70 scientific publications (ORCID 0000-0002-3514-8676; SPIN RSCI 0360-2110). He is a two-time laureate of the Government of the Komi Republic Prize (2017, 2023), winner of the republican "Best Doctor of the Year" competition, and holder of an Honorary Certificate of the Ministry of Health of the Russian Federation (2024).