Tenecteplase versus Alteplase Before Mechanical Thrombectomy: Experience from a U.S. Health Care System Undergoing a System-wide Transition of Primary Thrombolytic

Introduction: Tenecteplase (TNK) is a genetically modified variant of alteplase (tPA) and has been established as a non-inferior alternative to tPA in acute ischemic stroke (AIS). Whether TNK exerts distinct benefits in large vessel occlusion (LVO) AIS is still being investigated. Here, the authors portray their first-year experience after a health care system-wide transition from tPA to TNK as the primary thrombolytic.

Methods: AIS patients who received intravenous thrombolytics between 01/2020-08/2022 were retrospectively reviewed. All patients with LVO considered for mechanical thrombectomy (MT) were included. Spontaneous recanalization (SR) after TNK/tPA was defined as a composite variable of reperfusion > 50% of the target vessel territory on cerebral angiography or rapid, significant neurological recovery averting MT. Propensity-score-matching (PSM) was performed to compare SR rates between TNK and tPA.

Results: A total of 148 patients were identified; 51/148 (34.5%) received TNK and 97/148 (65.5%) received tPA. The middle cerebral artery M1 (60.8%) and M2 (29.1%) were the most frequent sites of occlusion. Baseline demographics were comparable between TNK and tPA groups. Spontaneous recanalization was significantly more frequently observed in the TNK group versus tPA (23.5% vs. 10.3%, p=0.032). PSM substantiated the observed SR rates. Symptomatic intracranial hemorrhage, 90-day mortality, and functional outcomes were similar between the TNK and tPA cohorts.

Conclusion : The preliminary experience from a real-world setting demonstrates the effectiveness and safety of TNK before MT. The higher spontaneous recanalization rates with TNK are striking. Additional studies are required to investigate whether TNK is superior to tPA in LVO AIS.