Tenecteplase versus Alteplase as Bridging Thrombolysis before Mechanical Thrombectomy for Medium and Distal Vessel...

The safety and efficacy of intravenous tenecteplase in patients with acute ischemic stroke (AIS) with primary medium and distal vessel occlusions (MDVO) selected for mechanical thrombectomy remain an area of active investigation. This observational study aimed to compare tenecteplase and alteplase in patients with MDVO treated with mechanical thrombectomy (MT).

This was a retrospective, propensity score-weighted analysis of 2 cohorts: patients with primary MDVO who received bridging intravenous thrombolysis before MT, from the multicenter TETRIS registry treated with tenecteplase, and patients from a tertiary center cohort treated with alteplase. The primary outcome was an mRS score of 0-2 at 90 days. Secondary outcomes included mortality, symptomatic intracranial hemorrhage (sICH), and early and final successful reperfusion rates, assessed using the extended TICI (eTICI) 2b-3 scale.

We included 110 patients, 65 receiving tenecteplase and 45 receiving alteplase. mRS 0-2 at 90 days was achieved in 53.8% of tenecteplase-treated patients versus 48.9% of alteplase-treated patients (P = .41). Mortality and sICH rates were similar between groups (12.3% versus 13.3%, P = .68; 3.1% versus 0%, P = .51, respectively). There was no significant difference in early reperfusion between tenecteplase and alteplase (40.2% versus 31.1%; P = .53). Final successful reperfusion did not significantly differ (80.4% versus 88.9%; P = .28).

In MDVO, tenecteplase yielded comparable safety and functional outcomes to alteplase, without statistically significant differences in early or final reperfusion. In light of recent trials questioning the benefit of MT in MDVO, these data suggest comparable safety and functional outcomes between tenecteplase and alteplase as bridging thrombolysis before mechanical thrombectomy, within the limits of this observational study.