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Related Concept Videos

Ischemic Stroke ll: Pathophysiology01:15

Ischemic Stroke ll: Pathophysiology

An ischemic stroke occurs when a cerebral blood vessel becomes obstructed, most often by a thrombus or embolus, interrupting the delivery of oxygen and glucose to brain tissue. Because neurons rely on continuous aerobic metabolism, energy failure begins within minutes of reduced perfusion. The region receiving the least blood flow becomes the infarct core, an area of irreversible cellular death. Surrounding this core lies the penumbra, a zone of hypoperfused but still viable tissue that is...

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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
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Trade-Off Between Early Reperfusion and First-Pass Effect With Tenecteplase Versus Alteplase Before Stroke

Tyler M Bielinski1, Kelsey E Kline1, Veronica N Bohl1

  • 1Geisinger Commonwealth School of Medicine Scranton PA.

Journal of the American Heart Association
|July 10, 2026
PubMed
Summary

Tenecteplase showed higher early reperfusion rates in large-vessel occlusion stroke thrombectomy compared to alteplase. However, alteplase demonstrated a greater first-pass effect, with similar overall functional outcomes between the two thrombolytic agents.

Keywords:
alteplaseearly reperfusionlarge‐vessel occlusion stroketenecteplase

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Area of Science:

  • Neurology
  • Interventional Cardiology
  • Vascular Surgery

Background:

  • Large-vessel occlusion (LVO) stroke thrombectomy relies on early reperfusion and first-pass effect.
  • Tenecteplase, with greater fibrin specificity, may improve early reperfusion over alteplase.
  • The impact of these thrombolytics on first-pass effect requires further investigation.

Purpose of the Study:

  • To compare the efficacy of tenecteplase and alteplase in achieving early reperfusion and first-pass effect in LVO stroke.
  • To identify predictors of reperfusion and first-pass effect.
  • To assess the association of these procedural outcomes with 90-day functional outcomes.

Main Methods:

  • Retrospective review of consecutive LVO stroke patients receiving thrombolysis before endovascular treatment.
  • Definition of early reperfusion (TICI ≥2b50) and first-pass effect (TICI 2c-3 after single pass).
  • Multivariable and ordinal logistic regression analyses to determine predictors and functional outcome associations.

Main Results:

  • Early reperfusion was more frequent with tenecteplase (24.4%) versus alteplase (11.2%).
  • First-pass effect was less frequent with tenecteplase (30.3%) versus alteplase (40.2%).
  • Both early reperfusion and first-pass effect independently predicted better functional outcomes, but overall outcomes were similar between agents.

Conclusions:

  • Tenecteplase achieved higher early reperfusion rates, while alteplase showed a greater first-pass effect.
  • The procedural advantage of tenecteplase may be counterbalanced by downstream factors like first-pass effect.
  • Evaluating both reperfusion and procedural efficiency is crucial for comparing thrombolytic strategies in LVO stroke.