Imaging patterns of hemorrhagic transformation after tenecteplase versus alteplase in real-world practice

While randomized trials have demonstrated noninferiority of tenecteplase compared with alteplase in terms of functional outcomes and symptomatic intracranial hemorrhage (sICH), differences in hemorrhagic imaging phenotypes remain insufficiently explored in real-world practice.

We conducted a retrospective real-world cohort study of consecutive patients with acute ischemic stroke treated with intravenous thrombolysis between January and December 2025. The primary endpoint was ordinal shift in hemorrhagic transformation severity according to the Heidelberg Bleeding Classification (HBC). Secondary endpoints included sICH. Multivariable logistic regression was performed to identify independent predictors of hemorrhage.

A total of 95 patients were included (alteplase n = 41; tenecteplase n = 54). Baseline characteristics were largely comparable between groups. No significant difference in sICH incidence was observed. Although remote hemorrhagic phenotypes were numerically more frequent in the tenecteplase group, no significant ordinal shift was detected between treatment groups. In multivariable analysis, higher baseline NIHSS score (OR 1.10, 95% CI 1.02-1.18, p = 0.013) and longer ONT (OR 1.12 per 10 min, 95% CI 1.02-1.23, p = 0.016) were independently associated with intracranial hemorrhage, whereas thrombolytic agent type was not.

In this small exploratory real-world cohort, tenecteplase was not associated with an obvious increase in hemorrhagic events compared with alteplase. However, because of the limited sample size and small number of severe hemorrhagic events, these findings should be interpreted as preliminary and hypothesis-generating. Imaging-based classification using the Heidelberg framework did not reveal a significant shift toward more severe hemorrhagic phenotypes.