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Updated: Aug 14, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Tenecteplase vs. Alteplase before Endovascular Thrombectomy for Acute Ischemic Stroke in Elderly Patients: A
Luca Scarcia1, Hilde Henon2, Gaspard Gerschenfeld2
1From the Department of Neuroradiology (L.S., E.K.), Henri Mondor Hospital, Créteil, France; EA4391 (ENT), Faculté de Santé (L.S.), Université Paris Est Créteil, Créteil, France; Department of Neurology (L.S., D.S., N.C.), Unité de Recherche Clinique (F.X.L.), Sud-Francilien Hospital, Corbeil-Essonnes, France; Department of Neurology (H.H.), Stroke Unit, CHRU Lille, France; AP-HP, Service des Urgences Cérébro-Vasculaires (G.G., S.A.), Neuroradiology (F.C.), Hôpital Pitié-Salpêtrière, Paris, France; Institute of Psychiatry and Neurosciences of Paris (G.G., S.A., W.B.H., P.S., A.M., D.S., N.C.), INSERM U1266, Paris, France; StrokeLink, French Clinical Research Infrastructure Network (F-CRIN) (G.G., S.A.), France; Department of Interventional Neuroradiology (J.C.), NEURI Brain Vascular Center, Bicêtre University Hospital, Le Kremlin-Bicêtre, France; CRMR AVANCE, Bicêtre University Hospital (J.C.), Le Kremlin-Bicêtre, France; Faculty of Medicine (J.C.), INSERM U1176, Paris-Saclay University, Le Kremlin-Bicêtre, France; Department of Neurology (S. O.), Neuroradiology (G.M.), Bordeaux University Hospital, France; Department of Neurology (F.P.), Centre Hospitalier de Versailles, Le Chesnay, France; Department of Neuroradiology (W.B.H.), Neurology (A.M.), GHU Paris Psychiatrie et Neurosciences, Paris, France; Department of Neurology (P.S.), Interventional Neuroradiology (M.P.), Rothschild Foundation Hospital, Paris, France; Université Paris Cité (A.M.), France; Sorbonne Université (F.C.), Paris, France; Université Paris- Saclay (D.S., N.C.), France and Univ. Lille, Inserm, CHU Lille (C.C.), U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France. lucascarcia@icloud.com.
Background:
Comparative data on tenecteplase versus alteplase in patients aged ≥80 years undergoing bridging therapy before thrombectomy are limited.
Methods:
We retrospectively analyzed two prospective cohorts of patients aged ≥80 years with anterior circulation large-vessel occlusion treated with bridging intravenous thrombolysis: the multicenter TETRIS registry (tenecteplase) and a single comprehensive stroke center (alteplase). Propensity score matching (1:1, 11 covariates, caliper 0.2 SD logit) was performed, with overlap weighting as sensitivity analysis; matched dichotomous outcomes were analyzed by conditional logistic regression and generalized estimating equations clustered on the matched pair. Because treatment was completely confounded with center and data source, analyses compare cohorts rather than isolate a drug effect. The primary outcome was modified Rankin Scale (mRS) ≤3 at 90 days. Secondary outcomes included substantial early neurological improvement (ENI: ≥8-point NIHSS improvement or NIHSS ≤1 at 24 h), complete early neurological recovery (NIHSS = 0 at 24 h), early reperfusion (eTICI 2b-3), symptomatic intracranial hemorrhage (sICH), and 90-day mortality.
Results:
Among 720 eligible patients, 278 matched pairs were analyzed. The primary outcome (mRS ≤3) occurred in 48.0% of tenecteplase- versus 43.5% of alteplase-treated patients (OR 1.20, 95% CI 0.86-1.67); an excellent outcome (mRS 0-2: 27.6% vs 27.0%), the ordinal mRS shift (common OR 1.06), early reperfusion (16.9% vs 16.5%), substantial ENI (40.2% vs 34.9%), sICH (3.7% vs 4.4%), and 90-day mortality (30.2% vs 30.2%) did not differ. Complete early neurological recovery (NIHSS = 0 at 24 h) was more frequent with tenecteplase (10.3% vs 2.6%; OR ≈4.3), but this difference was confined to the single NIHSS value 0, reversed at NIHSS = 1, left no trace in any 90-day endpoint, and was nullified by modest unmeasured confounding (E-value for the lower confidence bound ≈2-3).
Conclusions:
In patients aged ≥80 years undergoing bridging therapy, tenecteplase and alteplase were associated with similar 90-day functional outcomes and similar safety. An isolated 24-hour complete-recovery signal favoring tenecteplase is hypothesis-generating and vulnerable to ascertainment bias, given complete confounding of treatment with center. Dedicated randomized data in this age group are warranted.
