Tenecteplase versus alteplase for intravenous thrombolysis in acute ischemic stroke: a single-center...

Tenecteplase can be given as a single bolus, but comparative estimates from routine stroke care are susceptible to treatment-selection bias. Methods: We reviewed 269 adults treated at one center with intravenous tenecteplase (n = 110) or alteplase (n = 159) within 4.5 h of symptom onset from March 2024 through March 2026. The primary outcome was functional independence at 90 days [modified Rankin Scale (mRS) 0-2]. A logistic propensity-score model included pretreatment clinical and laboratory variables. Stabilized average-treatment-effect weights were truncated at the 1st and 99th percentiles. We report weighted risks, risk differences (RDs), odds ratios (ORs), and robust 95% confidence intervals (CIs). Secondary neurological/workflow and safety outcomes were adjusted within separate families using the Holm procedure.

After weighting, 90-day functional independence was 77.9% with tenecteplase and 81.3% with alteplase (RD, -3.5 percentage points; 95% CI, -17.0 to 10.1; p = 0.616; OR, 0.81; 95% CI, 0.36-1.82). Holm-adjusted p values for the other functional outcomes were 1.000. The weighted mean difference in door-to-needle time was -5.0 min (95% CI, -9.0 to -0.9; unadjusted p = 0.017; Holm-adjusted p = 0.068). Day-7 early neurological deterioration occurred in no tenecteplase recipient and nine alteplase recipients (weighted RD, -5.1 percentage points; 95% CI, -8.5 to -1.7; Holm-adjusted p = 0.016). SITS-MOST symptomatic intracranial hemorrhage occurred in four patients, with a weighted RD of 0.2 percentage points (95% CI, -1.7 to 2.1).

Tenecteplase was not associated with greater 90-day functional independence in this propensity-weighted cohort. No clear between-group difference was observed in major hemorrhagic outcomes. DNT was shorter before multiplicity adjustment, and day-7 deterioration was less frequent after adjustment within the secondary neurological/workflow family.