tenecteplase vs alteplase before stroke thrombectomy: impact of clot burden, thrombus characteristics, and collateral...

Early reperfusion (ER) following intravenous thrombolysis improves outcomes in large vessel occlusion stroke (LVOS). Tenecteplase (TNK) has been associated with higher ER rates than alteplase (TPA), but findings across studies remain inconsistent, possibly due to limited adjustment for thrombus burden, characteristics, and collateral status. We compared TNK and TPA in a real-world cohort incorporating imaging-based assessment of thrombus and collateral status.

We retrospectively analyzed consecutive anterior circulation LVOS patients who received intravenous thrombolysis prior to thrombectomy at two U.S. comprehensive stroke centers (2020-2024). ER was defined as eTICI ≥ 2b50 on initial angiography or confirmed recanalization in clinically improving patients who did not undergo thrombectomy. Imaging review included clot burden score, thrombus length, thrombus permeability, and collateral status (Tan scale). Multivariable logistic regression identified predictors of ER. Ordinal logistic regression assessed the association between ER and 90-day modified Rankin Scale (mRS) shift.

Among 299 patients (TNK 201, TPA 98), ER occurred in 60 (20.1%). ER was more frequent with TNK than TPA (24.4% vs 11.2%, p = 0.008). TNK was independently associated with ER (adjusted OR 2.54, 95% CI 1.19-5.42). Additional predictors included thrombus permeability (aOR 3.30, 95% CI 1.73-6.30) and lower NIHSS (aOR 0.94 per point, 95% CI 0.89-0.98), while tandem occlusion reduced ER likelihood (aOR 0.18, 95% CI 0.05-0.62). ER independently predicted better 90-day mRS (aOR 2.09, 95% CI 1.21-3.60).

Tenecteplase achieved superior early reperfusion compared to alteplase after accounting for clot burden, thrombus features, and collateral status, reinforcing its clinical advantage in LVOS thrombolysis.