Tenecteplase Versus Alteplase in Acute Ischemic Stroke: Time Window Analysis

Abstract

Introduction: Tenecteplase (TNK) has pharmacological advantages over alteplase (tPA) (longer half-life, single bolus, higher fibrin specificity). Whether TNK improves outcomes in acute ischemic stroke (AIS) within 4.5 hours remains unclear. Methods: Systematic review and meta-analysis of 6 RCTs (n=2,345) comparing TNK 0.25 mg/kg (single bolus) versus tPA 0.9 mg/kg (infusion). Primary outcome: modified Rankin Scale (mRS) 0–1 at 90 days. Secondary: symptomatic intracerebral hemorrhage (sICH), recanalization (CT angiography at 24 hours). Results: TNK was non-inferior for mRS 0–1 (52% vs 49%, OR 1.08, 95% CI 0.88–1.32, p=0.48). In patients with large vessel occlusion (LVO), TNK showed higher recanalization at 24 hours (71% vs 56%, OR 1.86, p=0.007) and a trend toward better functional outcome (OR 1.38, p=0.09). sICH rates were similar (2.7% vs 2.8%). Discussion: TNK's single-bolus administration reduces door-to-needle time, which may drive better outcomes in real-world settings. LVO subgroup benefit requires confirmatory trials. Conclusion: Tenecteplase is at least as effective as alteplase for AIS and may be superior for large vessel occlusion.