Comparison of functional outcomes between tenecteplase and alteplase as bridging thrombolysis prior to mechanical throm-bectomy for acute ischemic stroke patients with large vessel occlusion

ObjectiveTo compare the efficacy and safety of tenecteplase versus alteplase as bridging intravenous thrombolysis before mechanical thrombectomy in acute ischemic stroke (AIS) patients with large vessel occlusion.MethodsIn this retrospective cohort study, data were extracted from the Acute Stroke Patients for Stroke Management Quality Evaluation online database (CASE-Ⅱ, NCT04487340). Patients with AIS and large vessel occlusion who received tenecteplase or alteplase followed by mechanical thrombectomy within 24 hours of symptom onset from December 2022 to March 2025 were included. The patients were divided into the tenecteplase group and the alteplase group. Propensity score matching (1∶4) was performed based on age, sex, door-to-needle time (DNT), door-to-puncture time (DPT), and onset-to-door time. Binary logistic regression and general linear models were used to compare 3-month functional and safety outcomes. Sensitivity analysis was conducted for patients with onset-to-needle time (ONT)≤4.5 h, and subgroup analyses were performed based on age, sex, baseline National Institutes of Health Stroke Scale (NIHSS) score, occlusion site, DNT and DPT.ResultsAmong 1505 enrolled patients, 250 received tenecteplase and 1255 received alteplase. No significant differences were observed in 3-month functional outcomes between the two groups (all P>0.05). However, the tenecteplase group had lower 3-month all-cause mortality (OR=0.676, 95%CI: 0.470-0.972, P=0.032). After matching, 224 tenecteplase-treated and 767 alteplase-treated patients were included. There were no significant differences in functional or safety outcomes between the two groups (all P>0.05). Sensitivity analysis showed that among patients with an onset-to-needle time (ONT) ≤4.5 hours, there were no statistically significant differences in 3-month functional or safety outcomes between the tenecteplase group and the alteplase group (all P>0.05). Subgroup analyses indicated that no statistically significant differences in 3-month functional independence were observed across all subgroups (all P>0.05).ConclusionIn AIS patients with large vessel occlusion undergoing bridging thrombolysis before mechanical thrombectomy, tenecteplase and alteplase showed comparable 3-month functional and safety outcomes.