Comparison of tenecteplase vs. alteplase in addition to thrombectomy in patients with ischemic stroke caused by large vessel occlusion within 4.5 h: a network meta-analysis

TL;DR

This study compares tenecteplase and alteplase combined with thrombectomy for stroke, finding possible benefits for tenecteplase without increased risks.

Contribution

A network meta-analysis comparing tenecteplase and alteplase with thrombectomy for acute ischemic stroke.

Findings

Tenecteplase with thrombectomy may improve functional outcomes compared to thrombectomy alone.

No significant differences in safety outcomes like bleeding or mortality were observed.

Tenecteplase ranked highest in efficacy probability but with limited sample size.

Abstract

The optimal reperfusion approach for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) remains under debate. While endovascular thrombectomy (EVT) is the standard treatment, the role of intravenous thrombolysis before EVT—particularly with alteplase or tenecteplase—remains under investigation. This network meta-analysis (NMA) aimed to compare the efficacy and safety of three strategies: EVT alone, alteplase with EVT, and tenecteplase with EVT.

A comprehensive search of Web of Science, PubMed, Cochrane Library and Embase was performed to find randomized controlled trials (RCTs) comparing the above interventions in AIS patients with LVO treated within 4.5 h of symptom onset. A Bayesian NMA framework was used to estimate pooled effects. The primary endpoint was Proportion of patients achieving a modified Rankin Scale (mRS) score of 0–2 at 90 days. Secondary endpoints included mRS 0–1, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality.

Seven RCTs involving 2,793 patients were included. Among them, 1,290 received EVT alone, 1,124 alteplase with EVT, and 379 tenecteplase with EVT. Tenecteplase with EVT was associated with a higher rate of functional independence (mRS 0–2) at 90 days versus EVT alone (OR: 1.52; 95% CrI: 1.00–2.36), with the lower bound of the credible interval at the null. Tenecteplase with EVT also numerically outperformed alteplase plus EVT (OR: 1.48; 95% CrI: 0.97–2.36), although this difference was not statistically significant. No significant differences were observed among treatments in achieving excellent outcome (mRS 0–1), symptomatic intracerebral hemorrhage, or mortality. Tenecteplase plus EVT ranked highest in efficacy probability based on SUCRA values, but these rankings should be interpreted cautiously given the limited tenecteplase sample size and modest precision of the estimates.

Tenecteplase with EVT may be associated with better 90-day functional outcomes than EVT alone and may offer advantages compared to alteplase with EVT for AIS patients with LVO treated within 4.5 h, without an observed excess risk of sICH or mortality. However, these findings are based on a small number of tenecteplase-treated patients and borderline credible intervals, so they should be interpreted cautiously and confirmed in larger, rigorously designed randomized trials.

PROSPERO, identifier (CRD420251073350).

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