Comparing Tenecteplase and Alteplase for Acute Ischemic Stroke: A Real-World Evaluation of Efficacy and Safety
Catherine Wise, Katleen Chester, Olivia Morgan, Morgan Daniel; Grady Memorial Hospital, Atlanta, Georgia
Background:
Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality worldwide. Intravenous fibrinolytics have been the standard of care for AIS for decades, with alteplase historically being the fibrinolytic of choice, however, there is an expanding body of evidence supporting tenecteplase as a safe and effective alternative fibrinolytic. Tenecteplase is a genetically modified variant of alteplase, with increased fibrinogen binding specificity and extended half-life. Unlikealteplase, which has continuous infusions, tenecteplase is administered as a single intravenous bolus, offering practical advantages such as greater workflow efficiency and rapid treatment initiation, leading to shorter door-to-needle (DTN) times, which may translate to improved reperfusion and patient outcomes. Clinicaltrials, including the EXTEND-IA TNK trial further reported improved reperfusion rates when tenecteplase was administered prior to thrombectomy compared with alteplase. The AcT trial further demonstrated that tenecteplase achieves comparable rates of early recanalization and functional recovery, as assessed by the modified Rankin Scale (mRS). Observational cohort studies suggest real-world benefits, including shorter DTN and door-to-puncture (DPT) times. This study aims to further evaluate tenecteplase and alteplase in real-world practice, with an emphasis on safety and efficacy, to assess potential to enhance stroke care and optimize patient recovery within a high-volume comprehensive stroke center.
Methods:
This is a single-center retrospective chart review of patients who presented to Grady Memorial Emergency Care Center who received intravenous fibrinolytics (tenecteplase or alteplase) for AIS treatment between January 2021 to April 2025. Patients under the age of 18, received intravenous fibrinolytics en route to Grady Memorial Hospital via our Mobile Stroke Unit, and in-house stroke patients were excluded from this study. Data was obtained from Institutional Stroke Committeefibrinolytic pharmacy data reports and the Marcus Stroke and Neuroscience Center. The primary outcome of the study was the functional status, defined as mRS, at discharge. Secondary outcomes included average 90-day mRS score, functional independence at 90 days (mRS score of 0-2), Onset-to-Treatment Time (OTT), DNT, DPT for thrombectomy patients, incidence of thrombectomy, successful reperfusion, defined as a TICI score of 2b or 3, incidence of symptomatic intracranial hemorrhage (sICH), defined as neurological deterioration (≥4-point NIHSS increase) attributed to new intracranial hemorrhage on imaging, and overall length of stay (LOS).
Results:
A total of 625 patients were included in the analysis; 246 received tenecteplase and 379 received alteplase. Median admission mRS scores were 0 (IQR 0–1) in both groups. Median admission NIHSS scores and functional independence at discharge did not differ between the tenecteplase and alteplase groups. Discharge mRSscores, and hospital length of stay were similar between the two groups. Median OTT time and DTN times were also not found to be significantly different. Inmechanical thrombectomy patients, median DTP time was 83 minutes for tenecteplase and 90.5 minutes for alteplase (p = 0.381). Mechanical thrombectomy was performed in 24.4% of patients treated with tenecteplase and 21.1% of patients treated with alteplase (p = 0.336) with successful reperfusion was achieved in 100% of tenecteplase and 98.8% of alteplase patients (p = 0.728). SICH occurred in 0.4% of patients in the tenecteplase group and 1.3% of patients in the alteplase group (p = 0.41).
Conclusion:
Tenecteplase and alteplase are considered similar when it comes to safety and efficacy of the two fibrinolytics with no significant difference to show between the two medications. Similar safety and efficacy features can show that tenecteplase could become a strong medication as reflected in our 2026 acute ischemic stroke guidelines.
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