Stroke. 2026 Apr 9. doi: 10.1161/STROKEAHA.125.054791. Online ahead of print.
ABSTRACT
BACKGROUND: Tenecteplase improves reperfusion and functional outcomes compared with alteplase in patients with large vessel occlusion. We assessed whether this superiority varies with thrombolysis-to-puncture time (TTP).
METHODS: This retrospective analysis of a prospective multicenter cohort included patients with large vessel occlusion who received bridging therapy with either tenecteplase or alteplase between January 2022 and September 2025. Patients were stratified by TTP (<60 versus ≥60 minutes). We subsequently assessed the association of TTP with efficacy and safety outcomes between the alteplase and tenecteplase groups using multivariable logistic regression adjusted for age, baseline National Institutes of Health Stroke Scale score, and time from stroke onset to arterial puncture. Functional independence was defined as a modified Rankin Scale score of 0 to 2 at 3 months.
RESULTS: Of 1106 patients who received bridging therapy, 1003 were included in the primary analysis (tenecteplase, 488; alteplase, 515). The median age was 68 (interquartile range, 58-75) years in both groups, with males comprising 64.3% and 66.0%, respectively. Tenecteplase was associated with superior 3-month functional independence compared with alteplase (53.6% versus 48.1%; adjusted odds ratio, 1.37 [95% CI, 1.03-1.82]). This benefit was concentrated in patients with a TTP <60 minutes, where tenecteplase yielded higher rates of both early recanalization (19.0% versus 9.1%; adjusted odds ratio, 2.36 [95% CI, 1.32-4.23]; Pinteraction=0.047) and functional independence (61.0% versus 49.0%; adjusted odds ratio, 1.77 [95% CI, 1.13-2.77]; Pinteraction=0.111). No between-agent differences were significant with TTP ≥60 minutes. Safety outcomes were comparable, but each 30-minute TTP increase independently elevated hemorrhagic risks for both agents.
CONCLUSIONS: The recanalization superiority of tenecteplase over alteplase is time-dependent, evident only within a TTP <60 minutes. Although the translation of this advantage into functional outcome was not statistically modified by time, optimizing workflow to achieve this rapid window maximizes the potential benefit of tenecteplase, which should be prioritized in capable settings.
PMID:41953987 | DOI:10.1161/STROKEAHA.125.054791
