Tenecteplase versus Alteplase as Bridging Thrombolysis before Mechanical Thrombectomy for Medium and Distal Vessel Occlusions

Background and Purpose: The safety and efficacy of intravenous tenecteplase in acute ischemic stroke patients with primary medium and distal vessel occlusions (MDVO) selected for mechanical thrombectomy remain an area of active investigation. This observational study aimed to compare tenecteplase and alteplase in MDVO patients treated with mechanical thrombectomy (MT). Methods: A retrospective, propensity score–weighted analysis of two cohorts: patients with patients with primary MDVO who received bridging intravenous thrombolysis prior to MT, from the multicenter TETRIS registry treated with tenecteplase, and patients from a tertiary center cohort treated with alteplase. The primary outcome was a modified Rankin Scale (mRS) score of 0–2 at 90 days. Secondary outcomes included mortality, symptomatic intracranial hemorrhage (sICH), and early and final successful reperfusion rates, assessed using the extended Thrombolysis in Cerebral Infarction (eTICI) 2b–3 scale. Results: We included 110 patients, 65 receiving tenecteplase and 45 receiving alteplase. mRS 0–2 at 90 days was achieved in 53.8% of tenecteplase-treated patients versus 48.9% of alteplase-treated patients (p = 0.41). Mortality and sICH rates were similar between groups (12.3% vs. 13.3%, p=0.68; 3.1% vs. 0%, p = 0.51, respectively). There was no significant difference in early reperfusion between tenecteplase and alteplase (40.2% vs. 31.1%; p = 0.53). Final successful reperfusion did not significantly differ (80.4% vs. 88.9%; p = 0.28). Discussion and Conclusion: In MDVO, tenecteplase yielded comparable safety and functional outcomes to alteplase, without statistically significant differences in early or final reperfusion. In light of recent trials questioning the benefit of MT in MDVO, these data suggest comparable safety and functional outcomes between tenecteplase and alteplase as bridging thrombolysis prior to mechanical thrombectomy, within the limits of this observational study.