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 patients with acute ischemic stroke (AIS) and large vessel occlusion (LVO).MethodsIn this retrospective cohort study, data were extracted from the multicenter Chinese Acute Stroke Evaluation and Management Ⅱ (CASE-Ⅱ) database (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 NIHSS score, occlusion site, DNT, and DPT.ResultsAmong 1505 enrolled patients, 250 received tenecteplase and 1255 received alteplase. After matching, 224 tenecteplase-treated and 767 alteplase-treated patients were included. 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 before matching (OR=0.676, 95%CI: 0.470-0.972, P=0.032). After matching, there were no significant differences in functional or safety outcomes (all P>0.05). Sensitivity and subgroup analyses also showed no significant differences in 3-month functional independence (all P>0.05).ConclusionIn patients with AIS and large vessel occlusion undergoing bridging thrombolysis before mechanical thrombectomy, tenecteplase and alteplase showed comparable 3-month functional outcomes and safety profiles.