Tenecteplase versus alteplase as bridging therapy before endovascular treatment in acute ischemic stroke due to Basilar artery occlusion: a systematic review and meta-analysis

Basilar artery occlusion (BAO) is a highly morbid form of acute ischemic stroke, and evidence guiding the optimal intravenous thrombolytic agent before endovascular treatment (EVT) remains limited; this systematic review and meta-analysis compared the efficacy and safety of tenecteplase versus alteplase as bridging therapy exclusively in BAO. PubMed, Embase, and the Cochrane Library were systematically searched through 8 December 2025. Randomized controlled trials and observational studies directly comparing tenecteplase with alteplase as intravenous bridging therapy prior to EVT in adult patients with imaging-confirmed BAO treated within ≤ 4.5 hours of symptom onset were included. Primary outcomes were early reperfusion before EVT and final reperfusion after EVT (eTICI 2b–3). Secondary outcomes included functional outcomes at 90 days (modified Rankin Scale [mRS] 0–3, 0–2, and 0–1), symptomatic intracranial hemorrhage, parenchymal hematoma, any intracranial hemorrhage, and mortality. Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using random-effects models. Six studies including 381 patients treated with tenecteplase and 516 treated with alteplase were analyzed. Tenecteplase was associated with higher early reperfusion before EVT (RR 1.34, 95% CI 1.11–1.64) and a modest increase in final reperfusion after EVT (RR 1.06, 95% CI 1.00–1.11). No significant differences were observed in functional outcomes at 90 days, symptomatic intracranial hemorrhage, parenchymal hematoma, any intracranial hemorrhage, or mortality. In BAO, tenecteplase as bridging therapy prior to EVT improves early and final reperfusion without increasing hemorrhagic risk or mortality, with functional outcomes comparable to alteplase, although the current evidence is limited.