Tenecteplase vs alteplase as bridging thrombectomy in ischemic stroke patients: a systematic review and meta analysis

Background: Alteplase (ALT) is the standard medical therapy, and also approved by food and drug administration (FDA) for acute ischemic stroke (AIS) patients who present within 4.5 h of symptom onset. However, several randomized controlled trials (RCTs) have reported that tenecteplase (TNK) is non-inferior to alteplase. Recently, tenecteplase and alteplase have been compared in acute ischemic stroke patients undergoing mechanical thrombectomy. This study aimed to evaluate the benefits and risks of tenecteplase compared to alteplase in acute ischemic stroke patient’s undergone thrombectomy. Methods: We searched three key databases, including PubMed, Cochrane, and Proquest until November 10, 2024 for clinical studies evaluating the effects of tenecteplase versus alteplase in patients with either large vessel or medium vessel occlusion undergoing mechanical thrombectomy. A fixed-effect meta-analysis was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: Nine studies involving 4897 patients, consisting of 1852 patients given tenecteplase (37.8%) and 3045 patients given alteplase (62.2%) were included. Compared to patients given alteplase, patients given tenecteplase showed a significantly higher reperfusion rate as assessed by modified thrombolysis in cerebral infarction (mTICI) 2b-3 criteria (odds ratio 123, 95% CI [1.04–1.46], P value = 0.02) without increased risk of adverse event, namely symptomatic intracerebral hemorrhage (OR = 1.04, 95% CI [0.67–1.51], P value = 0.83) or parenchymal hematoma (OR = 0.88, 95% CI [0.67–1.15], P value = 0.34). TNK-treated patients showed the same rate of functional independence (modified ranking scale score ≤ 2) at 90 days (OR = 1.00, 95% CI [0.83–1.21], P value = 0.99) as ALT-treated patients, but a slightly higher rates of mortality within 90 days (OR = 1.01, 95% CI [0.80–1.28], P value = 0.93). Using albatross plot, tenecteplase showed significantly better in terms of length of stay. Conclusion: TNK is superior to ALT in achieving higher reperfusion rate as assessed by mTICI 2b-3 and length of stay. In terms of functional independence (mRS ≤ 2), mortality rate, intracerebral hemmorhage, and parenchymal hematoma, TNK is comparable to ALT.