Comparative effectiveness of Tenecteplase and Alteplase for ischemic stroke: real-world data from a stroke center

Tenecteplase (TNK) and Alteplase (rt-PA) are intravenous thrombolytics used in acute ischemic stroke (AIS). While Alteplase has long been the standard of care, TNK is now also approved for AIS by both the EMA and FDA. Its single-bolus administration and favorable pharmacokinetics offer practical advantages. Despite growing guideline support, real-world data comparing both agents remain limited. This study aimed to compare clinical characteristics, imaging findings, treatment outcomes, and complication rates of AIS patients treated with TNK versus Alteplase at a single stroke center. We conducted a retrospective monocentric analysis of 101 AIS patients treated with TNK (n = 39) or Alteplase (n = 62). We compared demographics, vascular risk factors, imaging findings, reperfusion therapies, and clinical outcomes using independent samples t-tests, Chi-square, and Mann–Whitney U-tests as appropriate. Baseline characteristics were comparable between groups, including age (TNK: 72.7 ± 14.4 vs. Alteplase: 70.1 ± 14.3), sex, and pre-stroke mRS. Initial NIHSS scores were similar (TNK: 6.0 ± 6.3 vs. Alteplase: 7.2 ± 8.2, p = 0.83). No significant differences were found in LVO rates (15.4% vs. 27.4%, p = 0.16), perfusion delay, or infarct demarcation. Functional outcomes at discharge (mRS: 2.3 ± 1.8 vs. 2.0 ± 1.9, p = 0.39) and rates of symptomatic intracranial hemorrhage (11.1% vs. 10.3%, p = 0.91) were similar. This real-world study found that TNK and alteplase had similar early clinical and safety outcomes during the initial implementation of TNK. These observational findings generate hypotheses and support the need for larger prospective studies to assess long-term outcomes and reduce confounding factors related to the transition.