1533: THROMBECTOMY WITH ALTEPLASE OR TENECTEPLASE: COMPARATIVE ANALYSIS FROM TRINETX REALWORLD DATA

Introduction: Acute ischemic stroke from large vessel occlusion (AIS-LVO) requires mechanical thrombectomy (MT). Prior to thrombectomy, eligible patients also receive intravenous thrombolytics. Alteplase (tPA) has been the traditional thrombolytic, but Tenecteplase (TNK) has recently been used more frequently due to its specificity for clot-bound fibrin and potentially reduced risk of bleeding complications. However, its efficacy and safety profile have been controversial. We hypothesized that tPA would demonstrate a safety profile comparable to TNK. Methods: This is a retrospective study, utilizing the global large realworld database TrinetX, which involves 130 contributing organizations and over 130 million patients. All adult patients with AIS-LVO and MT between 01/2016 to 07/2025 were eligible. Outcomes were hemorrhagic stroke (HS), major bleeding, and transfusion of any blood products. Patients who had HS prior to the index visits were excluded. Patients receiving tPA were matched with those receiving TNK via propensity score matching using demographics, past medical history and laboratory values. A priori sample size calculation suggested a total of 2480 patients Results: Our study analyzed 5462 patients (2731 [50%] per group). Mean age (土SD) was 67 (土13) for both groups, 53% (1450) were male per group. Mean Hemoglobin was 13.1 g/dL (土 2) for tPA vs. 12.5 g/dL (土 2, P< 0.001) for TNK groups. There were 104 (4.7%) patients with tPA sustaining HS, compared with 128 (5.8%) TNK patients (Risk Difference [RD] 0.011, 95% CI -0.002, 0.024, P=0.105). Major bleeding occurred in 16 (0.6%) tPA patients versus 10 (0.4%, RD -0.2%, 95%CI -0.006, 0.001), P=0.241) TNK patients. There were 112 (4.1%) transfusions in the tPA group vs. 59 (2.2%) in the TNK group (RD -1.9%, 95%CI -0.029, -0.010, P< 0.001). Conclusions: Among patients with AIS-LVO undergoing MT, receiving tPA was associated with a similar risk of hemorrhagic stroke or major bleeding. However, receiving tPA was associated with higher risk of transfusion. Further studies are necessary to confirm the efficacy of TNK versus tPA