Abstract Background and aims Tenecteplase is increasingly adopted in acute ischaemic stroke, yet its comparative effectiveness in mild stroke remains uncertain. Clarifying this subgroup is critical for optimising thrombolysis protocols. Aim To evaluate the efficacy and safety of tenecteplase versus alteplase in patients presenting with mild acute ischaemic stroke. Methods A systematic search of major databases identified randomised controlled trials comparing tenecteplase and alteplase specifically reporting outcomes for baseline NIHSS ≤5. Primary outcomes were functional independence (modified Rankin Scale mRS 0–1 at 90 days) and early neurological improvement. Secondary outcomes included symptomatic intracranial haemorrhage, mortality, and reperfusion success. Data were pooled using a random-effects model, reporting odds ratios (OR) with 95% confidence intervals (CI).se findings support its integration into thrombolysis pathways for mild presentations. Results Seven trials comprising 3,184 patients were included. Tenecteplase significantly increased the likelihood of achieving mRS 0–1 (OR 1.28, 95% CI 1.10–1.50; p = 0.002; I2 = 29%). Early neurological improvement also favoured tenecteplase (OR 1.34, 95% CI 1.08–1.68; p = 0.008; I2 = 41%). There was no difference in symptomatic intracranial haemorrhage (OR 0.92, 95% CI 0.53–1.59; p = 0.76; I2 = 0%) or mortality (OR 0.89, 95% CI 0.69–1.15; p = 0.38; I2 = 0%). Reperfusion-related imaging endpoints modestly favoured tenecteplase. Conclusions Tenecteplase appears superior to alteplase for functional outcomes in mild stroke without increasing haemorrhagic risk. These findings support its integration into thrombolysis pathways for mild presentations. Conflict of interest all authors have has nothing to disclose
Ibrahim Serag (Fri,) studied this question.