Trade‐Off Between Early Reperfusion and First‐Pass Effect With Tenecteplase Versus Alteplase Before Stroke Thrombectomy

BACKGROUND: Early reperfusion and first-pass effect are key procedural end points in large-vessel occlusion stroke thrombectomy. Because of greater fibrin specificity, tenecteplase may achieve higher early reperfusion rates compared with alteplase, yet impact of thrombolytic agents on first-pass effect remains unclear. METHODS: Consecutive patients with anterior circulation large-vessel occlusion stroke receiving intravenous thrombolysis before endovascular treatment at 2 US stroke centers were reviewed. Early reperfusion was defined as extended Thrombolysis in Cerebral Infarction ≥2b50 on initial angiography. First-pass effect was defined as extended Thrombolysis in Cerebral Infarction 2c-3 after a single pass. Multivariable logistic regression identified predictors of early reperfusion and first-pass effect. Ordinal logistic regression assessed associations of thrombolytic agent, early reperfusion, and first-pass effect with 90-day modified Rankin Scale shift. RESULTS: Among 299 patients (tenecteplase 201, alteplase 98), early reperfusion occurred in 60 (20.1%) and was more frequent with tenecteplase compared with alteplase (24.4% versus 11.2%; adjusted odds ratio OR, 2.31 95% CI, 1.07-4.98). Patients without early reperfusion were evaluated for first-pass effect. Of 237 patients, first-pass effect was less frequent with tenecteplase compared with alteplase (30.3% versus 40.2%; adjusted OR, 0.42 95% CI, 0.23-0.79). Early reperfusion and first-pass effect each independently predicted better functional outcome, but functional outcomes were similar between tenecteplase and alteplase overall. CONCLUSIONS: We observed higher early reperfusion rates with tenecteplase, but greater first-pass effect with alteplase, while functional outcomes were comparable. This may suggest that the early reperfusion advantage of tenecteplase could be offset by downstream procedural variables such as first-pass effect, highlighting the importance of jointly evaluating both reperfusion and procedural efficiency when comparing thrombolytic strategies.