The comparison of short-term outcome between tenecteplase and alteplase in minor acute ischemic stroke based on neutrophil-to-lymphocyte ratio stratification

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Minor acute ischemic stroke (n=234). Intervention: Tenecteplase vs. Alteplase. Primary outcome: Excellent short-term outcome (mRS 0-1 at discharge) (OR 2.34, 95% CI 1.25-4.40, p=0.008).

Q: What does this research mean for the field?

Tenecteplase is associated with better short-term functional outcomes than alteplase in patients with minor acute ischemic stroke who have a low neutrophil-to-lymphocyte ratio. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Liangxu Xiang; Jing Xu; Zhaohai Feng; Zhide Li; Yingwei Zheng; Yan Li; Pingping Zhu; Lu Liu; Meiying Li

doi:10.1038/s41598-026-74273-1

October 4, 2026Scientific ReportsOpen Access

The comparison of short-term outcome between tenecteplase and alteplase in minor acute ischemic stroke based on neutrophil-to-lymphocyte ratio stratification

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Key result

Tenecteplase linked to ~134% higher odds of excellent recovery vs. alteplase in minor stroke.

OR 2.34
95% CI 1.25-4.40
P=0.008
n=234

Why the study?

The comparative effects of intravenous thrombolysis with alteplase versus tenecteplase on short-term outcomes in minor acute ischemic stroke across different neutrophil-to-lymphocyte ratio levels were unclear.

Does tenecteplase improve excellent short-term functional outcomes compared to alteplase in patients with minor acute ischemic stroke, and does this effect vary by baseline neutrophil-to-lymphocyte ratio?

Key Points

To compare the short-term efficacy of intravenous thrombolysis using tenecteplase versus alteplase in patients with minor acute ischemic stroke stratified by baseline neutrophil-to-lymphocyte ratio.
Prospectively and consecutively enrolled 234 patients with minor acute ischemic stroke (NIHSS score ≤ 5) presenting within 4.5 hours of symptom onset.
Participants received intravenous thrombolysis with either alteplase (n = 86, 36.8%) or tenecteplase (n = 148, 63.2%).
Patients were stratified into low-NLR (≤ 2.34) and high-NLR (> 2.34) subgroups using the cohort median NLR of 2.34 (1.64, 3.89) to evaluate excellent functional outcome (mRS 0–1) at discharge.
Across the full cohort, tenecteplase achieved a significantly higher rate of excellent outcome compared to alteplase (76.4% vs. 52.3%; adjusted OR = 2.34, 95% CI: 1.25–4.40, p = 0.008).
In the low-NLR subgroup (≤ 2.34), tenecteplase was associated with significantly superior discharge outcomes over alteplase (82.9% vs. 51.1%; adjusted OR = 3.44, 95% CI: 1.25–9.47, p = 0.017).
In the high-NLR subgroup (> 2.34), excellent outcome rates did not differ significantly between tenecteplase and alteplase (69.2% vs. 53.8%; adjusted OR = 1.93, 95% CI: 0.80–4.69, p = 0.14).

Study Design

Type

Cohort (n=234)

Blinding

Single-blind

Multicenter

No

Structured PICO

Does tenecteplase improve excellent short-term functional outcomes compared to alteplase in patients with minor acute ischemic stroke, and does this effect vary by baseline neutrophil-to-lymphocyte ratio?

P

Population

234 adult patients with minor acute ischemic stroke (baseline NIHSS ≤ 5) presenting within 4.5 hours of symptom onset, evaluated for outcomes at hospital discharge.

E

Exposure

Tenecteplase 0.25 mg/kg (maximum dose 25 mg) administered as a single intravenous bolus over 5–10 seconds.

C

Comparator

Alteplase 0.9 mg/kg (maximum dose 90 mg), with 10% given as an intravenous bolus over 1 minute and the remainder as a continuous intravenous infusion over 1 hour. Thrombolytic agent was independently selected by the patient or family.

O

Outcome

Excellent short-term outcome at discharge (defined as a modified Rankin Scale [mRS] score of 0 or 1), assessed by a neurologist blinded to clinical information.hard clinical

Main Result

Odds Ratio: 2.34 (95% CI 1.25–4.4)

Absolute Event Rate: 76.4% vs 52.3%

p-value: p=0.008

Tenecteplase may be preferred over alteplase for improving short-term outcomes in patients with minor acute ischemic stroke presenting within 4.5 hours, particularly in those with a low baseline neutrophil-to-lymphocyte ratio.

Limitations

Single-center study with a small sample size
Non-randomized observational design with potential confounding factors
Outcomes were assessed at discharge rather than at 90 days
Delayed selection of thrombolytic agents based on NLR results may not align with current clinical workflows

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Implication

Tenecteplase may be preferable in low-NLR minor stroke; hypothesis-generating and should not change practice without randomized confirmation.

Abstract

This study aims to compare the effects of intravenous thrombolysis (IVT) with alteplase versus tenecteplase (TNK) on short-term outcomes in patients with minor acute ischemic stroke (AIS) across different levels of neutrophil-to-lymphocyte ratio (NLR). Patients with minor AIS (National Institutes of Health Stroke Scale [NIHSS] score ≤ 5) who underwent IVT were prospectively and consecutively enrolled. A total of 234 participants were included, among whom 86 (36.8%) received alteplase while 148 (63.2%) received TNK. At discharge, 158 (67.5%) patients achieved an excellent outcome [a modified Rankin Scale (mRS) of 0–1 point]. Using the median NLR value of 2.34 (1.64, 3.89), participants were stratified into a low-NLR group (NLR ≤ 2.34) and a high-NLR group (NLR > 2.34). In the low-NLR group, IVT with TNK was associated with an excellent outcome (OR = 3.44, 95% CI: 1.25–9.47, p = 0.017) but was not associated with an excellent outcome (OR = 1.93, 95% CI: 0.80–4.69, p = 0.14) in the high-NLR group. For patients with minor AIS within 4.5 h of onset, TNK may be considered a preferred option for IVT In the low-NLR subgroup.

Discussion

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Cite This Study

Xiang et al. (2026) conducted a cohort in Minor acute ischemic stroke (n=234). Tenecteplase vs. Alteplase was evaluated on Excellent short-term outcome (mRS 0-1 at discharge) (OR 2.34, 95% CI 1.25-4.40, p=0.008). Tenecteplase was associated with a higher rate of excellent short-term outcomes compared to alteplase in patients with minor acute ischemic stroke, a benefit primarily observed in those with low neutrophil-to-lymphocyte ratios.

synapsesocial.com/papers/6ac5e06db2dceb1c429fa7d2 https://doi.org/10.1038/s41598-026-74273-1

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The comparison of short-term outcome between tenecteplase and alteplase in minor acute ischemic stroke based on neutrophil-to-lymphocyte ratio stratification

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

The comparison of short-term outcome between tenecteplase and alteplase in minor acute ischemic stroke based on neutrophil-to-lymphocyte ratio stratification

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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