Key result
Tenecteplase achieves ~8% higher rates of excellent recovery at 3 months versus alteplase in ischemic stroke.
Why the study?
Varying results from comparisons of different tenecteplase doses with alteplase have made it challenging to establish clear guidelines for managing acute ischemic stroke.
Does intravenous tenecteplase 0.25 mg/kg improve functional recovery and recanalization without increasing hemorrhagic complications compared to alteplase 0.9 mg/kg in patients with acute ischemic stroke?
Meta-Analysis (n=3,647)
Yes
Does intravenous tenecteplase 0.25 mg/kg improve functional recovery and recanalization without increasing hemorrhagic complications compared to alteplase 0.9 mg/kg in patients with acute ischemic stroke?
Relative Risk: 1.079 (95% CI 1–1.15)
p-value: p=0.04
This meta-analysis demonstrates that single-bolus intravenous tenecteplase (0.25 mg/kg) is non-inferior in safety and superior in achieving excellent 90-day functional recovery compared to standard alteplase infusion in acute ischemic stroke.
Tenecteplase 0.25 mg/kg may be preferred over alteplase for acute ischemic stroke; extends prior variable trials with Level 1 evidence of superior excellent recovery and comparable safety.
Objectives: The varying results of comparing different doses of tenecteplase (TNK) with alteplase (ALT) make it challenging to establish clear guidelines for managing acute ischemic stroke (AIS). This meta-analysis aims to compare the benefits and risks of tenecteplase 0.25 mg/kg versus ALT. Materials & Methods: This study is a comprehensive search of multiple databases to identify randomized controlled trials (RCTs) comparing the effects of TNK 0.25mg/kg and ALT in patients with AIS, until June 10, 2024. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Pooled analyses were performed using Stata V.17. Results: The present study analyzed eight trials involving 3647 patients with AIS who were treated with TNK and ALT. Compared to alteplase, tenecteplase (TNK 0.25 mg/kg) demonstrated a significant improvement in excellent recovery at three months (RR: 1.079, 95% CI 1.00–1.15). TNK exhibited non-inferiority to ALT regarding complete recanalization (RR: 1.47, 95% CI 0.87–2.50), combined complete/partial recanalization (RR: 1.20, 95% CI 0.86–1.68), early neurological improvement (RR: 1.04, 95% CI 0.83–1.29), and good recovery (RR: 1.02, 95% CI 0.90–1.15). While these findings trended in favor of TNK 0.25 mg/kg, the differences did not reach statistical significance. Furthermore, no significant differences were observed between TNK and ALT regarding poor recovery (RR: 0.87, 95% CI 0.67–1.13), parenchymal hematoma (RR: 0.78, 95% CI 0.21–2.81), intracerebral hemorrhage (ICH) (RR: 0.91, 95% CI 0.77–1.08), ICH symptoms (RR: 1.05, 95% CI 0.71–1.56), or 90-day mortality (RR: 1.00, 95% CI 0.83–1.19) Conclusion: Intravenous thrombolysis with TNK 0.25mg/kg in patients with AIS was shown to be as effective and safe as ALT, demonstrating non-inferiority. TNK showed significant superiority in terms of excellent recovery when compared to ALT. However, given the limitations of the present study, further RCTs with larger populations and more specific objectives are needed.
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Asadi et al. (2026) conducted a meta-analysis in Acute ischemic stroke (n=3,647). Tenecteplase vs. Alteplase 0.9 mg/kg intravenous (10% bolus, 90% infused over 60 minutes) was evaluated on Excellent recovery at 3 months (modified Rankin Scale [mRS] score of 0-1) (RR 1.079, 95% CI 1.00-1.15, p=0.04). Tenecteplase 0.25 mg/kg significantly improved excellent functional recovery (mRS 0-1) at 3 months compared with alteplase in acute ischemic stroke (RR 1.079, 95% CI 1.00-1.15, p=0.04).
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