Evaluating the Safety and Efficacy of Alteplase Versus Tenecteplase in Acute Ischemic Stroke

Introduction: Acute ischemic stroke (AIS) is a medical emergency caused by a sudden blockage or reduction in blood flow within the brain. Thrombolytics are the mainstay pharmacologic agent utilized in patients presenting within 4.5 hours of symptom onset. Alteplase (tPA) and tenecteplase (TNK) are two thrombolytics FDA-approved for the management of AIS. This study aimed to compare outcomes of tPA versus TNK for AIS. The findings of this study may provide additional comparative evidence between these two agents, adding to the growing body of evidence in the treatment of AIS.


Methods: A multi-center, retrospective chart review was performed of individuals who received tPA from 9/1/23 to 11/30/23 or TNK from 1/1/24 to 3/31/24 for AIS within Piedmont Health System. We compared door-to-needle times (DNT), incidence of symptomatic intracranial hemorrhage, rate of successful reperfusion, mRS at discharge/90-days, and incidence of angioedema between study arms. A subgroup analysis was conducted on patients who underwent mechanical thrombectomy following thrombolytic administration. Door-to-needle times and mRS at discharge/90 days were evaluated utilizing an independent t-test. A chi-squared test was used for all other outcomes.


Results: A total of 314 patients were included in the study, 159 patients who received tPA and 155 who received TNK. DNT for tPA and TNK arms were 50 minutes and 49 minutes, respectively. Hemorrhagic conversion was identified in 7 tPA and 5 TNK recipients, average discharge/90-day mRS was 2.6 in the tPA arm and 2.5 in the TNK arm, and angioedema occurred in 1 tPA and 2 TNK recipients. In the subgroup analysis, symptomatic hemorrhagic conversion was identified in 4 tPA and 1 TNK recipient, average discharge/90-day mRS was 3.3 in the tPA arm and 4.0 in the TNK arm, and successful reperfusion was achieved in 14 tPA and 13 TNK recipients. None of the outcomes were statistically significant.


Conclusions: This study found no difference between tPA and TNK in door-to-needle times or secondary safety and efficacy outcomes including incidence of angioedema, rate of symptomatic hemorrhagic conversion, mRS at discharge/90 days, or rate of successful reperfusion. These results suggest that TNK is a safe and effective alternative thrombolytic to tPA for the management of acute ischemic stroke.