Safety and Efficacy of Alteplase Versus Tenecteplase for Acute Ischemic Stroke

Introduction: Fibrinolytic therapy with alteplase or tenecteplase (TNK) within 4.5 hours of symptom onset of acute ischemic stroke (AIS) improves functional outcomes and reduces long-term morbidity and mortality, but with increased risk of major bleeding. We sought to compare the safety and efficacy of alteplase and TNK for AIS.


Methods: Retrospective, observational, study of adult AIS patients who received alteplase or TNK from May 2020-June 2024. Patients were included if either fibrinolytic was given within 4.5 hours of symptom onset. Extended/wake-up stroke protocol patients were excluded. Primary outcome was incidence of symptomatic ICH (sICH) (National Institutes of Health Stroke Scale [NIHSS] change ≥ 4 and bleeding on computed tomography [CT] scan). Secondary outcomes were occurrence of major and minor bleeding, change in NIHSS score, hospital length of stay (LOS), and in-hospital mortality. Continuous data were analyzed using Mann Whitney U test and categorical data using Chi squared or Fisher’s Exact tests, as appropriate.


Results: A total of 479 patients were included; 224 alteplase (46.8%), 255 TNK (53.2%), median age 72 years (IQR 61-83), 53% male. Most patients had minor strokes (55%; NIHSS < 7) and received fibrinolytic in the emergency room (76%). More patients in the TNK group had a large vessel occlusion (26.8% vs. 36.8%). There were numerically more sICH and other major bleeding events in the TNK group; 4.5% vs. 6.7%, p=0.33 and 14.3% vs. 19.2%, p=0.16, respectively, although not statistically significant. There were no differences in minor bleeding events (3.5% vs. 6.7%), change in NIHSS score from admission to discharge (-4 vs -4), hospital LOS (4 days vs. 3 days), or in-hospital mortality (7.8% vs. 7.1%) between alteplase and TNK, respectively.


Conclusions: There were no statistically significant differences in safety or efficacy outcomes between alteplase and TNK use for patients with AIS. These results provide real-world experience in a large, older population, with minor stroke. It is possible type II error may be limiting these findings. Additional research is needed to identify patient or stroke related factors that may increase bleeding occurrence and further evaluate if a statistically significant increased risk of bleeding exists with one agent in the real-world AIS population.