Safety and Efficacy Comparison of Tenecteplase and Alteplase for Clinically Suspected Large Vessel Occlusion Strokes without Thrombectomy

Introduction: Tenecteplase is a thrombolytic with higher fibrin affinity and is potentially better in clot lysis. A higher spontaneous recanalisation rate for large vessel occlusion (LVO) strokes had been shown in comparison studies with alteplase. Results of the LVO studies reflect the composite effect of the thrombolytic and thrombectomy, as patients would be treated by thrombectomy had they not been recanalised by intravenous thrombolysis alone. Thrombectomy is not readily available in many parts of the world. Our study aimed to compare the outcomes of suspected LVO patients treated with tenecteplase versus alteplase only, without the confounding effect of thrombectomy. Methods: This is a retrospective review. Data of patients given tenecteplase from May 2020 to August 2023 and those given alteplase 0.9 mg/kg from January 2019 to August 2023 were retrieved. Due to fluctuation in supply of tenecteplase during the COVID pandemic, some LVO patients were given alteplase. Patients with anterior circulation, clinically suspected LVO strokes (defined as National Institutes of Health Stroke Scale (NIHSS) score ≥6, plus cortical signs or hyperdense vessel sign), with thrombolysis given within 4.5 h of stroke onset were analysed. Patients with thrombectomy done were excluded. Safety and efficacy outcomes were compared. Results: There were 245 tenecteplase-treated patients treated between May 1, 2020, and August 31, 2023, and 732 patients were treated with alteplase between January 1, 2019, to August 31, 2023. Out of these, 148 tenecteplase patients and 138 alteplase 0.9 mg/kg patients fulfilled the study criteria. The symptomatic intracerebral haemorrhage rate was non-significantly lower in the tenecteplase group (2.1% vs. 5.8%, p = 0.13). There were no significant differences in the rate of ≥8-point NIHSS improvement (23.6% vs. 23.7%, p = 1) or the ≥4-point improvement (40.5% vs. 40.7%, p = 1) at 24 h. At 3 months, 21.6% of tenecteplase patients had good functional outcome (modified Rankin scale [mRS] 0–2), compared to 26.3% in the alteplase group (p = 0.40). Conclusion: In this pragmatic study of clinically suspected anterior circulation LVO patients without thrombectomy, outcome solely reflects the effects of tenecteplase. Tenecteplase showed comparable safety and efficacy to alteplase, but the result should be interpreted with caution in view of its small sample size and non-randomised study design.