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Background <p>Intravenous thrombolysis remains a cornerstone in acute ischemic stroke (AIS) management, particularly in large vessel occlusion (LVO). While alteplase has long been the standard thrombolytic agent, tenecteplase has emerged as a promising alternative due to its pharmacokinetic advantages. This systematic review and meta-analysis aim to compare the efficacy and safety of tenecteplase versus alteplase in AIS patients with LVO.</p> Methods <p>A systematic search was conducted across PubMed, Scopus, Web of Science, Cochrane Library, and Embase until February 2025. Studies comparing tenecteplase and alteplase in AIS patients with LVO were included. The primary outcomes were functional independence at 3 months (modified Rankin Scale [mRS] 0–1 and 0–2), mortality, and symptomatic intracranial hemorrhage (sICH). Secondary outcomes included any bleeding, adverse events, and overall complications. Pooled estimates were calculated using risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI).</p> Results <p>A total of 14 studies (<i>N</i> = 9641 patients) were included, comprising 5898 patients receiving alteplase and 3743 receiving tenecteplase. No significant differences were observed in 3-month functional outcomes: mRS 0–1 (RR = 0.92, 95% CI: 0.78 to 1.1, <i>P</i> = 0.38) and mRS 0–2 (RR = 0.95, 95% CI: 0.83 to 1.08, <i>P</i> = 0.44). Mortality rates were comparable between groups (OR = 1.07, 95% CI: 0.88–1.30). No significant differences were found in intracranial hemorrhage (ICH) (OR = 1.25, 95% CI: 0.96–1.62), sICH (OR = 1.1, 95% CI: 0.91–1.33), or any bleeding (OR = 1.19, 95% CI: 0.9–1.57). The pooled OR for adverse events was 0.79 (95% CI: 0.53 to 1.17), indicating a comparable safety profile.</p> Conclusion <p>This meta-analysis supports the non-inferiority of tenecteplase compared to alteplase in LVO-associated AIS regarding efficacy and safety. While tenecteplase offers practical advantages, including single-bolus administration and potentially lower costs, further large-scale randomized controlled trials are needed to confirm these findings and optimize thrombolytic selection in stroke care.</p>

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Alteplase versus tenecteplase in acute ischemic stroke with large vessel occlusion: a systematic review and meta-analysis

  • 期刊论文

  • 发表日期：

    2026年1月17日

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  • Mostafa Hossam El Din Moawad,
  • Ibrahim Serag,
  • Ahmed A. Abo Elnaga,
  • Dina Essam Abo-elnour,
  • Hamza A. Abdul-Hafez,
  • Mohamed Ahmed Hammad,
  • Lobna Ahmed Mohamed,
  • Rawan Kamal Mohamed,
  • Amir N. Attia,
  • Abdelaziz A. Awad,
  • Ibraheem M. Alkhawaldeh,
  • Mahmoud Hegazy,
  • Mohamed Abouzid

摘要

Background

Intravenous thrombolysis remains a cornerstone in acute ischemic stroke (AIS) management, particularly in large vessel occlusion (LVO). While alteplase has long been the standard thrombolytic agent, tenecteplase has emerged as a promising alternative due to its pharmacokinetic advantages. This systematic review and meta-analysis aim to compare the efficacy and safety of tenecteplase versus alteplase in AIS patients with LVO.

Methods

A systematic search was conducted across PubMed, Scopus, Web of Science, Cochrane Library, and Embase until February 2025. Studies comparing tenecteplase and alteplase in AIS patients with LVO were included. The primary outcomes were functional independence at 3 months (modified Rankin Scale [mRS] 0–1 and 0–2), mortality, and symptomatic intracranial hemorrhage (sICH). Secondary outcomes included any bleeding, adverse events, and overall complications. Pooled estimates were calculated using risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI).

Results

A total of 14 studies (N = 9641 patients) were included, comprising 5898 patients receiving alteplase and 3743 receiving tenecteplase. No significant differences were observed in 3-month functional outcomes: mRS 0–1 (RR = 0.92, 95% CI: 0.78 to 1.1, P = 0.38) and mRS 0–2 (RR = 0.95, 95% CI: 0.83 to 1.08, P = 0.44). Mortality rates were comparable between groups (OR = 1.07, 95% CI: 0.88–1.30). No significant differences were found in intracranial hemorrhage (ICH) (OR = 1.25, 95% CI: 0.96–1.62), sICH (OR = 1.1, 95% CI: 0.91–1.33), or any bleeding (OR = 1.19, 95% CI: 0.9–1.57). The pooled OR for adverse events was 0.79 (95% CI: 0.53 to 1.17), indicating a comparable safety profile.

Conclusion

This meta-analysis supports the non-inferiority of tenecteplase compared to alteplase in LVO-associated AIS regarding efficacy and safety. While tenecteplase offers practical advantages, including single-bolus administration and potentially lower costs, further large-scale randomized controlled trials are needed to confirm these findings and optimize thrombolytic selection in stroke care.