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Randomized Controlled Trial
. 2025 Aug 1;46(8):1640-1644.
doi: 10.3174/ajnr.A8763.

Tenecteplase versus Alteplase and First-Pass Reperfusion in Endovascular Thrombectomy

William K Diprose  1   2 , Fouzi Bala  1   3 , Bijoy K Menon  1   4 , Nishita Singh  1   5 , Houman Khosravani  6 , Aleksander Tkach  7 , Ramana Appireddy  8 , MacKenzie Horn  1 , Luciana Catanese  9 , Dar Dowlatshahi  10 , Thalia S Field  11 , Gary Hunter  12 , Tolulope Sajobi  1   4 , Michael D Hill  1   4 , Brian Buck  13 , Richard Swartz  6 , Mohammed Almekhlafi  14   4
Affiliations
Randomized Controlled Trial

Tenecteplase versus Alteplase and First-Pass Reperfusion in Endovascular Thrombectomy

William K Diprose et al. AJNR Am J Neuroradiol. .

Abstract

Background and purpose: It is unknown whether thrombolysis with IV tenecteplase before endovascular thrombectomy (EVT) influences the probability of first-pass reperfusion when compared with IV alteplase. Therefore, we evaluated the effect of IV thrombolytic choice on this outcome.

Materials and methods: We investigated the effects of thrombolytic agent (IV tenecteplase or IV alteplase) on first-pass reperfusion in EVT patients from the Alteplase Compared to Tenecteplase in Patients with Acute Ischemic Stroke (AcT) trial. The primary outcome was first-pass reperfusion, defined as expanded Thrombolysis in Cerebral Infarction (eTICI) score 2c-3 with a single thrombectomy pass. Secondary outcomes were modified first-pass reperfusion (eTICI 2b-3 after 1 pass), final eTICI score, total number of thrombectomy passes, and time from arterial access to successful reperfusion. Univariable models and generalized linear mixed-effects models with a logit link function were constructed.

Results: Among the 506 patients who underwent EVT in the AcT trial, 445 patients were included (230 [51.7%] women; median [interquartile range {IQR}] age, 73 [63-81]). Two hundred twenty-six (50.8%) received IV tenecteplase and 219 patients received IV alteplase (49.2%). First-pass reperfusion and modified first-pass reperfusion was achieved in 169 (38.0%) and 245 (55.1%) patients, respectively. First-pass reperfusion was achieved in 79 (35.0%) IV tenecteplase and 90 (41.1%) IV alteplase patients (P = .20). Modified first-pass reperfusion was achieved in 123 (54.4%) IV tenecteplase and 122 (55.7%) IV alteplase patients (P = .85). Median (IQR) number of passes was 2 (1-3) in the tenecteplase group and 1 (1-2) in the alteplase group (P = .07). Median (IQR) time from arterial access to successful reperfusion was 36 (25-59) minutes and 34 (21-49) minutes in the tenecteplase and alteplase groups, respectively (P = .07). There was no difference in final eTICI 2c-3 scores. There were no significant interactions between sex, occlusion site, thrombus length, residual flow, clot burden score, hyperattenuated artery sign, or first-line thrombectomy technique with thrombolysis type on first-pass reperfusion.

Conclusions: IV thrombolytic agent did not influence the probability of first-pass reperfusion.

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