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. 2025 Aug 14:jnis-2025-023336.
doi: 10.1136/jnis-2025-023336. Online ahead of print.

Intravenous tenecteplase is associated with a higher incidence of thrombus movement before endovascular treatment for acute ischemic stroke: a secondary analysis of the AcT randomized controlled trial

Ibrahim Alhabli  1 , Noman Ishaque  2 , Mahesh Kate  2 , Anas Alrohimi  3 , Nishita Singh  4 , Faysal Benali  5 , MacKenzie Horn  1 , Brian Buck  3 , Ayoola Ademola  1 , Houman Khosravani  6 , Ramana Appireddy  7 , Francois Moreau  8 , Gordon Gubitz  9 , Aleksander Tkach  10 , Luciana Catanese  11 , Dariush Dowlatshahi  12 , Aleksandra Pikula  13 , Jai J Shankar  14 , Heather Williams  15 , Thalia S Field  16 , Atif Zafar  17 , Tolulope Sajobi  1 , Richard Swartz  6 , Alexandre Y Poppe  18 , Andrew M Demchuk  1 , Bijoy K Menon  1 , Mohammed Almekhlafi  1 , Fouzi Bala  19   20
Affiliations

Intravenous tenecteplase is associated with a higher incidence of thrombus movement before endovascular treatment for acute ischemic stroke: a secondary analysis of the AcT randomized controlled trial

Ibrahim Alhabli et al. J Neurointerv Surg. .

Abstract

Background: Thrombus migration can occur in patients receiving IV thrombolysis for acute stroke. This study compared the effects of IV tenecteplase (0.25 mg/kg) versus alteplase (0.9 mg/kg) on thrombus movement in patients undergoing endovascular treatment (EVT) in the AcT trial.

Methods: Patients with intracranial occlusion on baseline CT angiography (CTA) who underwent EVT were included. Thrombus movement from baseline CTA to first angiographic EVT run was classified as no thrombus movement, thrombus extension (TE, movement to a proximal location on DSA compared with CTA), thrombus migration (TM, movement to a more distal location), or recanalization. Outcomes were 90-day modified Rankin Scale (mRS) score 0-2 and final extended Thrombolysis in Cerebral Infarction score 2b-3. Mixed-effects logistic regression was performed.

Results: Of the 1577 patients in the AcT trial, 496 patients with intracranial occlusions underwent EVT (median age 73 years, 50.8% female). No thrombus movement was seen in 398 patients (80.2%), TE in six (1.2%), TM in 77 (15.5%), and complete recanalization in 15 (3.0%). Tenecteplase recipients (n=252) had higher TM rates than alteplase recipients (19.4% vs 11.5%, adjusted OR (aOR) 1.83, 95% CI 1.10 to 3.07). TM did not impact final successful reperfusion (aOR 0.76, 95% CI 0.40 to 1.38) but was associated with increased odds of 90-day mRS 0-2 (aOR 1.77, 95% CI 1.05 to 3.06). Thrombolytic type did not affect the relationship between thrombus movement and study outcomes (P>0.05).

Conclusion: IV tenecteplase is associated with higher thrombus migration rates before EVT compared with alteplase, which is linked to better functional outcomes. However, the type of thrombolytic agent did not affect final reperfusion and functional outcomes.

Keywords: Stroke; Thrombectomy; Thrombolysis.

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Conflict of interest statement

Competing interests: LC received payments from Servier and consulting fees from Ischaemavie RAPID, Circle NV and CMPA. JS has a grant from Medtronic to the University of Manitoba. TS has received consulting fees from Circle NVI. RHS has stock options in Follow-MD Inc and salary support for research from the Heart & Stroke Foundation of Canada, Sandra Black Centre for Brain Resilience & Recovery and Ontario Brain Institute. TSF received consulting fees from Roche Canada and is on the board of DESTINE Health. BKM has stock options in Circle NVI and consulted for Biogen and Boehringer Ingelheim. The other authors have no competing interests to disclose.

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