Switching from alteplase to tenecteplase for stroke thrombolysis: short-term effects on treatment metrics and early functional outcomes

Besides its more advantageous pharmacological profile compared to alteplase (rt-PA), increasing evidence suggest a favorable clinical efficacy and safety of tenecteplase (TNK) as alternative thrombolytic agent for the treatment of acute ischemic stroke (AIS). We aimed to analyze the short-term effects of the switch in thrombolytics at our tertiary care stroke center. We performed a retrospective analysis of patients receiving intravenous thrombolysis (IVT) for AIS in the time window < 4.5 h, including patients treated with rt-PA (from January 1st to June 30, 2024) and patients treated with TNK (from July 1st to December 31, 2024). Primary and secondary endpoints were the workflow times and the modified Rankin Scale (mRS) at discharge as the early functional outcome. Safety outcomes included any intracerebral hemorrhage (ICH) on follow-up imaging at 24 h, symptomatic (s)ICH and death by day 7. During the period of 12 months, n = 139 patients received IVT in the 4.5 h time window. Median door to needle (DTN) times were significantly shorter for patients treated with TNK (n = 74) compared to rt-PA (n = 65) (TNK 23 min [IQR 32–17] vs. rt-PA 28 min [IQR 33–22], p = 0.047). Patients undergoing endovascular thrombectomy (EVT) after TNK treatment had significantly shorter door to groin (DTG) times in comparison to treatment with rt-PA prior to EVT (p = 0.002). No significant differences between the groups were found for early functional outcome (p = 0.194 for patients with, p = 0.852 for patients without EVT), the rate of sICH (TNK vs. rt-PA: 17.6 vs. 4.2%, p = 0.290 with EVT and 3.6 vs. 0%, p = 0.507 without EVT) and mortality (TNK vs. rt-PA: 17.6 vs. 4.2%, p = 0.290 with EVT and 7.0 vs. 2.4%, p = 0.393 without EVT). Transition from rt-PA to TNK for AIS treatment < 4.5 h after onset at a tertiary care center seems feasible and resulted in shorter onset to treatment durations. Functional outcomes at discharge were comparable between the groups. Rates of ICH, sICH and mortality were numerically higher in the TNK group. Further data are required to assess the clinical efficacy and safety of TNK after the transition from rt-PA in real-world scenarios.