ABSTRACT NUMBER: ESOC2026A195 ACUTE STROKE REPERFUSION THERAPY WITH ALTEPLASE AND TENECTEPLASE: NEUROLOGICAL OUTCOMES, SINGLE-CENTRE REAL-WORLD ANALYSIS

Abstract Background and aims Tenecteplase is increasingly being used as an alternative to alteplase for intravenous thrombolysis in acute ischemic stroke, although comparative data across specific stroke etiologies remain limited. Prior trials demonstrate overall non-inferiority, but etiology-specific treatment effects have not been systematically explored. We aimed to determine whether clinical outcomes and early neurological recovery differ between tenecteplase and alteplase when stratified by cerebral infarct etiology. Methods We analyzed 500 consecutive patients treated with intravenous thrombolysis in a tertiary stroke centre: tenecteplase, n=79; alteplase, n=421. Stroke etiology was classified as cardioembolic, atherothrombotic, cryptogenic, lacunar, concurative, or other definite origin. Outcome measures were mortality and complication rate, NIH Stroke Scale (NIHSS), and modified Rankin Scale (mRS) difference before and after therapy. Comparisons were made in general and within the etiological subgroups. Results Overall mortality was similar between tenecteplase and alteplase (12.7% vs 9.5%; p=0.41), with no significant differences in any etiology. Tenecteplase yielded greater overall early neurological improvement (median NIHSS difference 7 vs 3; p<0.001). Etiology-stratified analysis demonstrated a marked tenecteplase advantage in cardioembolic (8.0 vs 3.0; p<0.001), cryptogenic (5.0 vs 3.0; p=0.025), and atherothrombotic strokes (4.0 vs 2.5; p=0.049). Other etiologies showed non-significant trends favoring tenecteplase. mRS difference did not differ between agents. Complication rates were comparable overall (19.0% vs 12.1%; p=0.14) and within all etiological groups. Conclusions This study provides etiology-stratified comparisons of tenecteplase and alteplase. Tenecteplase may preferentially enhance early neurological recovery in cardioembolic, cryptogenic, and atherothrombotic stroke without compromising safety. Conflict of interest Dr.Anastasija Solodjankina: nothing to disclose. Prof.Guntis Karelis: nothing to disclose