ABSTRACT NUMBER: ESOC2026YS266 TENECTEPLASE THROMBOLYSIS BEYOND 4.5 HOURS: REAL-WORLD DATA IN ISCHEMIC STROKE WITH AND WITHOUT LARGE-VESSEL OCCLUSIONS

Abstract Background and aims Current guidelines recommend intravenous thrombolysis (IVT) with tenecteplase (TNK) for patients with acute ischaemic stroke (AIS) due to large vessel occlusion (LVO) within 4.5 h from onset1. However, a substantial proportion of patients present beyond this time window. The use of TNK in extended window has been investigated mainly in selected LVO stroke; comparative data with alteplase remain limited2,3. Methods We conduct a single-center retrospective observational study on prospectively collected data, including AIS patients receiving IVT, with or without thrombectomy (EVT), 4.5 to 24 hours after onset/last known well (LKW), from 01/01/2020 to 01/01/2027. Patients with and without LVOs, with salvageable brain tissue, are included. Descriptive analyses are first reported. Patients receiving alteplase and TNK are compared using propensity score matching. Efficacy endpoints include mRS 0-2 at 90 days, early recanalization rate. Safety endpoints include symptomatic intracerebral hemorrhage (sICH), mortality. Subgroup analyses are conducted according to perfusion imaging parameters, emergent carotid stenting, LVOs presence/absence. Results 23 patients presenting beyond 4.5 hours were included until 31/12/2025, with mean time from onset/LKW 467 hours (+/-197), median NIHSS 14 (IQR 8-25). Salvageable brain tissue was estimated by CT perfusion in 16 patients. Median CBF<30% volume was 0mL (IQR 0-75), median mismatch volume 93mL (IQR 56-264), median ASPECTS 10. Twelve patients underwent bridging EVT, due to occlusion in M1 (n=8), P1 (n=1), tandem carotid-M1 occlusion (n=3). Early recanalization was achieved in 4 cases, including two M1 in tandem-occlusions. Median NIHSS at 24 hours was 4 (IQR 3-23). No sICH occurred. Conflict of interest nothing to disclose