Tenecteplase Versus Alteplase in Basilar Artery Occlusion Treated with Endovascular Thrombectomy: A Propensity Score–Matched Analysis of 90- and 180-Day Outcomes

<h3>BACKGROUND AND PURPOSE:</h3> Effectiveness of tenecteplase (TNK) versus alteplase as bridging thrombolysis in basilar artery occlusion (BAO) undergoing thrombectomy is uncertain. This study evaluates both drugs in adult patients with BAO undergoing endovascular thrombectomy (EVT). <h3>METHODS:</h3> We performed a retrospective cohort study using the TriNetX Research Network (113 healthcare organizations). Adults (≥18 years) with BAO stroke treated with intravenous thrombolysis plus EVT between 2016 and 2025 were identified using ICD-10-CM/PCS and RxNorm codes; documented NIHSS coding was required. Propensity score matching (1:1 nearest-neighbor greedy, without replacement, caliper 0.10 SD of the logit) adjusted for demographics, comorbidities, stroke severity categories, presenting neurologic symptoms, etiology proxies, relevant procedures, and antithrombotic medications. Outcomes at 90 and 180 days included major bleeding, intracranial hemorrhage (ICH), all-cause mortality, functional dependency (code-based proxy), emergency department visits for critical illness, and rehabilitation needs (code-based utilization). A prespecified sensitivity analysis was restricted to NIHSS ≥10. Bonferroni correction was performed to adjust for multiple testing. <h3>RESULTS:</h3> Among 553 patients (TNK 193; alteplase 360), matching produced 167 pairs for 90-day and 168 pairs for 180-day analyses with adequate covariate balance (post-match SMDs &lt;0.10 except altered mental status [0.10]). At 90 days (matched), rehabilitation needs were nominally higher with TNK (59.88% vs 46.11%; HR 1.48, 95% CI 1.10–2.00; raw P=0.007), but did not survive Bonferroni correction (adjusted P=0.08). There were no significant differences in major bleeding (HR 0.91, P=0.73), ICH (HR 0.98, P=0.95), mortality (HR 0.96, P=0.83), functional dependency (HR 1.05, P=0.81), or critical illness ED visits (HR 1.10, P=0.46). At 180 days (matched), findings were similar (rehabilitation: HR 1.48, raw P=0.007, adjusted P=0.08; all other outcomes non-significant). In the prespecified NIHSS ≥10 subgroup (110 matched pairs), no outcome differed between TNK and alteplase at either timepoint (rehabilitation 90-day: HR 1.06, P=0.74). <h3>CONCLUSIONS:</h3> Tenecteplase and alteplase demonstrated comparable safety, mortality, and functional outcomes through 180 days in BAO treated with bridging thrombolysis and EVT. A nominally higher rehabilitation utilization signal with tenecteplase did not survive multiple-testing correction and was not preserved in the NIHSS ≥10 subgroup, suggesting survivor bias, temporal confounding, and coding-based ascertainment rather than a true therapeutic difference.