Tenecteplase vs. Alteplase before Endovascular Thrombectomy for Acute Ischemic Stroke in Elderly Patients: A Multicenter Propensity Score-Matched Analysis.

Authors

Luca Scarcia, Hilde Henon, Gaspard Gerschenfeld, François-Xavier Laborne, Sonia Alamowitch, Jildaz Caroff, Stéphane Olindo, Gaultier Marnat, Fernando Pico, Wagih Ben Hassen, Pierre Seners, Michel Piotin, Erwah Kalsoum, Alexandra Maury, Frédéric Clarençon, Didier Smadja, Charlotte Cordonnier, Nicolas Chausson, TETRIS collaborators

Published in

AJNR. American journal of neuroradiology. Aug 12, 2026. Epub Aug 12, 2026.

Abstract

Comparative data on tenecteplase versus alteplase in patients aged ≥80 years undergoing bridging therapy before thrombectomy are limited.
We retrospectively analyzed two prospective cohorts of patients aged ≥80 years with anterior circulation large-vessel occlusion treated with bridging intravenous thrombolysis: the multicenter TETRIS registry (tenecteplase) and a single comprehensive stroke center (alteplase). Propensity score matching (1:1, 11 covariates, caliper 0.2 SD logit) was performed, with overlap weighting as sensitivity analysis; matched dichotomous outcomes were analyzed by conditional logistic regression and generalized estimating equations clustered on the matched pair. Because treatment was completely confounded with center and data source, analyses compare cohorts rather than isolate a drug effect. The primary outcome was modified Rankin Scale (mRS) ≤3 at 90 days. Secondary outcomes included substantial early neurological improvement (ENI: ≥8-point NIHSS improvement or NIHSS ≤1 at 24 h), complete early neurological recovery (NIHSS = 0 at 24 h), early reperfusion (eTICI 2b-3), symptomatic intracranial hemorrhage (sICH), and 90-day mortality.
Among 720 eligible patients, 278 matched pairs were analyzed. The primary outcome (mRS ≤3) occurred in 48.0% of tenecteplase- versus 43.5% of alteplase-treated patients (OR 1.20, 95% CI 0.86-1.67); an excellent outcome (mRS 0-2: 27.6% vs 27.0%), the ordinal mRS shift (common OR 1.06), early reperfusion (16.9% vs 16.5%), substantial ENI (40.2% vs 34.9%), sICH (3.7% vs 4.4%), and 90-day mortality (30.2% vs 30.2%) did not differ. Complete early neurological recovery (NIHSS = 0 at 24 h) was more frequent with tenecteplase (10.3% vs 2.6%; OR ≈4.3), but this difference was confined to the single NIHSS value 0, reversed at NIHSS = 1, left no trace in any 90-day endpoint, and was nullified by modest unmeasured confounding (E-value for the lower confidence bound ≈2-3).
In patients aged ≥80 years undergoing bridging therapy, tenecteplase and alteplase were associated with similar 90-day functional outcomes and similar safety. An isolated 24-hour complete-recovery signal favoring tenecteplase is hypothesis-generating and vulnerable to ascertainment bias, given complete confounding of treatment with center. Dedicated randomized data in this age group are warranted.

PMID:
42586761
Bibliographic data and abstract were imported from PubMed on 13 Aug 2026.

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