Rates of Intracranial and Systemic Complications in Patients with Large Vessel Occlusion Stroke Receiving Alteplase and Tenecteplase Prior to Thrombectomy

Introduction: Intracranial and extracranial hemorrhage as well as systemic complications are known risks of intravenous thrombolysis (IVT). Although the rates are established with alteplase (TPA), there is limited comparative real-world data with Tenecteplase (TNK), particularly in large vessel occlusion stroke (LVOS). This study aimed to compare the rates of complications among LVOS patients who received TNK compared to TPA prior to endovascular treatment (EVT).

Methods: Adult LVOS patients (n=280) who received IVT via TNK (n=181) or TPA (n=99), prior to emergent EVT from 01/2020-05/2024 were retrospectively reviewed. Intracranial hemorrhagic complications were analyzed per Heidelberg Bleeding Classification, and we reported rates of any ICH, parenchymal hematomas types 1 and 2 (PH type 1 and 2), subarachnoid hemorrhage (SAH), and symptomatic ICH (sICH). Systemic complications included access-site hematomas, retroperitoneal hematoma, gastrointestinal bleeding, and angioedema. Comparative statistical analyses were performed (TPA vs TNK).

Results: Of 280 patients, 181 (64.6%) received TNK and 99 (35.4%) received TPA. ICH of any kind was observed in 43.4% of TPA and 38.9% of TNK cases (p=0.524); PH type 1 and 2 occurred in 13.1% of TPA and 12.8% of TNK cases (p=1.000). SAH was noted in 6.1% of TPA and 7.2% of TNK cases (p=0.808), and sICH occurred in 2.0% of TPA and 2.8% of TNK patients (p=1.000). Access-site hematomas were comparable between TNK (9.8%) and TPA cases (6.4%) (p=0.343) as was angioedema with 2.0% of TPA and 1.1% of TNK patients (p=0.616). There were no cases of retroperitoneal hematoma or gastrointestinal bleeding. Multivariable analysis showed no significant association between thrombolytic type and occurrence of any ICH, PH, SAH, or sICH.

Conclusion : Among LVOS patients receiving TNK compared to TPA prior to EVT, similar rates of intracranial hemorrhage and systemic complications were observed, suggesting that both thrombolytics have a comparable safety profile in this subgroup of stroke patients.