Early Recanalization and Thrombus Migration in Large Vessel Occlusion Stroke Referred for Thrombectomy: A Comparison of Tenecteplase vs Alteplase

Introduction: Bridging thrombolysis remains standard of care for large vessel occlusion stroke (LVOS). Thrombolytics promote early recanalization and may lessen the need for endovascular treatment (EVT). However, the effects of alteplase (TPA) and tenecteplase (TNK) on complete versus partial clot dissolution and distal thrombus migration in relation to outcomes are not well understood. This study seeks to compare the efficacy of TPA and TNK in achieving early recanalization endpoints in LVOS patients.

Methods: This retrospective review included 280 consecutive LVOS patients treated with intravenous thrombolysis (TPA or TNK) and referred for EVT 01/2020 – 05/2024. Early recanalization endpoints were defined as: (1) neurological improvement precluding EVT, (2) eTICI 2b-3 on initial cerebral angiography, and (3) distal thrombus migration compared to initial CT angiography, with or without the need for thrombectomy.

Results: Of the 280 patients, 181 received TNK (64.6%) and 99 received TPA (35.4%). The most common occlusion sites were the M1 segment of the middle cerebral artery (46.4%), M2 segment (24.3%), and tandem ICA/MCA occlusion (15.7%). Any recanalization endpoint was achieved in 42/181 TNK (23.2%) versus 11/99 TPA cases (11.1%) (p=0.016). Neurological improvement precluded EVT in 4.4% of TNK versus 3.0% of TPA cases (p=0.752). Initial cerebral angiography showed eTICI 2b-3, leading to procedure termination, in 7.7% of TNK and 6.1% of TPA cases (p=0.603). Partial recanalization requiring mechanical thrombectomy occurred in 11% of TNK and 2% of TPA cases (p=0.009). Overall, partial recanalization was achieved in 17.3% of TNK versus 7.3% of TPA cases (p=0.026). Multivariable analysis identified lower baseline NIHSS and TNK administration as independent predictors of early recanalization.

Conclusion : In LVOS patients, thrombolysis with TNK is associated with higher rates of early recanalization compared to alteplase, primarily through partial recanalization and distal thrombus migration. The impact of these findings on functional outcomes warrants further investigation.