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Original research
Tenecteplase versus alteplase before mechanical thrombectomy: experience from a US healthcare system undergoing a system-wide transition of primary thrombolytic
  1. Philipp Hendrix1,2,3,
  2. Malie K Collins4,
  3. Christoph J Griessenauer5,
  4. Oded Goren1,
  5. Itay Melamed2,
  6. Gregory M Weiner2,
  7. Shamsher S Dalal1,
  8. Matthew J Kole1,
  9. Anthony Noto6,
  10. Clemens M Schirmer1,2
  1. 1 Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA
  2. 2 Department of Neurosurgery, Geisinger Health System, Wilkes-Barre, Pennsylvania, USA
  3. 3 Department of Neurosurgery, Saarland University Medical Center, Homburg, Germany
  4. 4 Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
  5. 5 Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
  6. 6 Department of Neurology, Geisinger Health System, Danville, Pennsylvania, USA
  1. Correspondence to Dr Philipp Hendrix, Department of Neurosurgery, Geisinger, Danville, PA 17821, USA; hendrix.philipp{at}


Background Tenecteplase (TNK) is a genetically modified variant of alteplase (TPA) and has been established as a non-inferior alternative to TPA in acute ischemic stroke (AIS). Whether TNK exerts distinct benefits in large vessel occlusion (LVO) AIS is still being investigated.

Objective To describe our first-year experience after a healthcare system-wide transition from TPA to TNK as the primary thrombolytic.

Methods Patients with AIS who received intravenous thrombolytics between January 2020 and August 2022 were retrospectively reviewed. All patients with LVO considered for mechanical thrombectomy (MT) were included in this analysis. Spontaneous recanalization (SR) after TNK/TPA was a composite variable of reperfusion >50% of the target vessel territory on cerebral angiography or rapid, significant neurological recovery averting MT. Propensity score matching (PSM) was performed to compare SR rates between TNK and TPA.

Results A total of 148 patients were identified; 51/148 (34.5%) received TNK and 97/148 (65.5%) TPA. The middle cerebral arteries M1 (60.8%) and M2 (29.7%) were the most frequent occlusion sites. Baseline demographics were comparable between TNK and TPA groups. Spontaneous recanalization was significantly more frequently observed in the TNK than in the TPA groups (unmatched: 23.5% vs 10.3%, P=0.032). PSM substantiated the observed SR rates (20% vs 10%). Symptomatic intracranial hemorrhage, 90-day mortality, and functional outcomes were similar.

Conclusions The preliminary experience from a real-world setting demonstrates the effectiveness and safety of TNK before MT. The higher spontaneous recanalization rates with TNK are striking. Additional studies are required to investigate whether TNK is superior to TPA in LVO AIS.

  • Stroke
  • Thrombolysis

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Twitter @PhilippHendrix, @malie_collins, @cgriessenauer, @oded_goren, @shamsherdalal, @ClemensSchirmer

  • Contributors PH, CS: conception of the work; PH: design of the work; PH, MKC, CJG: data collection; PH, CS: interpretation; PH: drafting of the article and final approval of the version to be published. All authors: data interpretation and critically revising of the article, final approval of the version to be published. PH: responsible for the overall content as guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.