Functional Outcome, Recanalization, and Hemorrhage Rates After Large Vessel Occlusion Stroke Treated With Tenecteplase Before Thrombectomy

Background and Objectives To investigate in routine care the efficacy and safety of IV thrombolysis (IVT) with tenecteplase prior to mechanical thrombectomy (MT) in patients with large vessel occlusion acute ischemic strokes (LVO-AIS), either secondarily transferred after IVT or directly admitted to a comprehensive stroke center (CSC). Methods We retrospectively analyzed clinical and procedural data of patients treated with 0.25 mg/kg tenecteplase within 270 minutes of LVO-AIS who underwent brain angiography. The main outcome was 3-month functional independence (modified Rankin Scale score ≤2). Recanalization (revised Treatment in Cerebral Ischemia score 2b–3) was evaluated before (pre-MT) and after MT (final). Results We included 588 patients (median age 75 years [interquartile range (IQR) 61–84]; 315 women [54%]; median NIH Stroke Scale score 16 [IQR 10–20]), of whom 520 (88%) were secondarily transferred after IVT. Functional independence occurred in 47% (n = 269/570; 95% confidence interval [CI] 43.0–51.4) of patients. Pre-MT recanalization occurred in 120 patients (20.4%; 95% CI 17.2–23.9), at a similar rate across treatment paradigms (direct admission, n = 14/68 [20.6%]; secondary transfer, n = 106/520 [20.4%]; p > 0.99) despite a shorter median IVT to puncture time in directly admitted patients (38 [IQR 23–55] vs 86 [IQR 70–110] minutes; p < 0.001). Final recanalization was achieved in 492 patients (83.7%; 95%CI 80.4–86.6). Symptomatic intracerebral hemorrhage occurred in 2.5% of patients (n = 14/567; 95% CI 1.4–4.1). Discussions Tenecteplase before MT is safe, effective, and achieves a fast recanalization in everyday practice in patients secondarily transferred or directly admitted to a CSC, in line with published results. These findings should encourage its wider use in bridging therapy. Classification of Evidence This study provides Class IV evidence that tenecteplase within 270 minutes of LVO-AIS increases the probability of functional independence.