Tenecteplase versus alteplase as bridging therapy before endovascular treatment in acute ischemic stroke due to Basilar artery occlusion: a systematic review and meta-analysis

BACKGROUND: Basilar artery occlusion (BAO) is a highly morbid form of acute ischemic stroke, and evidence guiding the optimal intravenous thrombolytic agent before endovascular treatment (EVT) remains limited; this systematic review and meta-analysis compared the efficacy and safety of tenecteplase versus alteplase as bridging therapy exclusively in BAO. METHODS: PubMed, Embase, and the Cochrane Library were systematically searched through 8 December 2025. Randomized controlled trials and observational studies directly comparing tenecteplase with alteplase as intravenous bridging therapy prior to EVT in adult patients with imaging-confirmed BAO treated within ≤ 4.5 hours of symptom onset were included. Primary outcomes were early reperfusion before EVT and final reperfusion after EVT (eTICI 2b-3). Secondary outcomes included functional outcomes at 90 days (modified Rankin Scale [mRS] 0-3, 0-2, and 0-1), symptomatic intracranial hemorrhage, parenchymal hematoma, any intracranial hemorrhage, and mortality. Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using random-effects models. RESULTS: Six studies including 381 patients treated with tenecteplase and 516 treated with alteplase were analyzed. Tenecteplase was associated with higher early reperfusion before EVT (RR 1.34, 95% CI 1.11-1.64) and a modest increase in final reperfusion after EVT (RR 1.06, 95% CI 1.00-1.11). No significant differences were observed in functional outcomes at 90 days, symptomatic intracranial hemorrhage, parenchymal hematoma, any intracranial hemorrhage, or mortality. CONCLUSION: In BAO, tenecteplase as bridging therapy prior to EVT improves early and final reperfusion without increasing hemorrhagic risk or mortality, with functional outcomes comparable to alteplase, although the current evidence is limited.