Intravenous Thrombolysis With Tenecteplase in Patients With Large Vessel Occlusions

Systematic Review and Meta-Analysis

Aristeidis H. Katsanos, MD; Apostolos Safouris, MD; Amrou Sarraj, MD; Georgios Magoufis, MD; Ronen R. Leker, MD; Pooja Khatri, MD; Charlotte Cordonnier, MD; Didier Leys, MD; Ashkan Shoamanesh, MD; Niaz Ahmed, MD; Andrei V. Alexandrov, MD; Georgios Tsivgoulis, MD


Stroke. 2021;52(1):308-312. 

In This Article


Our literature search is outlined in Figure I in the Data Supplement. After excluding duplicate records (n=47), retrieved records from database search, or full-text articles (n=6) not qualifying our systematic review inclusion and exclusion criteria (Table I in the Data Supplement), we included 4 RCTs including a total of 433 patients (Table II in the Data Supplement).[4,6–8] Risk of other bias was marked as high in 2 publications reporting analyses on subgroups of patients with confirmed LVO randomized within the original RCTs. The risk for performance bias was considered unclear in all RCTs, since neither participants nor treating physicians but only the outcome assessors were blinded to treatment assignment (Figure II in the Data Supplement).

All analyses and quality of summary evidence for each outcome of interest are briefly summarized in the Table. Patients with confirmed LVO receiving tenecteplase had higher odds of successful recanalization (odds ratio, 3.05 [95% CI, 1.73–5.40]; Figure [A]), higher odds of mRS scores of 0 to 2 (odds ratio, 2.06 [95% CI, 1.15–3.69]; Figure [B]), and functional improvement (common odds ratio, 1.84 [95% CI, 1.18–2.87]; Figure [C]) at 3 months compared with patients with confirmed LVO receiving alteplase. There was little or no heterogeneity between the results provided from included studies regarding the aforementioned outcomes (I2≤20%; P for Cochran Q>0.25).


Outcomes of patients with acute large vessel occlusions receiving intravenous tenecteplase compared to intravenous alteplase.
Forest plots on the odds of (A) successful recanalization, (B) modified Rankin Scale score of 0 to 2 at 3 mo, and (C) functional improvement at 3 mo between patients with acute large vessel occlusions randomized to intravenous tenecteplase or alteplase. ATTEST indicates Alteplase-Tenecteplase Trial Evaluation for Stroke Thrombolysis; EXTEND-IA, Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke; IV, inverse variance; and TNK, tenecteplase.

No treatment group differences in the outcomes of early neurological improvement, symptomatic ICH, any ICH, mRS score of 0 to 1, or all-cause mortality (Figures III through VII in the Data Supplement) at 3 months were detected. No evidence of funnel plot asymmetry was uncovered in any of the outcomes with >2 studies included in the meta-analysis (Figures VIII through XIII in the Data Supplement).