A comparative review of alteplase and tenecteplase in the management of acute ischaemic stroke
Katie Hallsworth, Richard Clark, Hayley ChouhdryBackground:
Acute ischaemic stroke is a major cause of mortality and long-term disability worldwide. Intravenous alteplase has long been the standard thrombolytic therapy; however, tenecteplase has emerged as a promising alternative because of its pharmacokinetic advantages and simplified administration.
Objective:
To critically evaluate the efficacy and safety of tenecteplase compared to alteplase in the treatment of acute ischaemic stroke, with a focus on functional outcomes and risk of symptomatic intracranial haemorrhage.
Methods:
A structured narrative review of 10 randomised controlled trials involving adult patients with acute ischaemic stroke was conducted. The primary outcomes were functional independence at 90 days, measured by the modified Rankin Scale (0–1) and the incidence of symptomatic intracranial haemorrhage within 36 hours. Studies included comparisons of standard-dose alteplase (0.9 mg/kg) with varying doses of tenecteplase, most commonly 0.25 mg/kg.
Results:
Across the included trials, tenecteplase at 0.25 mg/kg demonstrated comparable and in some studies superior, efficacy to alteplase in achieving good functional outcomes. The incidence of symptomatic intracranial haemorrhage was similar between groups, with no significant increase observed with tenecteplase. Higher doses (0.4 mg/kg) were associated with increased bleeding risk and poorer outcomes.
Conclusions:
Tenecteplase at 0.25 mg/kg is a safe and effective alternative to alteplase for acute ischaemic stroke thrombolysis. Its single-bolus administration and cost-effectiveness offer additional advantages, particularly in pre-hospital or resource-limited settings. Further large-scale blinded trials are warranted to confirm these findings and guide clinical practice.