Tenecteplase versus alteplase in acute ischemic stroke: systematic review and meta-analysis

Tenecteplase is a product of genetic modification of recombinant tissue plasminogen activator with superior pharmacodynamic and pharmacokinetic properties. This meta-analysis was to determine whether intravenous thrombolysis with tenecteplase in patients with acute ischemic stroke has better efficacy and safety outcomes than with intravenous alteplase. PubMed, Cochrane Central Register of Controlled Trials, WHO International clinical trials registry platform (ICTRP), Australian New Zealand Clinical Trials Registry (ANZCTR), EU Clinical Trials Register (EU-CTR) and ClinicalTrials.gov were searched for trials comparing tenecteplase with alteplase in acute ischemic stroke. Functional outcomes (modified Rankin Scale at 90 days), early major neurological improvement, rates of any intracerebral haemorrhage, symptomatic intracerebral haemorrhage and mortality rate at 90 days were the outcomes compared. Four randomized controlled trials involving 1334 patients were included. The Tenecteplase group compared to the alteplase group had significantly better early major neurological improvement (RR = 1.56, 95% CI [1.00, 2.43], p = 0.05). There was no significant difference between tenecteplase and alteplase in excellent functional outcome at 90 days, good functional outcome at 90 days, any intracerebral haemorrhage, symptomatic intracerebral haemorrhage or mortality at 90 days. Our meta-analysis found tenecteplase to be significantly favouring one outcome: early major neurological improvement. Other outcomes did not differ between the tenecteplase and alteplase groups. Trials of cost-effective/benefit analysis comparing tenecteplase versus alteplase and tenecteplase versus endovascular treatment are necessary to reinforce the evidence for the potential cost advantage of tenecteplase.