Home›Neurology› Tenecteplase shows higher mRS 0 to 1 rates in distal M3 and beyond occlusions
Tenecteplase shows higher mRS 0 to 1 rates in distal M3 and beyond occlusionsTrial shows tenecteplase may help specific types of stroke
StrokePublished September 2, 2026Study authors: Yogendrakumar Vignan, Phung Justin, Johns Hannah T, Churilov Leonid, Garcia-Esperon Carlos, Sharma G…PubMed ↗DOI ↗Editorial oversight: Dr. Ji-eun Park, MD · Brain, Mind & Pain
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Key Takeaway
Tenecteplase is associated with higher mRS 0-1 rates in distal M3 and beyond occlusions compared to alteplase.
This secondary analysis of a randomized clinical trial evaluated 492 patients presenting within 4.5 hours of symptom onset with perfusion imaging-confirmed stroke and evidence of target mismatch (penumbra/core ratio >1.8 and an absolute difference >15 mL). The study compared tenecteplase to alteplase for patients with various occlusion sites.
For patients with distal (M3 and beyond) occlusions, tenecteplase resulted in an mRS score of 0 to 1 in 62/81 (77%) of patients compared to 59/93 (63%) in the alteplase group (adjusted risk ratio, 1.23; 95% CI, 1.04-1.46). For distal M2 occlusions, tenecteplase showed a numerically higher rate of mRS 0 to 1 (30/46, 65%) compared to alteplase (28/48, 58%), but this did not reach statistical significance (95% CI, 0.84-1.54). For anterior cerebral artery occlusions, tenecteplase showed a numerically higher rate of mRS 0 to 1 (12/21, 57%) compared to alteplase (5/13, 38%), but this also did not reach statistical significance (95% CI, 0.71-3.00).
No treatment differences were observed across all occlusion sites or across ischemic core, penumbra, and core growth rate subgroups. Safety data, including adverse events and tolerability, were not reported. As a secondary analysis, the findings regarding distal M3 and beyond occlusions suggest a potential advantage for tenecteplase in specific distal locations, though results for other specific sites did not reach statistical significance.
How this fits prior evidence
How this fits prior evidence: This finding addresses a gap in the management of specific stroke occlusion types. While prior coverage has addressed prehospital magnesium sulfate, dual antiplatelet therapy for minor stroke, early oral anticoagulants, and post-stroke rehabilitation, this study specifically focuses on the comparison of tenecteplase versus alteplase in patients with perfusion-confirmed mismatch.
Researchers conducted a secondary analysis of a clinical trial involving 492 patients who arrived at a hospital within 4.5 hours of stroke symptoms. The study compared two medications, tenecteplase and alteplase, to see which was more effective for patients with specific types of brain blockages.
The results showed that tenecteplase was associated with a higher rate of favorable outcomes in patients with distal M3 and beyond occlusions. In these specific cases, 77% of patients receiving tenecteplase achieved a good recovery score compared to 63% of those receiving alteplase. Other types of blockages showed some numerical differences, but these were not statistically confirmed.
Because this is a secondary analysis, the findings are not yet definitive for everyday medical practice. While the data shows a link between tenecteplase and better outcomes in certain stroke locations, the results for other areas were not significantly different between the two drugs. Patients should talk to their doctors about these options based on their specific medical needs.
What this means for you:
Tenecteplase showed better results for specific types of stroke blockages in a secondary analysis.
Common questions
What is the difference between tenecteplase and alteplase?
Both are medications used to treat stroke. This study looked at how they performed in patients arriving within 4.5 hours of symptoms. The study found that tenecteplase was associated with a higher proportion of favorable outcomes specifically in patients with distal M3 and beyond occlusions compared to alteplase.
Is tenecteplase better for all types of stroke?
The study did not find a significant difference between the two treatments across all occlusion sites. While tenecteplase showed a higher success rate for distal M3 and beyond occlusions, the results for other areas, like distal M2 or anterior cerebral artery occlusions, did not reach statistical significance.
How many people were involved in this study?
The primary analysis included 492 patients who were part of a larger group of 680 people enrolled in the trial. All patients in the study arrived within 4.5 hours of their stroke symptoms and had specific imaging confirmed by doctors.
BACKGROUND: Tenecteplase has been previously evaluated in large- and medium-sized vessel occlusion subgroups, but its effectiveness in more distal occlusions, particularly those involving the distal middle cerebral artery branches or the anterior cerebral artery and posterior cerebral artery territories, and across varying ischemic core and perfusion profiles, remains uncertain.
METHODS: We performed a secondary analysis of TASTE (Tenecteplase Versus Alteplase for Stroke Thrombolysis Evaluation), a randomized clinical trial comparing tenecteplase and alteplase in patients presenting within 4.5 hours of symptom onset with perfusion imaging-confirmed stroke and evidence of target mismatch (penumbra/core ratio >1.8 and an absolute difference >15 mL). The primary outcome was the modified Rankin Scale (mRS) score of 0 to 1 at 90 days. We compared the effect of tenecteplase versus alteplase in subgroups based on occlusion site (proximal M2, distal M2, M3 and beyond, anterior cerebral artery, and posterior cerebral artery), ischemic core, core growth rate, and penumbra. The treatment effect of tenecteplase and alteplase was compared stratifying by the subgroup of interest, adjusting for age, baseline National Institutes of Health Stroke Scale score, and premorbid mRS score in modified Poisson regression models.
RESULTS: Of the 680 patients enrolled, 492 were included in the primary analysis (median age, 73 [interquartile range, 63-82] years; male sex: 306/492 [62%]). Two hundred forty-two (49%) received tenecteplase, and 250 (51%) received alteplase. Tenecteplase was associated with a higher proportion of mRS score of 0 to 1 with distal (M3 and beyond) occlusions (tenecteplase: 62/81 [77%] versus alteplase: 59/93 [63%]; adjusted risk ratio, 1.23 [95% CI, 1.04-1.46]). Numerically higher rates of mRS score of 0 to 1 were observed with distal M2 (tenecteplase: 30/46 [65%] versus alteplase 28/48 [58%]; adjusted risk ratio, 1.14 [95% CI, 0.84-1.54]) and anterior cerebral artery occlusions (tenecteplase: 12/21 [57%] versus alteplase 5/13 [38%]; adjusted risk ratio, 1.46 [95% CI, 0.71-3.00]). No treatment differences were seen for proximal M2 or posterior cerebral artery occlusions ( across all occlusion sites: 0.89). Across ischemic core, penumbra, and core growth rate subgroups, no difference in treatment effect was observed.
CONCLUSIONS: Patients with distal middle cerebral artery occlusions who are treated with tenecteplase are more likely to achieve an mRS score of 0 to 1 at 90 days than those treated with alteplase.
REGISTRATION: URL: https://www.anzctr.org.au; Unique identifier: ACTRN12613000243718.
