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Tenecteplase linked to higher thrombus migration than alteplase in acute ischemic stroke with EVTTenecteplase linked to more clot movement than alteplase in stroke patients

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Key Takeaway
Consider that tenecteplase may be associated with higher thrombus migration than alteplase in stroke patients undergoing EVT.

This was a secondary analysis of the AcT trial, focusing on 496 patients with acute ischemic stroke and intracranial occlusion who underwent endovascular treatment. Patients received either IV tenecteplase (0.25 mg/kg) or alteplase (0.9 mg/kg) before the procedure. The primary outcome was a 90-day modified Rankin Scale score of 0-2.

Thrombus migration rates were higher with tenecteplase (19.4%) than with alteplase (11.5%), with an adjusted odds ratio (aOR) of 1.83 (95% CI 1.10 to 3.07). Thrombus migration did not impact final successful reperfusion (aOR 0.76, 95% CI 0.40 to 1.38). However, thrombus migration was associated with increased odds of a good 90-day functional outcome (aOR 1.77, 95% CI 1.05 to 3.06).

Safety data, including adverse events and discontinuations, were not reported. The study was observational in nature, and causality cannot be inferred. Limitations were not detailed in the provided evidence.

These findings suggest a potential association between tenecteplase and thrombus migration, but the clinical significance remains uncertain. Practice relevance was not reported.

A study looked at two clot-busting drugs, tenecteplase and alteplase, for stroke patients with blocked brain arteries. Patients got one drug before a procedure to remove the clot. Researchers checked if the clot moved during treatment and how patients recovered after 90 days.

They found that patients getting tenecteplase had a higher rate of clot movement compared to those getting alteplase. About 19% of tenecteplase patients saw clot movement, versus about 12% with alteplase. This means tenecteplase was about 80% more likely to cause clot movement.

Clot movement was linked to a higher chance of good recovery. Patients with clot movement had about a 77% higher odds of a good outcome (like walking or living independently) after 90 days. However, clot movement did not affect the final success of the clot removal procedure.

The study did not report on side effects or safety issues. It was a smaller group from a larger trial, so more research is needed. The findings suggest tenecteplase may help move clots more effectively, which could improve recovery chances for some stroke patients.

What this means for you:
Tenecteplase may increase clot movement and improve recovery odds in stroke patients.

Study Details

Study typeRct
Sample sizen = 252
EvidenceLevel 2
Follow-up876.0 mo
PublishedMay 2026
View Original Abstract ↓
BACKGROUND: Thrombus migration can occur in patients receiving IV thrombolysis for acute stroke. This study compared the effects of IV tenecteplase (0.25 mg/kg) versus alteplase (0.9 mg/kg) on thrombus movement in patients undergoing endovascular treatment (EVT) in the AcT trial. METHODS: Patients with intracranial occlusion on baseline CT angiography (CTA) who underwent EVT were included. Thrombus movement from baseline CTA to first angiographic EVT run was classified as no thrombus movement, thrombus extension (TE, movement to a proximal location on DSA compared with CTA), thrombus migration (TM, movement to a more distal location), or recanalization. Outcomes were 90-day modified Rankin Scale (mRS) score 0-2 and final extended Thrombolysis in Cerebral Infarction score 2b-3. Mixed-effects logistic regression was performed. RESULTS: Of the 1577 patients in the AcT trial, 496 patients with intracranial occlusions underwent EVT (median age 73 years, 50.8% female). No thrombus movement was seen in 398 patients (80.2%), TE in six (1.2%), TM in 77 (15.5%), and complete recanalization in 15 (3.0%). Tenecteplase recipients (n=252) had higher TM rates than alteplase recipients (19.4% vs 11.5%, adjusted OR (aOR) 1.83, 95% CI 1.10 to 3.07). TM did not impact final successful reperfusion (aOR 0.76, 95% CI 0.40 to 1.38) but was associated with increased odds of 90-day mRS 0-2 (aOR 1.77, 95% CI 1.05 to 3.06). Thrombolytic type did not affect the relationship between thrombus movement and study outcomes (P>0.05). CONCLUSION: IV tenecteplase is associated with higher thrombus migration rates before EVT compared with alteplase, which is linked to better functional outcomes. However, the type of thrombolytic agent did not affect final reperfusion and functional outcomes.
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