Comparative Effectiveness of Intravenous Tenecteplase versus Alteplase in Posterior Circulation Ischemic Stroke: A Systematic Review and Meta‐Analysis

Abstract

ABSTRACT Background Posterior circulation ischemic stroke (PCIS) is associated with substantial morbidity and mortality, and the optimal intravenous thrombolytic strategy in this subgroup remains unclear. Methods We searched databases for studies comparing intravenous tenecteplase with alteplase in adults with PCIS. The primary outcome was functional independence at 90 days (mRS 0–2). Secondary outcomes included other functional outcomes, reperfusion, hemorrhagic complications, and mortality. Results Five studies involving 997 patients were included. Regarding efficacy outcomes, tenecteplase was associated with a significantly greater likelihood of achieving an ambulatory functional outcome at 90 days (mRS 0–3) [RR 1.29, 95% CI 1.03–1.60; p = 0.02] and improved pre‐EVT perfusion [RR 2.18, 95% CI 1.06–4.46; p = 0.03]. No significant differences were observed for excellent functional outcome (mRS 0–1) [RR 1.19, 95% CI 0.91–1.56; p = 0.20], functional independence (mRS 0–2) [RR 1.10, 95% CI 0.89–1.37; p = 0.39], or post‐EVT perfusion [RR 1.12, 95% CI 0.89–1.40; p = 0.34]. Regarding safety outcomes, no significant differences were observed between tenecteplase and alteplase for symptomatic intracranial hemorrhage (sICH) [RR 0.89, 95% CI 0.36–2.22; p = 0.81], any intracranial hemorrhage [RR 1.02, 95% CI 0.59–1.78; p = 0.94], parenchymal hematoma [RR 0.76, 95% CI 0.24–2.38; p = 0.64], or 90‐day mortality [RR 0.88, 95% CI 0.66–1.17; p = 0.39]. Conclusion Tenecteplase may improve reperfusion and ambulatory recovery without increasing hemorrhagic complications or mortality compared with alteplase in PCIS, although larger PCIS‐specific studies are needed.