5th Edition of International Neurology Conference 2026

Abstract

Intravenous alteplase has long been the standard thrombolytic therapy for acute ischemic stroke (AIS). Tenecteplase, a genetically modified variant of alteplase with greater fibrin specificity and a longer half-life, has emerged as an alternative agent with practical and biological advantages. Over the past decade, multiple randomized controlled trials and meta-analyses have demonstrated that tenecteplase administered at a dose of 0.25 mg/kg is non-inferior to alteplase for functional outcomes in AIS patients treated within 4.5 hours of symptom onset, with comparable rates of symptomatic intracerebral hemorrhage and mortality.
Beyond overall non-inferiority, growing evidence suggests that tenecteplase may offer particular advantages in patients with large vessel occlusion (LVO), the stroke subtype responsible for the greatest burden of disability. Randomized trials evaluating tenecteplase prior to mechanical thrombectomy have demonstrated higher rates of early angiographic reperfusion compared with alteplase, without an associated increase in hemorrhagic complications. Observational studies in drip-and-ship populations further suggest that these early reperfusion benefits persist in patients initially treated at non-thrombectomy-capable hospitals, supporting the relevance of tenecteplase across diverse stroke system configurations.
Importantly, additional randomized data indicate that tenecteplase confers clinical benefit in selected patients with LVO who do not undergo thrombectomy, reinforcing the concept that tenecteplase possesses greater thrombolytic potency in this high-risk population. While these findings do not alter established treatment paradigms, they provide biological and clinical support for preferential use of tenecteplase when intravenous thrombolysis is pursued.
Taken together, the evidence demonstrates that tenecteplase is non-inferior to alteplase for AIS overall and offers clinically meaningful advantages in LVO patients through improved early reperfusion. Given that LVO strokes account for a disproportionate share of stroke-related morbidity and that early reperfusion benefits apply regardless of on-site thrombectomy
capability, tenecteplase represents a rational first-line thrombolytic agent for hospitals across the spectrum of stroke care.