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Clinical Question

Tenecteplase or alteplase?

Synthesises 12 trialshead-to-head IVT comparisons across geographies, dose, and time-window extensions

What does the guideline say?

The trials cited in the guideline's supportive text appear below.

Trials in this question· 12

NOR-TEST2017
Tenecteplase 0.4 mg/kg in predominantly mild stroke shows no benefit; cohort too mild to detect.
NSOR 1.08 (NS)
EXTEND-IA TNK2018
TNK 0.25 mg/kg achieves more reperfusion before EVT than alteplase 0.9 mg/kg in LVO patients within 4.5h.
Superior22% vs 10% reperfusion
AcT2022
Tenecteplase 0.25 mg/kg non-inferior to alteplase in routine IVT within 4.5 h.
NI metRD +2.1%
NOR-TEST 2 (Part A)2022
Tenecteplase 0.4 mg/kg in moderate-severe stroke caused 6× more sICH and 3× more deaths vs alteplase.
HarmOR 0.45 mRS 0–1
TASTE2024
Tenecteplase in perfusion-selected early-window stroke met per-protocol NI; ITT borderline.
NI (PP)RD +3%
TWIST2023
Non-contrast CT-only selection of wake-up stroke for tenecteplase failed to show benefit.
NeutralOR 1.18
ATTEST-22024
Tenecteplase 0.25 mg/kg noninferior to alteplase in standard-window IVT (UK).
NI metOR 1.07
TRACE-22023
Tenecteplase 0.25 mg/kg non-inferior to alteplase in EVT-ineligible standard-window stroke (sICH 2% both arms).
NI metRR 1.07
ORIGINAL2024
Tenecteplase 0.25 mg/kg noninferior to alteplase within 4.5 h (mRS 0–1 72.7% vs 70.3%).
NI metRR 1.03 (0.97–1.09)
TIMELESS2024
IV tenecteplase 4.5–24 h with perfusion mismatch did not improve mRS shift; not a verdict against late IVT broadly.
NeutralOR 1.13
TRACE-III2024
IV tenecteplase 4.5–24 h with perfusion mismatch in EVT-ineligible LVO improves mRS 0–1 at 90 d.
NNT 11+8.8% mRS 0–1
RAISE2024
Reteplase superior to alteplase for mRS 0–1 at 90 d (79.5% vs 70.4%; P=0.002).
NNT 11RR 1.13

Related questions

When can I give tPA?

0–3 h classic window through imaging-selected extended window

Perfusion imaging or non-contrast CT for late-window selection?

evolution from CT-perfusion / MRI mismatch (DAWN, DEFUSE-3) to plain-CT and MRI ASPECTS selection (RESCUE-Japan LIMIT, LASTE, SELECT2, ANGEL-ASPECT)

Minor non-disabling stroke. Alteplase, DAPT, or aspirin?

the trade-off between thrombolysis benefit, DAPT noninferiority, and aspirin baseline in mild stroke

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