Intravenous tenecteplase is associated with a higher incidence of thrombus movement before endovascular treatment for acute ischemic stroke: a secondary analysis of the AcT randomized controlled trial
Clinical Snapshot
PICO Framework
| P — Population | Patients with acute ischemic stroke and intracranial occlusion on baseline CT angiography undergoing endovascular treatment (n=496, median age 73 years, 50.8% female) |
| I — Intervention | Intravenous tenecteplase 0.25 mg/kg |
| C — Comparator | Intravenous alteplase 0.9 mg/kg |
| O — Outcomes | Primary: thrombus movement patterns (no movement, thrombus extension, thrombus migration, recanalization). Secondary: 90-day modified Rankin Scale 0-2, final extended TICI 2b-3 |
Bottom Line
This secondary analysis of the AcT trial demonstrates that tenecteplase causes nearly twice the rate of thrombus migration compared to alteplase before endovascular treatment (19.4% vs 11.5%). Importantly, thrombus migration was associated with better 90-day functional outcomes, suggesting this represents beneficial clot fragmentation rather than harmful embolisation. The finding supports tenecteplase use in bridging therapy, as the increased thrombus mobility may facilitate endovascular retrieval and improve patient outcomes. However, final reperfusion rates were similar between agents. Australian stroke physicians should consider these mechanistic insights when choosing between thrombolytic agents, particularly given tenecteplase's practical advantages including single bolus administration and recent PBS approval for stroke.
Key Findings
P Value: Not explicitly stated but CI excludes 1.0
Effect Size: Adjusted OR 1.83 for thrombus migration with tenecteplase
Primary Outcome: Thrombus migration rate: tenecteplase 19.4% vs alteplase 11.5%
Nnt Or Sensitivity: Number needed to treat: approximately 13 patients to cause one additional thrombus migration
Confidence Interval: 95% CI 1.10 to 3.07
Clinical Application
Highly feasible - both agents available in Australian comprehensive stroke centres Relevant to Australian stroke networks; tenecteplase increasingly adopted per recent ACSQHC guidelines and PBS listing for stroke indication Acute ischemic stroke patients with large vessel occlusion eligible for combined IV thrombolysis and endovascular treatment
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.
References
- 1.Alhabli, I., Ishaque, N., Kate, M., Alrohimi, A., Singh, N., Benali, F., Horn, M., Buck, B., Ademola, A., Khosravani, H., Appireddy, R., Moreau, F., Gubitz, G., Tkach, A., Catanese, L., Dowlatshahi, D., Pikula, A., Shankar, J. J., Williams, H., Field, T. S., Zafar, A., Sajobi, T., Swartz, R., Poppe, A. Y., Demchuk, A. M., Menon, B. K., Almekhlafi, M., & Bala, F. (2026). Intravenous tenecteplase is associated with a higher incidence of thrombus movement before endovascular treatment for acute ischemic stroke: a secondary analysis of the AcT randomized controlled trial. Journal of Neurointerventional Surgery. https://doi.org/10.1136/jnis-2025-023336
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