Objective:

To indirectly compare the efficacy and safety of intra-arterial Tenecteplase (TNK) versus Alteplase following Mechanical Thrombectomy (MT) in Acute Ischemic Stroke (AIS).

Background:

Incomplete reperfusion after mechanical thrombectomy (MT) for acute ischemic stroke (AIS) limits recovery. Adjunctive intra-arterial thrombolysis (IAT) is increasingly used to improve microvascular reperfusion.

Design/Methods:

A systematic review of PubMed, Embase, Scopus, and ClinicalTrials.gov identified randomized controlled trials (RCTs) in adults with AIS undergoing MT with or without adjunctive IAT. Trials comparing TNK or alteplase versus MT alone and reporting 90-day modified Rankin Scale (mRS 0–1), symptomatic intracranial hemorrhage (sICH), or mortality were included. Direct TNK–alteplase comparisons were excluded. Log risk ratios were calculated, and indirect comparisons were performed using the Bucher method, with MT alone as the common comparator. Analyses were conducted using JASP 0.95.

Results:

Five RCTs met inclusion criteria—three TNK+MT and two alteplase+MT. Indirect comparison showed no significant difference in excellent functional outcome at 90 days (RR 0.82; 95% CI 0.62–1.08). The risk of sICH was higher with TNK but not statistically significant (RR 1.84; 95% CI 0.69–4.93). Ninety-day mortality was lower with TNK without statistical significance (RR 0.81; 95% CI 0.47–1.42).

Conclusions:

Indirect comparison suggests similar efficacy and safety between TNK and alteplase as adjunctive intra-arterial therapy post-MT. Either agent may be appropriate, but direct comparative RCTs are needed to determine the optimal strategy.