Abstract Body: Introduction: Outcomes after thrombolysis with alteplase (tPA) versus tenecteplase (TNK) prior to endovascular thrombectomy (EVT) have not been directly compared in real-world data (RWD). We leveraged systematic analysis for RWD from 2 major academic stroke centers that solely used tPA or TNK prior to EVT over a 4-year period to determine potential differences in recanalization, reperfusion and clinical outcomes.

Methods: A retrospective, cohort, multicenter study was conducted to investigate outcomes for patients with large vessel occlusions receiving either tPA+EVT or TNK+EVT. tPA was used exclusively for thrombolysis at one center (n=74), while TNK was used exclusively for thrombolysis at another center (n=130). The primary outcome that was measured was functional independence (defined by a modified Rankin score of 0-1) at discharge. Secondary outcomes that were measured include good functional outcomes (defined by a modified Rankin score of 0-2) at discharge and early neurologic improvement (ENI; defined as an improvement in NIH scores by 8 or more in a 24 hour time period). Safety outcomes included symptomatic intracranial hemorrhage (sICH; defined as a worsening of NIH scores by 4 or more with concurrent PH-2 hemorrhagic transformation in a 24 hour time period), any hemorrhagic transformation (HT), and all-cause mortality by discharge.

Results: The rate of functional independence was 25.7% for the tPA+EVT group and 33.8% for the TNK+EVT group (p-value 0.291; RR 1.32 [95% CI 0.55, 3.14]). The rate of good functional outcomes was 35.1% vs 37.7% (p-value 0.831; RR 1.07 [95% CI 0.57, 2.02]). The rate of ENI was 50.0% vs 47.7% (p-value 0.864; RR 0.95 [95% CI 0.63, 1.44]). The rate of sICH was 2.7% vs 0.8% (p-value 0.298; RR 3.51 [95% CI 0.32, 38.1]). The rate of any HT was 32.4% vs 38.4% (p-value 0.45; RR 0.84 [95% CI 0.57, 1.25]). The rate of all cause mortality was 6.8% vs 6.9% (p-value 1.0; RR 0.98 [95% CI 0.34, 2.80]).

Conclusions: Real-world evidence on tPA versus TNK prior to EVT reveals potential equivalence in outcomes after acute ischemic stroke. Detailed analyses (site of arterial occlusion, recanalization and reperfusion effectiveness, and transfer times between hospitals) will be conducted to determine if there are practical advantages in utilizing one thrombolytic over another as an adjunct to EVT in patients with large vessel occlusions in real-world practice.