Comparative Effectiveness of Tenecteplase and Alteplase for Ischemic Stroke: Real-World Data from a Stroke Center

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While Alteplase has long been the standard of care, TNK is now also approved for AIS by both the EMA and FDA. Its single-bolus administration and favorable pharmacokinetics offer practical advantages. Despite growing guideline support, real-world data comparing both agents remain limited. This study aimed to compare clinical characteristics, imaging findings, treatment outcomes, and complication rates of AIS patients treated with TNK versus Alteplase at a single stroke center. Methods: We conducted a retrospective monocentric analysis of 101 AIS patients treated with TNK (n = 39) or Alteplase (n = 62). We compared demographics, vascular risk factors, imaging findings, reperfusion therapies, and clinical outcomes using independent samples t-tests, Chi-square, and Mann–Whitney U-tests as appropriate. Results: Baseline characteristics were comparable between groups, including age (TNK: 72.7 ± 14.4 vs. Alteplase: 70.1 ± 14.3), sex, and pre-stroke mRS. Initial NIHSS scores were similar (TNK: 6.0 ± 6.3 vs. Alteplase: 7.2 ± 8.2, p = 0.83). No significant differences were found in LVO rates (15.4% vs. 27.4%, p = 0.16), perfusion delay, or infarct demarcation. Functional outcomes at discharge (mRS: 2.3 ± 1.8 vs. 2.0 ± 1.9, p = 0.39) and rates of symptomatic intracranial hemorrhage (11.1% vs. 10.3%, p = 0.91) were similar. Conclusion: In this real-world cohort, TNK and Alteplase showed comparable safety and efficacy profiles. Functional outcomes and complication rates did not differ significantly, supporting TNK as a viable alternative to Alteplase in AIS. Acute ischemic stroke Tenecteplase Alteplase intravenous thrombolysis door-to-needle time Figures Figure 1 Figure 2 Introduction In acute ischemic stroke (AIS), a leading cause of death and disability worldwide, timely reperfusion therapy remains the cornerstone of effective treatment [ 1 ]. Intravenous thrombolysis with alteplase (recombinant tissue plasminogen activator, rt-PA) has long represented the gold standard in acute ischemic stroke treatment, backed by strong clinical evidence and regulatory approval, including from the U.S. Food and Drug Administration (FDA) [ 2 ]. However, its use is limited by a narrow therapeutic window and a complex administration regimen involving an initial bolus followed by a continuous infusion period over one hour [ 3 ]. Tenecteplase (TNK), a genetically engineered variant of the tissue plasminogen activator originally developed for acute myocardial infarction, is now approved for the treatment of acute ischemic stroke by both the FDA and the European Medicine Agency (EMA). Its single bolus administration, greater fibrin specificity, and higher resistance to plasminogen activator inhibitor-1 are practical and pharmacologic advantages over alteplase. Major stroke organizations also endorse its use: the European Stroke Organization issues a strong recommendation for 0.25 mg/kg TNK as a safe and effective alternative to alteplase within 4.5 hours of stroke onset (and prefers TNK for large-vessel-occlusion candidates), while the AHA/ASA recognizes TNK as an alternative in its guidelines [ 4 – 8 ]. Some studies suggest that TNK achieves comparable or even superior reperfusion and functional independence rates compared to alteplase, particularly in patients undergoing endovascular therapy or with large-vessel occlusions [ 4 , 9 ]. However, the results of these studies are inconsistent, due to differences in dosing regimens, patient selection, and imaging protocols. Although the evidence base for TNK is growing, head-to-head comparisons with alteplase in routine clinical practice remain sparse. Much of the literature originates from randomized controlled trials and selected stroke networks or high-volume centers, which can limit external validity. More multicenter, real-world studies —spanning diverse hospital types, workflows, and dosing protocols— are needed to confirm TNK effectiveness and safety in broader, unselected populations. In this retrospective, single-center cohort study, we compared patients with acute ischemic stroke who were treated with intravenous thrombolysis (IVT) using either Tenecteplase or Alteplase. We assessed differences in baseline characteristics, imaging findings, recanalization metrics, and clinical outcomes, with the aim of informing the comparative effectiveness and safety of these two agents in real-world stroke care. Methods Study Design This retrospective cohort study included consecutive adults (>18 years) with acute ischemic stroke (AIS) who were treated with intravenous thrombolysis (IVT) with either Alteplase (Actilyse) or Tenecteplase (TNK) at the University Hospital of Giessen, Germany between May 1 and October 31, 2024. During the initial phase (May-July 2024), alteplase was the sole thrombolytic agent. Following an institutional protocol change, Tenecteplase replaced Alteplase as the default IVT agent on August 1, 2024. Prior to implementation, all personnel involved in acute stroke care—including emergency medicine and neurology physicians and nursing staff—completed structured training on the updated protocol, including dosing, preparation, administration, and documentation. Patients were assigned to Alteplase or Tenecteplase group according to the agent administered. We identified all eligible cases from the institutional stroke database and excluded patients who underwent endovascular therapy (EVT) without preceding IVT. Clinical data were extracted from the institutional stroke registry and electronic medical records. Variables included demographic characteristics, vascular risk factors, imaging findings, stroke severity assessed by the National Institutes of Health Stroke Scale (NIHSS) at admission, treatment times metrics including door-to-needle (DTN), door-to-groin (DTG), and functional outcomes at discharge assessed by the modified Rankin Scale (mRS) and NIHSS after 24 h and at discharge[10, 11]. In patients who underwent additional EVT successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction (mTICI) score (≥2b). Local stroke treatment Both thrombolytic agents were administered in accordance with current German stroke treatment guidelines. Alteplase was dosed at 0.9 mg/kg body weight (maximum 90 mg), with 10% of the dose as an initial bolus followed by a 60-minute infusion. TNK was administered as a single intravenous bolus of 0.25 mg/kg (maximum 25 mg); using standardized dosing cards to ensure accurate preparation and administration. Pretreatment imaging included either multimodal cranial CT imaging, including non-contrast CT, CT angiography, and CT perfusion or magnetic resonance imaging (MRI). For patients presenting within the 4.5-hour of last seen well, treatment decisions were primarily based on non-contrast CT findings. For presentation beyond the 4.5-hours, perfusion imaging or mismatch profiles were used to guide thrombolysis eligibility. Patients receiving oral anticoagulants were assessed individually based on laboratory parameters and guideline recommendations. Intravenous thrombolysis (IVT) was administered in patients on vitamin K antagonists if the international normalized ratio (INR) did not exceed 1.7. For patients receiving direct oral anticoagulants (DOACs), IVT eligibility required drug-specific thresholds: an anti-Xa activity ≤100 ng/ml for factor Xa inhibitors, and Dabigatran plasma levels ≤100 ng/ml as determined by the Hemoclot assay. Stroke etiology was classified according to the TOAST criteria as large-artery atherosclerosis (macroangiopathy), small-vessel occlusion (microangiopathy), cardioembolism, other determined etiology, and undetermined etiology (e.g., ESUS: embolic stroke of undetermined source) [12]. Classification was based on an integrated review of the clinical presentation, neuro, and vascular imaging; cardiac diagnostics (e.g., ECG/telemetry, echocardiography), and relevant laboratory tests obtained during the index hospitalization. Outcomes The primary outcome of this study was defined as the treatment metrics (e.g. DTN and DTG). The Secondary outcomes included functional recovery at discharge, as assessed by the mRS and the NIHSS, as well as the degree of arterial recanalization in patients undergoing endovascular thrombectomy, as evaluated by the TICI score. Successful reperfusion was defined as a TICI score of ≥2b. Safety outcomes included: (i) radiologically confirmed intracranial hemorrhages by imaging at any follow-up; (ii) classification of hemorrhage subtypes according to the Heidelberg Bleeding Classification (e.g., PH1, PH2, SAH); (iii) presence and extent of infarct demarcation and cerebral edema; (iv) in-hospital mortality; and (v) angioedema. Statistical analysis Statistical analysis was performed using JASP version 0.19.3. Categorical variables were expressed as absolute and relative frequencies and compared using the chi-square test or Fisher’s exact test. Continuous variables were assessed using the student’s t-test or Mann–Whitney U test, depending on normality of distribution. A p-value <0.05 was considered statistically significant. Subgroup analyses were conducted for patients treated within and beyond 4.5 hours of stroke onset, as well as by stroke severity at baseline. Results Patient Inclusion and Baseline Characteristics Between May 1 and October 31, 2024, 101 patients with acute ischemic stroke received intravenous thrombolysis at the University Hospital of Giessen. Of these, 39 were treated with Tenecteplase and 62 with Alteplase. Patients treated exclusively with endovascular therapy (EVT) without prior thrombolysis were excluded (n = 72) (shown in Fig. 1 ). Demographic and vascular risk factors were largely balanced between groups (Table 1 ). Mean age was 72.7 ± 14.4 years in the Tenecteplase group and 70.1 ± 14.3 years in the Alteplase group, and approximately half of patients were female in both groups. Common vascular risk factors, including hypertension and hypercholesterolemia, were similarly distributed. A trend toward a higher prevalence of diabetes was observed with Tenecteplase (28.2% vs 12.9%; p = 0.05). Premorbid functional status, assessed by the modified Rankin Scale (mRS), did not differ significantly (Tenecteplase: 1.09 ± 1.38 vs Alteplase: 0.74 ± 1.28; p = 0.20). Prior use of antiplatelet or anticoagulant agents was comparable between groups (Table 1 ). Table 1 Baseline Demographics and Vascular Risk Factors Baseline Demographics TNK (n = 39) rt-PA (n = 62) P-value Age a 72.7 ± 14.4 70.1 ± 14.3 0.35 Weight a 78.9 ± 13.3 80.6 ± 18.2 0.84 BMI a 27.7 ± 4.1 27.2 ± 4.9 0.72 Male b 21 (53.8 ) 32 (51.6 ) 0.96 Female b 18 (46.2) 29 (46.8) 0.96 Risk Factors Hypertension b 30/39 (76.9) 48/62 (77.4) 0.95 Diabetes mellitus b 11/39 (28.2) 8/62 (12.9) 0.05 Hypercholesterolemia b 18/39 (46.2) 31/62 (50.0) 0.71 Kidney failure b 1/39 (2.6) 2/62 (3.2) 0.85 Atrial fibrillation b 6/39 (15.4) 8/62 (12.9) 0.81 Atrial fibrillation ED b 2/6 (33.3) 6/8 (75.0) 0.24 Premorbid mRS a 1.09 ± 1.38 (n = 35) 0.74 ± 1.28 (n = 61) 0.20 Premedication ASS b 12 (30.8) 22 (35.5) 0.63 Clopidogrel b 2 (5.1) 2 (3.2) 0.63 OAC b 1 (2.6) 1 (1.6) 0.74 DOAC b 1 (2.6) 5 (8.2) 0.25 a Mean ± SD. b n (%). Stroke Characteristics Clinical profiles and baseline stroke severity were similar between the Tenecteplase and Alteplase groups (Table 2 ). Table 2 Clinical Characteristics and TOAST-classification Clinical Characteristics TNK (n = 39) rt-PA (n = 62) P-value NIHSS at admission a 6.0 ± 6.3 (n = 34) 7.2 ± 8.2 (n = 61) 0.83 NIHSS after 24h a 10.5 ± 13.5 (n = 34) 9.7 ± 13.2 (n = 58) 0.74 DTN a 42.8 ± 27.1 (n = 30) 37.5 ± 20.9 (n = 49) 0.62 DTG (door-to-groin time) a 87.6 ± 48.8 (n = 9) 64.6 ± 73.7 (n = 22) 0.39 TOAST-classification Microangiopathy b 11/38 (28.9) 15/59 (25.4) 0.70 Macroangiopathy b 9/38 (23.7) 20/59 (33.9) 0.28 Cardioembolic b 8/38 (21.1) 14/59 (23.7) 0.76 ESUS b 5/38 (13.2) 8/59 (13.6) 0.95 Other b 5/38 (13.2) 2/59 (3.4) 0.07 a Mean ± SD. b n (%). The distribution of stroke subtypes according to the TOAST classification was comparable between groups (Table 2 ). Microangiopathic stroke was present in 28.9% of Tenecteplase-treated patients and 25.4% of those receiving Alteplase (p = 0.70). Macroangiopathy was observed in 23.7% and 33.9% of patients, respectively (p = 0.28). Cardioembolic strokes occurred in 21.1% of the Tenecteplase group versus 23.7% in the Alteplase group (p = 0.76), while ESUS accounted for 13.2% and 13.6% (p = 0.95), respectively. Other determined etiologies were slightly more frequent in the Tenecteplase group (13.2%) compared to the Alteplase group (3.4%), but without reaching statistical significance (p = 0.07). Imaging and Treatment Characteristics Most patients underwent initial imaging with perfusion- CT (CTP) (Tenecteplase: 97.4%, Alteplase: 98.4%; Table 3 ). Large vessel occlusion (LVO) was detected in 15.4% of the Tenecteplase group and 27.4% of the Alteplase group (p = 0.16). EVT was performed in 23.1% vs. 36.7%, respectively (p = 0.15). The choice between CT and MRI was mainly determined by clinical availability, time of presentation, and patient stability, with CT being the preferred first-line modality in acute settings, while MRI was used in selected cases when contraindications for CT existed or when patients presented outside the typical therapeutic window. Table 3 Imaging Findings and Outcomes Imaging TNK (n = 39) rt-PA (n = 62) P-value PCT b 38/39 (97.4) 61/62 (98.4) 0.07 MRI b 3/39 (7.7) 3/62 (4.8) 0.55 Infarct demarcation b 2/39 (5.1) 3/61 (4.9) 0.96 Perfusion delay/DWI b 21/38 (55.3) 36/53 (67.9) 0.22 Large vessel occlusion b 6/39 (15.4) 17/62 (27.4) 0.16 Distal VO b 7/39 (17.9) 9/62 (14.5) 0.65 EVT b 9 (23.1) 22 (36.7) 0.15 Successful recanalization b 9/9 (100) 21/22 (95.5) 0.52 Stent placement b 1/38 (2.6) 7/59 (11.9) 0.11 Intra-arterial thrombolysis b 3/9 (33.3) 9/22 (40.9) 0.69 Hemorrhage b 4/36 (11.1) 6/58 (10.3) 0.91 Heidelberg Bleeding Classification HI1 b 0 (0.0) 3 (4.8) .830 HI2 b 1 (2.6) 0 (0.0) PH1 b 3 (7.7) 2 (3.2) PH2 b 0 (0.0) 1 (1.6) IVH b 2 (5.1) 1 (1.6) .316 SAH b 1 (2.6) 6 (9.7) .174 Outcome NIHSS at discharge a 3.8 ± 7.8 (n = 33) 2.2 ± 4.5 (n = 54) 0.17 mRS at discharge a 2.3 ± 1.8 (n = 34) 2.0 ± 1.9 (n = 54) 0.39 PEG placement b 0/38 (0) 2/59 (3.4) 0.25 Death b 3/39 (7.7) 4/63 (6.3) 0.86 a Mean ± SD. b n (%). Successful recanalization is defined as TICI 2b-3. Primary outcomes Regarding primary outcomes Door-to-needle time (DTN) was slightly longer for Tenecteplase (42.8 ± 27.1 minutes) compared to Alteplase (37.5 ± 20.9 minutes; p = 0.62), without reaching statistical significance (Table 2 ). Door-to-groin time (DTG) was also longer in the Tenecteplase group (87.6 ± 48.8 minutes, n = 9) compared to the Alteplase group (64.6 ± 73.7 minutes, n = 22), although this difference did not reach statistical significance ( p = 0.39). Secondary and Safety Outcomes Secondary and safety outcomes were broadly similar between groups (Table 3 ). NIHSS at 24 hours did not differ (Tenecteplase 10.5 ± 13.5 vs Alteplase 9.7 ± 13.2; p = 0.74), and mean NIHSS at discharge was 3.8 ± 7.8 vs 2.2 ± 4.5 (p = 0.17). Discharge mRS distributions were comparable (shown in Fig. 2 ): favorable outcome (mRS 0–2) in 59% (20/34) with Tenecteplase and 64% (38/59) with Alteplase; excellent outcome (mRS 0–1) in 38% (13/34) vs 48% (28/59); and severe disability or death (mRS 5–6) in 18% (6/34) vs 14% (8/59). Safety endpoints showed no meaningful differences. Any intracranial hemorrhage occurred in 11.1% vs 10.3% (p = 0.91), and infarct demarcation on follow-up imaging in 44.7% vs 42.9% (p = 0.862). Regarding hemorrhagic complications assessed by the Heidelberg Bleeding Classification, relevant bleeding subtypes occurred in both groups, albeit at low frequency and the distribution of haemorrhagic complications did not differ significantly between the two groups. Haemorrhagic infarction type 1 (HI1) occurred in no patients (0.0%) in group A (TNK) and in 3 patients (4.8%) in group B (rt-PA) ( p = .830). Haemorrhagic infarction type 1 (HI1) occurred in 0 patients (0.0%) treated with Tenecteplase and in 3 patients (4.8%) treated with alteplase ( p = .830). Haemorrhagic infarction type 2 (HI2) was observed in 1 patient (2.6%) in the Tenecteplase group and in none of the patients in the alteplase group. Parenchymal hematoma type 1 (PH1) was documented in 3 patients (7.7%) in the Tenecteplase group and 2 patients (3.2%) in the Alteplase group, whereas parenchymal hematoma type 2 (PH2) occurred in none of the patients in the Tenecteplase group and in 1 patient (1.6%) in the Alteplase group. Intraventricular haemorrhage (IVH) was seen in 2 patients (5.1%) treated with Tenecteplase and in 1 patient (1.6%) treated with Alteplase ( p = .316). Subarachnoid haemorrhage (SAH) was observed in 1 patient (2.6%) in the Tenecteplase group compared with 6 patients (9.7%) in the Alteplase group ( p = .174). Overall, there was no statistically significant difference between groups in the occurrence of bleeding patterns, indicating a comparable hemorrhagic risk profile. Among patients who underwent EVT, successful reperfusion (mTICI ≥ 2b) was achieved in 100% with Tenecteplase and 95.5% with Alteplase (p = 0.52). In-hospital mortality was 7.7% (3 patients) vs 6.3% (4 patients) (p = 0.86). Rates of PEG placement and other complications were low in both groups. Discussion In this single-center, retrospective cohort study, we compared the clinical and radiological outcomes of intravenous thrombolysis with Tenecteplase (TNK) versus Alteplase (rt-PA) in patients with acute ischemic stroke. Our findings showed comparable safety and efficacy between the two treatment groups, with no significant differences in most clinical and procedural parameters. The demographic and clinical baseline characteristics were largely balanced between the groups, though the Tenecteplase group was slightly younger. The distribution of stroke severity, as measured by baseline NIHSS, was similar, which allowed for meaningful comparisons of treatment outcomes. These findings are in line with previous studies suggesting comparable baseline profiles in real-world cohorts receiving TNK or rt-PA [ 13 , 14 ]. In our cohort, the door-to-needle time (DTN) was numerically longer with Tenecteplase than with Alteplase (42.8 ± 27.1 vs. 37.5 ± 20.9 minutes), a difference that was not statistically significance (p = 0.62). Although TNK’s single bolus-regimen is often associated with shorter DTN, the observed pattern likely reflects early implementation effects during the transition to a new agent—e.g., additional verification steps, pharmacy workflow adjustments, and adaptation to new order sets and dosing cards. Prior studies have reported shorter DTN with TNK owing to the elimination of infusion-related steps and simplified dosing [ 15 ]. Our findings suggest that these operational advantages may not be realized immediately in settings undergoing therapeutic transition, underscoring the value of structured roll-out and continuing team training to capture the full time-saving potential of Tenecteplase. With maturation of processes and ongoing team training, TNK may still streamline acute stroke workflows, but our data emphasize that these advantages depend on structured implementation rather than the agent alone. Similarly, door-to-groin time (DTG) was longer in the TNK group (87.6 ± 48.8 minutes) compared to the Alteplase group (64.6 ± 73.7 minutes), although this difference also did not reach statistical significance ( p = 0.39). This trend may reflect selection differences, procedural complexity, or system-related delays unrelated to the thrombolytic agent itself. Given the small EVT subgroup (n = 31), these results should be interpreted with caution. Nevertheless, the data highlights the critical importance of workflow optimization throughout the entire acute stroke pathway—not only at the point of thrombolysis but also during coordination for thrombectomy. In our analysis of stroke etiology based on the TOAST classification, no significant differences were observed between the TNK and rt-PA groups across the major etiological subtypes, including large-artery atherosclerosis, cardioembolism, small-vessel occlusion, and stroke of undetermined cause (p > 0.05 for all). This balanced distribution suggests that the observed clinical and radiological outcomes were not driven by differences in underlying stroke mechanisms. It also underlines the applicability of Tenecteplase across a broad spectrum of ischemic stroke etiologies. These findings are consistent with prior studies reporting similar efficacy and safety of TNK across etiological subtypes [ 13 , 16 ]. We found no statistically significant differences between Tenecteplase and Alteplase in angiographic reperfusion (mTICI among EVT patients), early neurological improvement (24-h NIHSS), or functional status at discharge (mRS). These results add real-world support to the growing evidence base that Tenecteplase, at contemporary dosing, achieves efficacy comparable to rt-PA in terms of reperfusion and early clinical recovery[ 17 , 18 ]. While our study was not powered to detect small between-group differences, the consistency across endpoints aligns with noninferiority signals reported in randomized trials and meta-analyses. Hemorrhagic complications were uncommon in both treatment groups and align with reports in randomized and real-world studies [ 19 , 20 ]. The distribution of bleeding subtypes was comparable between groups and consistent with previously reported safety data. These findings support the evolving evidence suggesting that Tenecteplase has a safety profile like that of Alteplase, even when applying a nuanced hemorrhage classification system. Importantly, this adds granularity to bleeding risk assessment beyond binary outcomes like sICH and supports the use of Tenecteplase in standard stroke workflows with continued vigilance for rare hemorrhagic patterns. Rates of angioedema and in-hospital mortality were likewise low and similar across groups, further supporting the safe adoption of Tenecteplase in everyday practice—even during the early phases of a center-wide transition. While our sample was not powered to detect small differences in rare adverse events, the overall pattern reinforces growing evidence that Tenecteplase offers safety comparable to Alteplase. While our findings are consistent with randomized and observational studies supporting TNK as an effective alternative to Alteplase, they also speak to its real-world implementation in a large academic stroke center. Notably, TNK was not associated with faster door-to-needle times in our cohort, likely reflecting early transition effects (e.g., protocol familiarization and workflow adjustments). Thus, any operational time savings commonly attributed to TNK were not immediately realized here. This study has several limitations. First, the retrospective design is subject to inherent biases, including selection bias and missing data. Second, the relatively small sample size may have limited our ability to detect statistically significant differences. Third, functional outcome was assessed only at discharge, without follow-up data beyond hospitalization, which may underestimate the full recovery potential. Finally, imaging assessments, such as ASPECTS or perfusion mismatch, were based on local evaluation and may introduce inter-rater variability. Despite these limitations, our real-world data support the continued evaluation of Tenecteplase as a viable alternative to Alteplase in acute ischemic stroke management. Further large-scale, prospective studies are needed to confirm these findings and define patient subgroups who may particularly benefit from TNK. Conclusions In this retrospective, single-center analysis, Tenecteplase demonstrated safety and effectiveness comparable to Alteplase for the treatment of acute ischemic stroke. Time metrics, including door-to-needle, did not differ significantly; however, the single-bolus administration of Tenecteplase may offer practical advantages once implementation is mature. Realizing these operational benefits depends on structured, multidisciplinary training and standardized workflows (e.g., dosing cards, order sets, and pharmacy procedures). Overall, our findings support Tenecteplase as a viable alternative to Alteplase in real-world stroke care. Abbreviations AIS: Acute ischemic stroke CT: Computed tomography DOAC: Direct oral anticoagulants DTN: Door-to-needle time DTG: Door-to-groin time EVT: Endovascular treatment ICH: Intracranial hemorrhage INR: International normalized ratio IQR: Interquartile range IVT: Intravenous thrombolysis LVO: Large vessel occlusion MRI: Magnetic resonance imaging mRS: Modified Rankin Scale NIHSS: National Institutes of Health Stroke Scale rt-PA: recombinant tissue plasminogen activator or Alteplase TICI: Thrombolysis in Cerebral Infarction TNK: Tenecteplase Declarations Funding Sources The author(s) received no financial support for the research, authorship, and/or publication of this article. Competing interests The authors declare no competing interests. Availability of data and materials : The datasets used and/or analysis during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate: The study was conducted in accordance with the Declaration of Helsinki and approved by the local institutional review board of the Department of Medicine at Justus Liebig University in Giessen, Germany (approval number: AZ220/21; clinicaltrials.gov: NCT05295862). Ethic approval date 22 January 2025. Patient consent was waived by the local institutional review board of the Department of Medicine at Justus Liebig University in Giessen, Germany. Consent for publications : Not applicable. Author Contribution OAO conceived the research idea, analyzed the data, prepared and reviewed the first draft and final version of manuscript. TM and FC collected and analyzed the data as well as prepared, edited and reviewed the first draft. MS, PB, SH, SG, TB, MV, MJ und HK provided equally data, reviewed results, and provided guidance on data analysis and approved the final version of the manuscript. Acknowledgement The present work contains essential parts from the medical thesis of Merve-Melis Sayar at Justus-Liebig University, Giessen, Germany. Data Availability The datasets used and/or analysis during the current study are available from the corresponding author on reasonable request. References Aguiar de Sousa, D., et al., Access to and delivery of acute ischaemic stroke treatments: a survey of national scientific societies and stroke experts in 44 European countries. European stroke journal, 2019. 4 (1): p. 13-28. Disorders, N.I.o.N. and S.r.-P.S.S. Group, Tissue plasminogen activator for acute ischemic stroke. New England Journal of Medicine, 1995. 333 (24): p. 1581-1588. Wardlaw, J.M., et al., Thrombolysis for acute ischaemic stroke. Cochrane database of systematic reviews, 2014(7). Potla, N. and L. Ganti, Tenecteplase vs. alteplase for acute ischemic stroke: a systematic review. International journal of emergency medicine, 2022. 15 (1): p. 1. Hoffman, M., FDA Approves Tenecteplase for Acute Ischemic Stroke. Grotta, J.C. and E.C. Haley Jr, Food and Drug Administration Approval of Tenecteplase: What This Means for the Field of Acute Stroke Treatment . 2025. p. e001824. Parsons, M.W., et al., Tenecteplase versus alteplase for thrombolysis in patients selected by use of perfusion imaging within 4· 5 h of onset of ischaemic stroke (TASTE): a multicentre, randomised, controlled, phase 3 non-inferiority trial. The Lancet Neurology, 2024. 23 (8): p. 775-786. Alamowitch, S., et al., European Stroke Organisation (ESO) expedited recommendation on tenecteplase for acute ischaemic stroke. Eur Stroke J, 2023. 8 (1): p. 8-54. Logallo, N., C.E. Kvistad, and L. Thomassen, Therapeutic potential of tenecteplase in the management of acute ischemic stroke. CNS drugs, 2015. 29 : p. 811-818. Mistry, E.A., et al., Predicting 90-day outcome after thrombectomy: baseline-adjusted 24-hour NIHSS is more powerful than NIHSS score change. Stroke, 2021. 52 (8): p. 2547-2553. Chalos, V., et al., National Institutes of Health Stroke Scale: an alternative primary outcome measure for trials of acute treatment for ischemic stroke. Stroke, 2020. 51 (1): p. 282-290. Fure, B., T. Wyller, and B. Thommessen, TOAST criteria applied in acute ischemic stroke. Acta Neurologica Scandinavica, 2005. 112 (4): p. 254-258. Yogendrakumar, V., et al., Safety and efficacy of tenecteplase in older patients with large vessel occlusion: a pooled analysis of the EXTEND-IA TNK trials. Neurology, 2022. 98 (12): p. e1292-e1301. Zitek, T., R. Ataya, and I. Brea, Using tenecteplase for acute ischemic stroke: what is the hold up? Western Journal of Emergency Medicine, 2020. 21 (2): p. 199. Sekita, A., et al., Switch to tenecteplase for intravenous thrombolysis in stroke patients: experience from a German high-volume stroke center. Neurological Research and Practice, 2025. 7 (1): p. 28. Zhong, W., et al., Minor non-disabling stroke patients with large vessel severe stenosis or occlusion might benefit from thrombolysis. brain sciences, 2021. 11 (7): p. 945. Singh, N., et al., Effect of time to thrombolysis on clinical outcomes in patients with acute ischemic stroke treated with tenecteplase compared to alteplase: analysis from the AcT randomized controlled trial. Stroke, 2023. 54 (11): p. 2766-2775. Menon, B.K., et al., Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial. The Lancet, 2022. 400 (10347): p. 161-169. Bala, F., et al., Safety and efficacy of tenecteplase compared with alteplase in patients with large vessel occlusion stroke: a prespecified secondary analysis of the ACT randomized clinical trial. JAMA neurology, 2023. 80 (8): p. 824-832. Li, S., et al., Safety and efficacy of tenecteplase versus alteplase in patients with acute ischaemic stroke (TRACE): a multicentre, randomised, open label, blinded-endpoint (PROBE) controlled phase II study. Stroke and Vascular Neurology, 2022. 7 (1). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 23 Jan, 2026 Read the published version in BMC Neurology → Version 1 posted Editorial decision: Revision requested 18 Dec, 2025 Reviews received at journal 17 Dec, 2025 Reviews received at journal 29 Nov, 2025 Reviewers agreed at journal 29 Nov, 2025 Reviewers agreed at journal 25 Nov, 2025 Reviewers agreed at journal 25 Nov, 2025 Reviewers invited by journal 25 Nov, 2025 Editor invited by journal 24 Nov, 2025 Editor assigned by journal 13 Nov, 2025 Submission checks completed at journal 13 Nov, 2025 First submitted to journal 11 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8089533","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":552586459,"identity":"9a3f17ee-8a79-4877-b12d-1e07ae4e97e6","order_by":0,"name":"Toska Maxhuni","email":"data:image/png;base64,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","orcid":"","institution":"University of Giessen","correspondingAuthor":true,"prefix":"","firstName":"Toska","middleName":"","lastName":"Maxhuni","suffix":""},{"id":552586461,"identity":"afe94ac8-5e3c-404f-8459-de5ff49ac593","order_by":1,"name":"Francesca Culaj","email":"","orcid":"","institution":"University of Giessen","correspondingAuthor":false,"prefix":"","firstName":"Francesca","middleName":"","lastName":"Culaj","suffix":""},{"id":552586463,"identity":"ecd233d6-9db3-4ed9-8586-28614371196e","order_by":2,"name":"Merve-Melis Sayar","email":"","orcid":"","institution":"University of Giessen","correspondingAuthor":false,"prefix":"","firstName":"Merve-Melis","middleName":"","lastName":"Sayar","suffix":""},{"id":552586465,"identity":"baad7a35-673e-4fe4-9071-2365fcd83169","order_by":3,"name":"Priyanka Böttger","email":"","orcid":"","institution":"University of Giessen","correspondingAuthor":false,"prefix":"","firstName":"Priyanka","middleName":"","lastName":"Böttger","suffix":""},{"id":552586467,"identity":"1df0ed8f-2baf-4ab4-9867-bd13ac80d2c7","order_by":4,"name":"Samra Hamzic","email":"","orcid":"","institution":"University of Giessen","correspondingAuthor":false,"prefix":"","firstName":"Samra","middleName":"","lastName":"Hamzic","suffix":""},{"id":552586469,"identity":"f3c8cc12-5712-4587-a3d5-6f79773016d9","order_by":5,"name":"Stefan T. Gerner","email":"","orcid":"","institution":"University of Giessen","correspondingAuthor":false,"prefix":"","firstName":"Stefan","middleName":"T.","lastName":"Gerner","suffix":""},{"id":552586472,"identity":"9ece562c-47fe-4fd9-9beb-137bbbe237c2","order_by":6,"name":"Tobias Braun","email":"","orcid":"","institution":"University of Giessen","correspondingAuthor":false,"prefix":"","firstName":"Tobias","middleName":"","lastName":"Braun","suffix":""},{"id":552586473,"identity":"8c834e13-321e-4e06-9903-b17fb02d4a76","order_by":7,"name":"Maxime Viard","email":"","orcid":"","institution":"Kantonsspital Winterthur","correspondingAuthor":false,"prefix":"","firstName":"Maxime","middleName":"","lastName":"Viard","suffix":""},{"id":552586474,"identity":"33af205f-557d-4f0f-a427-89e3bff70ad1","order_by":8,"name":"Juenemann Martin","email":"","orcid":"","institution":"University of Giessen","correspondingAuthor":false,"prefix":"","firstName":"Juenemann","middleName":"","lastName":"Martin","suffix":""},{"id":552586475,"identity":"6af3a4cc-3880-476b-9e34-4f17f3bcd10b","order_by":9,"name":"Heidrun H. 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13:47:03","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":94411,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8089533/v1/c112bcceeeae7dbbbee778b0.html"},{"id":97366758,"identity":"ee9b4027-94a6-4695-a3bb-c18090e4d9aa","added_by":"auto","created_at":"2025-12-03 16:07:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":57519,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of patient selection for inclusion in the study. \u003c/strong\u003eA total of \u003cem\u003en\u003c/em\u003e = 173 patients receiving intravenous thrombolysis (IVT) were screened. After application of exclusion criteria, \u003cem\u003en\u003c/em\u003e = 72 patients were eligible and included in the final analysis, divided into the Tenecteplase (TNK) and Alteplase (rt-PA) treatment groups\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8089533/v1/a00169e00dd14649256463f1.png"},{"id":97258282,"identity":"910b7b31-3c12-4338-b290-7f62b179801b","added_by":"auto","created_at":"2025-12-02 13:47:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34129,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of modified Rankin Scale (mRS) scores at discharge in patients treated with Tenecteplase (TNK) versus Alteplase (rt-PA). \u003c/strong\u003eStacked bar charts display the proportion of patients across the full mRS range (0–6) at hospital discharge. Favorable outcome was defined as mRS 0–2, unfavorable outcome as mRS 3–6. Numbers within the bars indicate absolute patient counts for each mRS category. TNK group: \u003cem\u003en\u003c/em\u003e= 34; rt-PA group: \u003cem\u003en\u003c/em\u003e = 59.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8089533/v1/f54913ff73e05e76e2ef29ef.png"},{"id":101152964,"identity":"dc349b05-dcd2-4eaf-9de3-eb95b46a56b2","added_by":"auto","created_at":"2026-01-26 16:13:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1017369,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8089533/v1/4fc5124b-9736-4ce2-a380-de2b345155e3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Effectiveness of Tenecteplase and Alteplase for Ischemic Stroke: Real-World Data from a Stroke Center","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn acute ischemic stroke (AIS), a leading cause of death and disability worldwide, timely reperfusion therapy remains the cornerstone of effective treatment [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Intravenous thrombolysis with alteplase (recombinant tissue plasminogen activator, rt-PA) has long represented the gold standard in acute ischemic stroke treatment, backed by strong clinical evidence and regulatory approval, including from the U.S. Food and Drug Administration (FDA) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, its use is limited by a narrow therapeutic window and a complex administration regimen involving an initial bolus followed by a continuous infusion period over one hour [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e Tenecteplase (TNK), a genetically engineered variant of the tissue plasminogen activator originally developed for acute myocardial infarction, is now approved for the treatment of acute ischemic stroke by both the FDA and the European Medicine Agency (EMA). Its single bolus administration, greater fibrin specificity, and higher resistance to plasminogen activator inhibitor-1 are practical and pharmacologic advantages over alteplase. Major stroke organizations also endorse its use: the European Stroke Organization issues a strong recommendation for 0.25 mg/kg TNK as a safe and effective alternative to alteplase within 4.5 hours of stroke onset (and prefers TNK for large-vessel-occlusion candidates), while the AHA/ASA recognizes TNK as an alternative in its guidelines [\u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSome studies suggest that TNK achieves comparable or even superior reperfusion and functional independence rates compared to alteplase, particularly in patients undergoing endovascular therapy or with large-vessel occlusions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, the results of these studies are inconsistent, due to differences in dosing regimens, patient selection, and imaging protocols.\u003c/p\u003e\u003cp\u003eAlthough the evidence base for TNK is growing, head-to-head comparisons with alteplase in routine clinical practice remain sparse. Much of the literature originates from randomized controlled trials and selected stroke networks or high-volume centers, which can limit external validity. More multicenter, real-world studies \u0026mdash;spanning diverse hospital types, workflows, and dosing protocols\u0026mdash; are needed to confirm TNK effectiveness and safety in broader, unselected populations.\u003c/p\u003e\u003cp\u003eIn this retrospective, single-center cohort study, we compared patients with acute ischemic stroke who were treated with intravenous thrombolysis (IVT) using either Tenecteplase or Alteplase. We assessed differences in baseline characteristics, imaging findings, recanalization metrics, and clinical outcomes, with the aim of informing the comparative effectiveness and safety of these two agents in real-world stroke care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cu\u003eStudy Design\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective cohort study included consecutive adults (\u0026gt;18 years) with acute ischemic stroke (AIS) who were treated with intravenous thrombolysis (IVT) with either Alteplase (Actilyse) or Tenecteplase (TNK) at the University Hospital of Giessen, Germany between May 1 and October 31, 2024. During the initial phase (May-July 2024), alteplase was the sole thrombolytic agent. Following an institutional protocol change, Tenecteplase replaced Alteplase as the default IVT agent on August 1, 2024. Prior to implementation, all personnel involved in acute stroke care\u0026mdash;including emergency medicine and neurology physicians and nursing staff\u0026mdash;completed structured training on the updated protocol, including dosing, preparation, administration, and documentation. Patients were assigned to Alteplase or Tenecteplase group according to the agent administered. We identified all eligible cases from the institutional stroke database and excluded patients who underwent endovascular therapy (EVT) without preceding IVT.\u003c/p\u003e\n\u003cp\u003eClinical data were extracted from the institutional stroke registry and electronic medical records. Variables included demographic characteristics, vascular risk factors, imaging findings, stroke severity assessed by the National Institutes of Health Stroke Scale (NIHSS) at admission, treatment times metrics including door-to-needle (DTN), door-to-groin (DTG), and functional outcomes at discharge assessed by the modified Rankin Scale (mRS) and NIHSS after 24 h and at discharge[10, 11]. In patients who underwent additional EVT successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction (mTICI) score (\u0026ge;2b).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eLocal stroke treatment\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eBoth thrombolytic agents were administered in accordance with current German stroke treatment guidelines. Alteplase was dosed at 0.9 mg/kg body weight (maximum 90 mg), with 10% of the dose as an initial bolus followed by a 60-minute infusion. TNK was administered as a single intravenous bolus of 0.25 mg/kg (maximum 25 mg);\u0026nbsp;using standardized dosing cards to ensure accurate preparation and administration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePretreatment imaging included either multimodal cranial CT imaging, including non-contrast CT, CT angiography, and CT perfusion or magnetic resonance imaging (MRI). For patients presenting within the 4.5-hour of last seen well, treatment decisions were primarily based on non-contrast CT findings.\u0026nbsp;For presentation beyond the 4.5-hours, perfusion imaging or mismatch profiles were used to guide thrombolysis eligibility. Patients receiving oral anticoagulants were assessed individually based on laboratory parameters and guideline recommendations.\u0026nbsp;Intravenous thrombolysis (IVT) was administered in patients on vitamin K antagonists if the international normalized ratio (INR) did not exceed 1.7. For patients receiving direct oral anticoagulants (DOACs), IVT eligibility required drug-specific thresholds: an anti-Xa activity \u0026le;100 ng/ml for factor Xa inhibitors, and Dabigatran plasma levels \u0026le;100 ng/ml as determined by the Hemoclot assay.\u003c/p\u003e\n\u003cp\u003eStroke etiology was classified according to the TOAST criteria as large-artery atherosclerosis (macroangiopathy), small-vessel occlusion (microangiopathy), cardioembolism, other determined etiology, and undetermined etiology (e.g., ESUS:\u0026nbsp;embolic stroke of undetermined source) [12]. Classification was based on an integrated review of the clinical presentation, neuro, and vascular imaging; cardiac diagnostics (e.g., ECG/telemetry, echocardiography), and relevant laboratory tests obtained during the index hospitalization.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eOutcomes\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome of this study was defined as the treatment metrics (e.g. DTN and DTG). The Secondary outcomes included functional recovery at discharge, as assessed by the mRS and the NIHSS, as well as the degree of arterial recanalization in patients undergoing endovascular thrombectomy, as evaluated by the TICI score. Successful reperfusion was defined as a TICI score of \u0026ge;2b. Safety outcomes included: (i) radiologically confirmed intracranial hemorrhages by imaging at any follow-up; (ii) classification of hemorrhage subtypes according to the Heidelberg Bleeding Classification (e.g., PH1, PH2, SAH); (iii) presence and extent of infarct demarcation and cerebral edema; (iv) in-hospital mortality; and (v) angioedema.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStatistical analysis\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed using JASP version 0.19.3. Categorical variables were expressed as absolute and relative frequencies and compared using the chi-square test or Fisher\u0026rsquo;s exact test. Continuous variables were assessed using the student\u0026rsquo;s t-test or Mann\u0026ndash;Whitney U test, depending on normality of distribution. A p-value \u0026lt;0.05 was considered statistically significant. Subgroup analyses were conducted for patients treated within and beyond 4.5 hours of stroke onset, as well as by stroke severity at baseline.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePatient Inclusion and Baseline Characteristics\u003c/h2\u003e\u003cp\u003eBetween May 1 and October 31, 2024, 101 patients with acute ischemic stroke received intravenous thrombolysis at the University Hospital of Giessen. Of these, 39 were treated with Tenecteplase and 62 with Alteplase. Patients treated exclusively with endovascular therapy (EVT) without prior thrombolysis were excluded (n\u0026thinsp;=\u0026thinsp;72) (shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eDemographic and vascular risk factors were largely balanced between groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Mean age was 72.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.4 years in the Tenecteplase group and 70.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3 years in the Alteplase group, and approximately half of patients were female in both groups. Common vascular risk factors, including hypertension and hypercholesterolemia, were similarly distributed. A trend toward a higher prevalence of diabetes was observed with Tenecteplase (28.2% vs 12.9%; p\u0026thinsp;=\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003ePremorbid functional status, assessed by the modified Rankin Scale (mRS), did not differ significantly (Tenecteplase: 1.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38 vs Alteplase: 0.74\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28; p\u0026thinsp;=\u0026thinsp;0.20). Prior use of antiplatelet or anticoagulant agents was comparable between groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline Demographics and Vascular Risk Factors\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBaseline Demographics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTNK (n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ert-PA (n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78.9\u0026thinsp;\u0026plusmn;\u0026thinsp;13.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80.6\u0026thinsp;\u0026plusmn;\u0026thinsp;18.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.84\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.72\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21 (53.8 )\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (51.6 )\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (46.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29 (46.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRisk Factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypertension \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30/39 (76.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48/62 (77.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.95\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes mellitus \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11/39 (28.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8/62 (12.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypercholesterolemia \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18/39 (46.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31/62 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKidney failure \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1/39 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2/62 (3.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtrial fibrillation \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6/39 (15.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8/62 (12.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtrial fibrillation ED \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2/6 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6/8 (75.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePremorbid mRS \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38 (n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.74\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28 (n\u0026thinsp;=\u0026thinsp;61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePremedication\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASS \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (30.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (35.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClopidogrel \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (3.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOAC \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.74\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDOAC \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (8.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eMean \u0026plusmn; SD.\u003c/p\u003e\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e\u003cem\u003en\u003c/em\u003e (%).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStroke Characteristics\u003c/h3\u003e\n\u003cp\u003eClinical profiles and baseline stroke severity were similar between the Tenecteplase and Alteplase groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClinical Characteristics and TOAST-classification\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical Characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTNK (n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ert-PA (n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNIHSS at admission \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3 (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2 (n\u0026thinsp;=\u0026thinsp;61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNIHSS after 24h \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5 (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.7\u0026thinsp;\u0026plusmn;\u0026thinsp;13.2 (n\u0026thinsp;=\u0026thinsp;58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.74\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDTN \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42.8\u0026thinsp;\u0026plusmn;\u0026thinsp;27.1 (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37.5\u0026thinsp;\u0026plusmn;\u0026thinsp;20.9 (n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDTG (door-to-groin time) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e87.6\u0026thinsp;\u0026plusmn;\u0026thinsp;48.8 (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64.6\u0026thinsp;\u0026plusmn;\u0026thinsp;73.7 (n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.39\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTOAST-classification\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMicroangiopathy \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11/38 (28.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15/59 (25.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.70\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMacroangiopathy \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9/38 (23.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20/59 (33.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCardioembolic \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8/38 (21.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14/59 (23.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eESUS \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5/38 (13.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8/59 (13.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.95\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5/38 (13.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2/59 (3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eMean \u0026plusmn; SD.\u003c/p\u003e\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e\u003cem\u003en\u003c/em\u003e (%).\u003c/p\u003e\u003cp\u003eThe distribution of stroke subtypes according to the TOAST classification was comparable between groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Microangiopathic stroke was present in 28.9% of Tenecteplase-treated patients and 25.4% of those receiving Alteplase (p\u0026thinsp;=\u0026thinsp;0.70). Macroangiopathy was observed in 23.7% and 33.9% of patients, respectively (p\u0026thinsp;=\u0026thinsp;0.28). Cardioembolic strokes occurred in 21.1% of the Tenecteplase group versus 23.7% in the Alteplase group (p\u0026thinsp;=\u0026thinsp;0.76), while ESUS accounted for 13.2% and 13.6% (p\u0026thinsp;=\u0026thinsp;0.95), respectively. Other determined etiologies were slightly more frequent in the Tenecteplase group (13.2%) compared to the Alteplase group (3.4%), but without reaching statistical significance (p\u0026thinsp;=\u0026thinsp;0.07).\u003c/p\u003e\n\u003ch3\u003eImaging and Treatment Characteristics\u003c/h3\u003e\n\u003cp\u003eMost patients underwent initial imaging with perfusion- CT (CTP) (Tenecteplase: 97.4%, Alteplase: 98.4%; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Large vessel occlusion (LVO) was detected in 15.4% of the Tenecteplase group and 27.4% of the Alteplase group (p\u0026thinsp;=\u0026thinsp;0.16). EVT was performed in 23.1% vs. 36.7%, respectively (p\u0026thinsp;=\u0026thinsp;0.15). The choice between CT and MRI was mainly determined by clinical availability, time of presentation, and patient stability, with CT being the preferred first-line modality in acute settings, while MRI was used in selected cases when contraindications for CT existed or when patients presented outside the typical therapeutic window.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eImaging Findings and Outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImaging\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTNK (n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ert-PA (n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePCT \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38/39 (97.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61/62 (98.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMRI \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3/39 (7.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3/62 (4.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.55\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInfarct demarcation \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2/39 (5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3/61 (4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerfusion delay/DWI \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21/38 (55.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36/53 (67.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLarge vessel occlusion \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6/39 (15.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17/62 (27.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistal VO \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7/39 (17.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9/62 (14.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.65\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEVT \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (23.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (36.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSuccessful recanalization \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9/9 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21/22 (95.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.52\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStent placement \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1/38 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7/59 (11.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntra-arterial thrombolysis \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3/9 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9/22 (40.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHemorrhage \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4/36 (11.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6/58 (10.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHeidelberg Bleeding Classification\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHI1 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (4.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e.830\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHI2 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePH1 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (7.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (3.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePH2 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIVH \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.316\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSAH \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.174\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOutcome\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNIHSS at discharge \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5 (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emRS at discharge \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.39\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePEG placement \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/38 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2/59 (3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeath \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3/39 (7.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4/63 (6.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eMean \u0026plusmn; SD.\u003c/p\u003e\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e\u003cem\u003en\u003c/em\u003e (%).\u003c/p\u003e\u003cp\u003eSuccessful recanalization is defined as TICI 2b-3.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003ePrimary outcomes\u003c/h2\u003e\u003cp\u003eRegarding primary outcomes Door-to-needle time (DTN) was slightly longer for Tenecteplase (42.8\u0026thinsp;\u0026plusmn;\u0026thinsp;27.1 minutes) compared to Alteplase (37.5\u0026thinsp;\u0026plusmn;\u0026thinsp;20.9 minutes; p\u0026thinsp;=\u0026thinsp;0.62), without reaching statistical significance (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDoor-to-groin time (DTG) was also longer in the Tenecteplase group (87.6\u0026thinsp;\u0026plusmn;\u0026thinsp;48.8 minutes, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9) compared to the Alteplase group (64.6\u0026thinsp;\u0026plusmn;\u0026thinsp;73.7 minutes, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;22), although this difference did not reach statistical significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.39).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eSecondary and Safety Outcomes\u003c/h2\u003e\u003cp\u003eSecondary and safety outcomes were broadly similar between groups (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). NIHSS at 24 hours did not differ (Tenecteplase 10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5 vs Alteplase 9.7\u0026thinsp;\u0026plusmn;\u0026thinsp;13.2; p\u0026thinsp;=\u0026thinsp;0.74), and mean NIHSS at discharge was 3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 vs 2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5 (p\u0026thinsp;=\u0026thinsp;0.17). Discharge mRS distributions were comparable (shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e): favorable outcome (mRS 0\u0026ndash;2) in 59% (20/34) with Tenecteplase and 64% (38/59) with Alteplase; excellent outcome (mRS 0\u0026ndash;1) in 38% (13/34) vs 48% (28/59); and severe disability or death (mRS 5\u0026ndash;6) in 18% (6/34) vs 14% (8/59).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSafety endpoints showed no meaningful differences. Any intracranial hemorrhage occurred in 11.1% vs 10.3% (p\u0026thinsp;=\u0026thinsp;0.91), and infarct demarcation on follow-up imaging in 44.7% vs 42.9% (p\u0026thinsp;=\u0026thinsp;0.862). Regarding hemorrhagic complications assessed by the Heidelberg Bleeding Classification, relevant bleeding subtypes occurred in both groups, albeit at low frequency and the distribution of haemorrhagic complications did not differ significantly between the two groups. Haemorrhagic infarction type 1 (HI1) occurred in no patients (0.0%) in group A (TNK) and in 3 patients (4.8%) in group B (rt-PA) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.830). Haemorrhagic infarction type 1 (HI1) occurred in 0 patients (0.0%) treated with Tenecteplase and in 3 patients (4.8%) treated with alteplase (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.830). Haemorrhagic infarction type 2 (HI2) was observed in 1 patient (2.6%) in the Tenecteplase group and in none of the patients in the alteplase group. Parenchymal hematoma type 1 (PH1) was documented in 3 patients (7.7%) in the Tenecteplase group and 2 patients (3.2%) in the Alteplase group, whereas parenchymal hematoma type 2 (PH2) occurred in none of the patients in the Tenecteplase group and in 1 patient (1.6%) in the Alteplase group. Intraventricular haemorrhage (IVH) was seen in 2 patients (5.1%) treated with Tenecteplase and in 1 patient (1.6%) treated with Alteplase (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.316). Subarachnoid haemorrhage (SAH) was observed in 1 patient (2.6%) in the Tenecteplase group compared with 6 patients (9.7%) in the Alteplase group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.174). Overall, there was no statistically significant difference between groups in the occurrence of bleeding patterns, indicating a comparable hemorrhagic risk profile. Among patients who underwent EVT, successful reperfusion (mTICI\u0026thinsp;\u0026ge;\u0026thinsp;2b) was achieved in 100% with Tenecteplase and 95.5% with Alteplase (p\u0026thinsp;=\u0026thinsp;0.52). In-hospital mortality was 7.7% (3 patients) vs 6.3% (4 patients) (p\u0026thinsp;=\u0026thinsp;0.86). Rates of PEG placement and other complications were low in both groups.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this single-center, retrospective cohort study, we compared the clinical and radiological outcomes of intravenous thrombolysis with Tenecteplase (TNK) versus Alteplase (rt-PA) in patients with acute ischemic stroke. Our findings showed comparable safety and efficacy between the two treatment groups, with no significant differences in most clinical and procedural parameters.\u003c/p\u003e\u003cp\u003eThe demographic and clinical baseline characteristics were largely balanced between the groups, though the Tenecteplase group was slightly younger. The distribution of stroke severity, as measured by baseline NIHSS, was similar, which allowed for meaningful comparisons of treatment outcomes. These findings are in line with previous studies suggesting comparable baseline profiles in real-world cohorts receiving TNK or rt-PA [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn our cohort, the door-to-needle time (DTN) was numerically longer with Tenecteplase than with Alteplase (42.8\u0026thinsp;\u0026plusmn;\u0026thinsp;27.1 vs. 37.5\u0026thinsp;\u0026plusmn;\u0026thinsp;20.9 minutes), a difference that was not statistically significance (p\u0026thinsp;=\u0026thinsp;0.62). Although TNK\u0026rsquo;s single bolus-regimen is often associated with shorter DTN, the observed pattern likely reflects early implementation effects during the transition to a new agent\u0026mdash;e.g., additional verification steps, pharmacy workflow adjustments, and adaptation to new order sets and dosing cards. Prior studies have reported shorter DTN with TNK owing to the elimination of infusion-related steps and simplified dosing [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Our findings suggest that these operational advantages may not be realized immediately in settings undergoing therapeutic transition, underscoring the value of structured roll-out and continuing team training to capture the full time-saving potential of Tenecteplase. With maturation of processes and ongoing team training, TNK may still streamline acute stroke workflows, but our data emphasize that these advantages depend on structured implementation rather than the agent alone. Similarly, door-to-groin time (DTG) was longer in the TNK group (87.6\u0026thinsp;\u0026plusmn;\u0026thinsp;48.8 minutes) compared to the Alteplase group (64.6\u0026thinsp;\u0026plusmn;\u0026thinsp;73.7 minutes), although this difference also did not reach statistical significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.39). This trend may reflect selection differences, procedural complexity, or system-related delays unrelated to the thrombolytic agent itself. Given the small EVT subgroup (n\u0026thinsp;=\u0026thinsp;31), these results should be interpreted with caution. Nevertheless, the data highlights the critical importance of workflow optimization throughout the entire acute stroke pathway\u0026mdash;not only at the point of thrombolysis but also during coordination for thrombectomy.\u003c/p\u003e\u003cp\u003eIn our analysis of stroke etiology based on the TOAST classification, no significant differences were observed between the TNK and rt-PA groups across the major etiological subtypes, including large-artery atherosclerosis, cardioembolism, small-vessel occlusion, and stroke of undetermined cause (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for all). This balanced distribution suggests that the observed clinical and radiological outcomes were not driven by differences in underlying stroke mechanisms. It also underlines the applicability of Tenecteplase across a broad spectrum of ischemic stroke etiologies. These findings are consistent with prior studies reporting similar efficacy and safety of TNK across etiological subtypes [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWe found no statistically significant differences between Tenecteplase and Alteplase in angiographic reperfusion (mTICI among EVT patients), early neurological improvement (24-h NIHSS), or functional status at discharge (mRS). These results add real-world support to the growing evidence base that Tenecteplase, at contemporary dosing, achieves efficacy comparable to rt-PA in terms of reperfusion and early clinical recovery[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. While our study was not powered to detect small between-group differences, the consistency across endpoints aligns with noninferiority signals reported in randomized trials and meta-analyses.\u003c/p\u003e\u003cp\u003eHemorrhagic complications were uncommon in both treatment groups and align with reports in randomized and real-world studies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The distribution of bleeding subtypes was comparable between groups and consistent with previously reported safety data. These findings support the evolving evidence suggesting that Tenecteplase has a safety profile like that of Alteplase, even when applying a nuanced hemorrhage classification system. Importantly, this adds granularity to bleeding risk assessment beyond binary outcomes like sICH and supports the use of Tenecteplase in standard stroke workflows with continued vigilance for rare hemorrhagic patterns. Rates of angioedema and in-hospital mortality were likewise low and similar across groups, further supporting the safe adoption of Tenecteplase in everyday practice\u0026mdash;even during the early phases of a center-wide transition. While our sample was not powered to detect small differences in rare adverse events, the overall pattern reinforces growing evidence that Tenecteplase offers safety comparable to Alteplase.\u003c/p\u003e\u003cp\u003eWhile our findings are consistent with randomized and observational studies supporting TNK as an effective alternative to Alteplase, they also speak to its real-world implementation in a large academic stroke center. Notably, TNK was not associated with faster door-to-needle times in our cohort, likely reflecting early transition effects (e.g., protocol familiarization and workflow adjustments). Thus, any operational time savings commonly attributed to TNK were not immediately realized here.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, the retrospective design is subject to inherent biases, including selection bias and missing data. Second, the relatively small sample size may have limited our ability to detect statistically significant differences. Third, functional outcome was assessed only at discharge, without follow-up data beyond hospitalization, which may underestimate the full recovery potential. Finally, imaging assessments, such as ASPECTS or perfusion mismatch, were based on local evaluation and may introduce inter-rater variability.\u003c/p\u003e\u003cp\u003eDespite these limitations, our real-world data support the continued evaluation of Tenecteplase as a viable alternative to Alteplase in acute ischemic stroke management. Further large-scale, prospective studies are needed to confirm these findings and define patient subgroups who may particularly benefit from TNK.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this retrospective, single-center analysis, Tenecteplase demonstrated safety and effectiveness comparable to Alteplase for the treatment of acute ischemic stroke. Time metrics, including door-to-needle, did not differ significantly; however, the single-bolus administration of Tenecteplase may offer practical advantages once implementation is mature. Realizing these operational benefits depends on structured, multidisciplinary training and standardized workflows (e.g., dosing cards, order sets, and pharmacy procedures). Overall, our findings support Tenecteplase as a viable alternative to Alteplase in real-world stroke care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAIS: Acute ischemic stroke\u003c/p\u003e\n\u003cp\u003eCT: Computed tomography \u003c/p\u003e\n\u003cp\u003eDOAC: Direct oral anticoagulants\u003c/p\u003e\n\u003cp\u003eDTN: Door-to-needle time\u003c/p\u003e\n\u003cp\u003eDTG: Door-to-groin time\u003c/p\u003e\n\u003cp\u003eEVT: Endovascular treatment\u003c/p\u003e\n\u003cp\u003eICH: Intracranial hemorrhage\u003c/p\u003e\n\u003cp\u003eINR: International normalized ratio \u003c/p\u003e\n\u003cp\u003eIQR: Interquartile range\u003c/p\u003e\n\u003cp\u003eIVT: Intravenous thrombolysis \u003c/p\u003e\n\u003cp\u003eLVO: Large vessel occlusion\u003c/p\u003e\n\u003cp\u003eMRI: Magnetic resonance imaging \u003c/p\u003e\n\u003cp\u003emRS: Modified Rankin Scale \u003c/p\u003e\n\u003cp\u003eNIHSS: National Institutes of Health Stroke Scale\u003c/p\u003e\n\u003cp\u003ert-PA: recombinant tissue plasminogen activator or Alteplase \u003c/p\u003e\n\u003cp\u003eTICI: Thrombolysis in Cerebral Infarction\u003c/p\u003e\n\u003cp\u003eTNK: Tenecteplase \u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding Sources\u003c/h2\u003e\n\u003cp\u003eThe author(s) received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAvailability of data and materials\u003c/span\u003e:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analysis during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eEthics approval and consent to participate:\u003c/h2\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the local institutional review board of the Department of Medicine at Justus Liebig University in Giessen, Germany (approval number: AZ220/21; clinicaltrials.gov: NCT05295862). Ethic approval date 22 January 2025. Patient consent was waived by the local institutional review board of the Department of Medicine at Justus Liebig University in Giessen, Germany.\u003c/p\u003e\n\u003ch2\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eConsent for publications\u003c/span\u003e:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eOAO conceived the research idea, analyzed the data, prepared and reviewed the first draft and final version of manuscript. TM and FC collected and analyzed the data as well as prepared, edited and reviewed the first draft. MS, PB, SH, SG, TB, MV, MJ und HK provided equally data, reviewed results, and provided guidance on data analysis and approved the final version of the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe present work contains essential parts from the medical thesis of Merve-Melis Sayar at Justus-Liebig University, Giessen, Germany.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analysis during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAguiar de Sousa, D., et al., \u003cem\u003eAccess to and delivery of acute ischaemic stroke treatments: a survey of national scientific societies and stroke experts in 44 European countries.\u003c/em\u003e European stroke journal, 2019. \u003cstrong\u003e4\u003c/strong\u003e(1): p. 13-28.\u003c/li\u003e\n\u003cli\u003eDisorders, N.I.o.N. and S.r.-P.S.S. Group, \u003cem\u003eTissue plasminogen activator for acute ischemic stroke.\u003c/em\u003e New England Journal of Medicine, 1995. \u003cstrong\u003e333\u003c/strong\u003e(24): p. 1581-1588.\u003c/li\u003e\n\u003cli\u003eWardlaw, J.M., et al., \u003cem\u003eThrombolysis for acute ischaemic stroke.\u003c/em\u003e Cochrane database of systematic reviews, 2014(7).\u003c/li\u003e\n\u003cli\u003ePotla, N. and L. Ganti, \u003cem\u003eTenecteplase vs. alteplase for acute ischemic stroke: a systematic review.\u003c/em\u003e International journal of emergency medicine, 2022. \u003cstrong\u003e15\u003c/strong\u003e(1): p. 1.\u003c/li\u003e\n\u003cli\u003eHoffman, M., \u003cem\u003eFDA Approves Tenecteplase for Acute Ischemic Stroke.\u003c/em\u003e\u003c/li\u003e\n\u003cli\u003eGrotta, J.C. and E.C. Haley Jr, \u003cem\u003eFood and Drug Administration Approval of Tenecteplase: What This Means for the Field of Acute Stroke Treatment\u003c/em\u003e. 2025. p. e001824.\u003c/li\u003e\n\u003cli\u003eParsons, M.W., et al., \u003cem\u003eTenecteplase versus alteplase for thrombolysis in patients selected by use of perfusion imaging within 4\u0026middot; 5 h of onset of ischaemic stroke (TASTE): a multicentre, randomised, controlled, phase 3 non-inferiority trial.\u003c/em\u003e The Lancet Neurology, 2024. \u003cstrong\u003e23\u003c/strong\u003e(8): p. 775-786.\u003c/li\u003e\n\u003cli\u003eAlamowitch, S., et al., \u003cem\u003eEuropean Stroke Organisation (ESO) expedited recommendation on tenecteplase for acute ischaemic stroke.\u003c/em\u003e Eur Stroke J, 2023. \u003cstrong\u003e8\u003c/strong\u003e(1): p. 8-54.\u003c/li\u003e\n\u003cli\u003eLogallo, N., C.E. Kvistad, and L. Thomassen, \u003cem\u003eTherapeutic potential of tenecteplase in the management of acute ischemic stroke.\u003c/em\u003e CNS drugs, 2015. \u003cstrong\u003e29\u003c/strong\u003e: p. 811-818.\u003c/li\u003e\n\u003cli\u003eMistry, E.A., et al., \u003cem\u003ePredicting 90-day outcome after thrombectomy: baseline-adjusted 24-hour NIHSS is more powerful than NIHSS score change.\u003c/em\u003e Stroke, 2021. \u003cstrong\u003e52\u003c/strong\u003e(8): p. 2547-2553.\u003c/li\u003e\n\u003cli\u003eChalos, V., et al., \u003cem\u003eNational Institutes of Health Stroke Scale: an alternative primary outcome measure for trials of acute treatment for ischemic stroke.\u003c/em\u003e Stroke, 2020. \u003cstrong\u003e51\u003c/strong\u003e(1): p. 282-290.\u003c/li\u003e\n\u003cli\u003eFure, B., T. Wyller, and B. Thommessen, \u003cem\u003eTOAST criteria applied in acute ischemic stroke.\u003c/em\u003e Acta Neurologica Scandinavica, 2005. \u003cstrong\u003e112\u003c/strong\u003e(4): p. 254-258.\u003c/li\u003e\n\u003cli\u003eYogendrakumar, V., et al., \u003cem\u003eSafety and efficacy of tenecteplase in older patients with large vessel occlusion: a pooled analysis of the EXTEND-IA TNK trials.\u003c/em\u003e Neurology, 2022. \u003cstrong\u003e98\u003c/strong\u003e(12): p. e1292-e1301.\u003c/li\u003e\n\u003cli\u003eZitek, T., R. Ataya, and I. Brea, \u003cem\u003eUsing tenecteplase for acute ischemic stroke: what is the hold up?\u003c/em\u003e Western Journal of Emergency Medicine, 2020. \u003cstrong\u003e21\u003c/strong\u003e(2): p. 199.\u003c/li\u003e\n\u003cli\u003eSekita, A., et al., \u003cem\u003eSwitch to tenecteplase for intravenous thrombolysis in stroke patients: experience from a German high-volume stroke center.\u003c/em\u003e Neurological Research and Practice, 2025. \u003cstrong\u003e7\u003c/strong\u003e(1): p. 28.\u003c/li\u003e\n\u003cli\u003eZhong, W., et al., \u003cem\u003eMinor non-disabling stroke patients with large vessel severe stenosis or occlusion might benefit from thrombolysis.\u003c/em\u003e brain sciences, 2021. \u003cstrong\u003e11\u003c/strong\u003e(7): p. 945.\u003c/li\u003e\n\u003cli\u003eSingh, N., et al., \u003cem\u003eEffect of time to thrombolysis on clinical outcomes in patients with acute ischemic stroke treated with tenecteplase compared to alteplase: analysis from the AcT randomized controlled trial.\u003c/em\u003e Stroke, 2023. \u003cstrong\u003e54\u003c/strong\u003e(11): p. 2766-2775.\u003c/li\u003e\n\u003cli\u003eMenon, B.K., et al., \u003cem\u003eIntravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial.\u003c/em\u003e The Lancet, 2022. \u003cstrong\u003e400\u003c/strong\u003e(10347): p. 161-169.\u003c/li\u003e\n\u003cli\u003eBala, F., et al., \u003cem\u003eSafety and efficacy of tenecteplase compared with alteplase in patients with large vessel occlusion stroke: a prespecified secondary analysis of the ACT randomized clinical trial.\u003c/em\u003e JAMA neurology, 2023. \u003cstrong\u003e80\u003c/strong\u003e(8): p. 824-832.\u003c/li\u003e\n\u003cli\u003eLi, S., et al., \u003cem\u003eSafety and efficacy of tenecteplase versus alteplase in patients with acute ischaemic stroke (TRACE): a multicentre, randomised, open label, blinded-endpoint (PROBE) controlled phase II study.\u003c/em\u003e Stroke and Vascular Neurology, 2022. \u003cstrong\u003e7\u003c/strong\u003e(1).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acute ischemic stroke, Tenecteplase, Alteplase, intravenous thrombolysis, door-to-needle time","lastPublishedDoi":"10.21203/rs.3.rs-8089533/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8089533/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eTenecteplase (TNK) and Alteplase (rt-PA) are intravenous thrombolytics used in acute ischemic stroke (AIS). While Alteplase has long been the standard of care, TNK is now also approved for AIS by both the EMA and FDA. Its single-bolus administration and favorable pharmacokinetics offer practical advantages. Despite growing guideline support, real-world data comparing both agents remain limited. This study aimed to compare clinical characteristics, imaging findings, treatment outcomes, and complication rates of AIS patients treated with TNK versus Alteplase at a single stroke center.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eWe conducted a retrospective monocentric analysis of 101 AIS patients treated with TNK (n\u0026thinsp;=\u0026thinsp;39) or Alteplase (n\u0026thinsp;=\u0026thinsp;62). We compared demographics, vascular risk factors, imaging findings, reperfusion therapies, and clinical outcomes using independent samples t-tests, Chi-square, and Mann\u0026ndash;Whitney U-tests as appropriate.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eBaseline characteristics were comparable between groups, including age (TNK: 72.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.4 vs. Alteplase: 70.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3), sex, and pre-stroke mRS. Initial NIHSS scores were similar (TNK: 6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3 vs. Alteplase: 7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2, p\u0026thinsp;=\u0026thinsp;0.83). No significant differences were found in LVO rates (15.4% vs. 27.4%, p\u0026thinsp;=\u0026thinsp;0.16), perfusion delay, or infarct demarcation. Functional outcomes at discharge (mRS: 2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 vs. 2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9, p\u0026thinsp;=\u0026thinsp;0.39) and rates of symptomatic intracranial hemorrhage (11.1% vs. 10.3%, p\u0026thinsp;=\u0026thinsp;0.91) were similar.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eIn this real-world cohort, TNK and Alteplase showed comparable safety and efficacy profiles. Functional outcomes and complication rates did not differ significantly, supporting TNK as a viable alternative to Alteplase in AIS.\u003c/p\u003e","manuscriptTitle":"Comparative Effectiveness of Tenecteplase and Alteplase for Ischemic Stroke: Real-World Data from a Stroke Center","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-02 13:46:59","doi":"10.21203/rs.3.rs-8089533/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-18T08:13:25+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-17T18:08:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-29T08:30:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73151477629155209110572833867619944830","date":"2025-11-29T07:59:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183300472837576549432882933973452328493","date":"2025-11-26T02:32:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57792805408829962143256734839237331802","date":"2025-11-25T23:34:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-25T23:30:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-24T16:06:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-13T08:23:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-13T08:20:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2025-11-11T18:15:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"816b6c6e-7c54-4724-afc5-cb59f0c6d716","owner":[],"postedDate":"December 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:10:44+00:00","versionOfRecord":{"articleIdentity":"rs-8089533","link":"https://doi.org/10.1186/s12883-026-04655-5","journal":{"identity":"bmc-neurology","isVorOnly":false,"title":"BMC Neurology"},"publishedOn":"2026-01-23 15:57:34","publishedOnDateReadable":"January 23rd, 2026"},"versionCreatedAt":"2025-12-02 13:46:59","video":"","vorDoi":"10.1186/s12883-026-04655-5","vorDoiUrl":"https://doi.org/10.1186/s12883-026-04655-5","workflowStages":[]},"version":"v1","identity":"rs-8089533","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8089533","identity":"rs-8089533","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}