Tenecteplase strengthens its case before thrombectomy

Clinical Takeaway: Although the trial compared tenecteplase with a low-dose alteplase regimen commonly used in Japan and other parts of Asia, the results are consistent with prior studies supporting tenecteplase before thrombectomy, with greater early reperfusion and a comparable safety profile.

Tenecteplase has gained increasing acceptance in acute ischemic stroke because of its single-bolus administration and evidence suggesting improved reperfusion before thrombectomy. However, direct comparisons with low-dose alteplase, which remains standard practice in several Asian countries, have been lacking.

The T-FLAVOR trial was the first randomized study to compare standard-dose tenecteplase (0.25 mg/kg) with low-dose alteplase (0.6 mg/kg) in patients with large-vessel occlusion stroke eligible for intravenous thrombolysis followed by mechanical thrombectomy. A total of 218 treated patients were included in the primary analysis.

Substantial reperfusion on the initial angiogram before thrombectomy occurred in 10.3% of patients receiving tenecteplase compared with 3.6% of those receiving alteplase, an absolute difference of 6.5 percentage points that met the study's prespecified superiority criterion.

Although the trial wasn't powered to detect differences in functional outcomes, results favored tenecteplase. The estimated odds ratio for a shift toward better 90-day functional outcomes was 1.47, and early neurologic improvement at 72 hours occurred in 67.3% of patients receiving tenecteplase versus 55.9% of those receiving alteplase.

Safety outcomes were similar between groups. Symptomatic intracranial hemorrhage occurred in 2.8% of patients receiving tenecteplase and 1.8% receiving alteplase, while 90-day mortality was 6.5% and 9.9%, respectively.

For US clinicians, the study provides additional evidence supporting tenecteplase as a thrombolytic option before thrombectomy. Although the comparator was low-dose alteplase rather than the standard-dose regimen commonly used in the United States, the results are broadly consistent with prior randomized trials.

Source: Inoue M, et al. 2026 June 1. JAMA Neurology. Standard-Dose Tenecteplase vs Low-Dose Alteplase for Acute Ischemic Stroke From Large-Vessel Occlusion