Efficacy and safety of adjunctive intra-arterial tenecteplase following endovascular thrombectomy for large vessel occlusion acute ischemic stroke: a systematic review and meta-analysis

Gonçalves O.R.; Leal M.T.; Damasceno Gentil Arruda G.A.; Donato K.; Santos de Oliveira M.Í.; Ohannesian V.A.; de Lima Barbosa A.M.; Pereira da Silva A.M.; Corrêa M.R.; Ribeiro F.V.; de Bastos Maximiano M.L.; Ferreira M.Y.; Ferreira C.; Bocanegra-Becerra J.E.; Almeida K.J.; Serulle Y. · Journal of Clinical Neuroscience (2025) · DOI: 10.1016/j.jocn.2025.111670

Resumen

Background Despite the widespread adoption of endovascular thrombectomy (EVT), a significant proportion of patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) remain disabled or deceased at 90 days. Adjunctive intra-arterial administration of tenecteplase (IA-TNK) has emerged as a potential strategy to enhance recanalization and improve clinical outcomes following EVT. Objective To evaluate the efficacy and safety of adjunctive IA-TNK administration following EVT in patients with AIS due to LVO, compared to EVT alone. Methods A systematic review and meta-analysis were conducted according to PRISMA guidelines. PubMed, Embase, and Cochrane Library databases were searched up to July 2025. Eligible studies included randomized controlled trials (RCTs) and observational cohorts comparing IA-TNK administration after EVT with EVT alone. The primary outcomes were excellent and favorable functional outcomes, defined as modified Rankin Scale (mRS) scores of 0–1 and 0–2, respectively. Secondary outcomes included early neurological improvement, successful reperfusion (expanded Thrombolysis in Cerebral Infarction [eTICI] 2c–3), symptomatic intracranial hemorrhage (sICH), any intracranial hemorrhage (aICH), and mortality. Pooled Risk Ratios (RR) and Mean Differences (MD) were calculated using the Mantel-Haenszel method with a random-effects model. Heterogeneity was assessed using the I2 statistic and Cochran’s Q test. Analyses were performed with R software (version 4.4.0). Results A total of seven studies were included (4 RCTs and 3 observational studies). Pooled analysis showed that IA-TNK was associated with a significantly higher rate of excellent functional outcomes (RR 1.20; 95% CI (1.03–1.40)) particularly in randomized controlled trials. However, no significant differences were found in favorable functional outcomes (RR 1.06 95% CI; (0.96–1.17), early neurological improvement (RR 1.15; 95% CI (0.80–1.66)), or successful reperfusion (RR 0.97; 95% CI (0.89–1.05)). IA-TNK was not linked to increased rates of symptomatic (RR 1.34; 95% CI (0.85–2.12)) or any intracranial hemorrhage (RR, 1.13; 95% CI (0.93–1.38)), and mortality was similar between groups (RR 0.92; 95% CI (0.75–1.13). Subgroup analyses suggested potential benefit in younger patients and those with cardioembolic stroke, but not across other baseline characteristics. Conclusion Our meta-analysis suggests that IA-TNK may offer a modest benefit in achieving excellent functional outcomes (mRS 0–1), particularly in select subgroups such as younger patients and those with cardioembolic stroke. While these findings indicate a potential signal of efficacy in specific contexts, the overall evidence remains inconclusive. Further large-scale, high-quality RCTs are warranted to clarify the clinical utility, optimal patient selection, and risk–benefit balance of IA-TNK as an adjunct to EVT in AIS.

Instituciones: Universidad Peruana Cayetano Heredia