Comparative Effectiveness of Intravenous Tenecteplase versus Alteplase in Posterior Circulation Ischemic Stroke: A Systematic Review and Meta-Analysis

Background Posterior circulation ischemic stroke (PCIS) is associated with substantial morbidity and mortality, and the optimal intravenous thrombolytic strategy in this subgroup remains unclear. Methods We searched databases for studies comparing intravenous tenecteplase with alteplase in adults with PCIS. Primary outcomes were 90-day functional outcomes (mRS 0–1, mRS 0–2, and mRS 0–3). Secondary outcomes included perfusion, hemorrhagic complications, and mortality. Results Five studies involving 997 patients were included. Tenecteplase was associated with significantly greater likelihood of ambulatory functional outcome at 90 days (mRS 0–3) [RR 1.29, 95% CI 1.03–1.60; p = 0.02] and pre-EVT perfusion [RR 2.18, 95% CI 1.06–4.46; p = 0.03]. No significant differences were observed for excellent functional outcome (mRS 0–1) [RR 1.19, 95% CI 0.91–1.56; p = 0.20], functional independence (mRS 0–2) [RR 1.10, 95% CI 0.89–1.37; p = 0.39], post-EVT perfusion [RR 1.12, 95% CI 0.89–1.40; p = 0.34; I² = 38%], sICH [RR 0.89, 95% CI 0.36–2.22; p = 0.81], any intracranial hemorrhage [RR 1.02, 95% CI 0.59–1.78; p = 0.94], parenchymal hematoma [RR 0.76, 95% CI 0.24–2.38; p = 0.64], or 90-day mortality [RR 0.88, 95% CI 0.66–1.17; p = 0.39]. Conclusion Tenecteplase may improve reperfusion and ambulatory recovery without increasing hemorrhagic complications, mortality compared with alteplase in PCIS, although larger PCIS-specific studies are needed.