Bridging thrombolysis can facilitate early recanalization in LVOS, potentially reducing the need for EVT. The relative efficacy of TPA versus TNK in achieving complete versus partial clot dissolution and its influence on subsequent EVT requires further investigation.

This retrospective review included 280 consecutive LVOS patients treated with intravenous thrombolysis (TPA or TNK) and referred for EVT between January 2020 and May 2024. Early recanalization endpoints were defined as: (1) neurological improvement precluding EVT, (2) eTICI 2b-3 on cerebral angiography, and (3) distal thrombus migration compared to initial CT angiography, with or without the need for mechanical thrombectomy.

Of the 280 patients, 181 received TNK (64.6%) and 99 received TPA (35.4%). The most common occlusion sites were the M1 segment of the middle cerebral artery (46.4%), M2 segment (24.3%), and tandem ICA/MCA occlusion (15.7%). Any recanalization endpoint was achieved in 42/181 TNK cases (23.2%) versus 11/99 TPA cases (11.1%) (p=0.016). Neurological improvement precluded EVT in 4.4% of TNK cases versus 3.0% of TPA cases (p=0.752). First-pass angiography showed eTICI 2b-3, leading to procedure termination in 7.7% of TNK and 6.1% of TPA cases (p=0.603). First-pass angiography also demonstrated partial recanalization and a need for mechanical thrombectomy in 11% of TNK and 2% of TPA cases (p=0.009). Overall, partial recanalization occurred in 17.3% of TNK cases versus 7.3% of TPA cases (p=0.026). Multivariable analysis identified lower baseline NIHSS and TNK administration as independent predictors of early recanalization.

In LVOS patients, thrombolysis with tenecteplase is associated with higher rates of early recanalization compared to alteplase, primarily due to partial recanalization and distal thrombus migration.