Document resource
Background Tenecteplase (TNK) offers pharmacologic advantages over alteplase (tPA) including greater fibrin specificity, longer half-life, and single-bolus administration. While TNK has demonstrated higher reperfusion rates in large vessel occlusion strokes, evidence in basilar artery occlusion (BAO) remains limited. We aimed to compare clinical outcomes between TNK and tPA as bridging thrombolysis in adults with BAO treated with endovascular thrombectomy (EVT).Methods We conducted a retrospective cohort study using the TriNetX Research Network (113 healthcare organizations, January 2016 to November 2025). Adults (18 years or older) with BAO stroke who received intravenous thrombolysis (TNK or tPA) plus EVT within 1 day were identified using ICD-10-CM/PCS and RxNorm codes. BAO was defined using codes for cerebral infarction due to thrombosis, embolism, or occlusion of basilar, vertebral, posterior cerebral, and cerebellar arteries. Documentation of NIHSS score was required. Propensity score matching (nearest-neighbor greedy algorithm) balanced demographics (age, sex, race), comorbidities (atrial fibrillation, hypertension, ischemic heart disease, heart failure, hyperlipidemia, diabetes, obesity, chronic kidney disease, peripheral vascular disease, liver disease, cerebral atherosclerosis), stroke severity categories, neurologic symptoms (dizziness, ataxia, dysarthria, dysphagia, altered mental status, visual field defects), intracranial hemorrhage subtypes, procedures, and medications. Primary outcomes at 90 and 180 days included major bleeding, intracranial hemorrhage (ICH), all-cause mortality, functional dependency, emergency department visits for critical illness, and rehabilitation needs.Results Among 553 patients (TNK 193; tPA 360), propensity score matching produced 173 pairs for 90-day and 171 pairs for 180-day analyses with adequate covariate balance (all SMD less than 0.20). Before matching, the TNK cohort was older (69.1 vs 66.1 years, p=0.02), with higher prevalence of heart failure (33.7% vs 25.6%, p=0.04), peripheral vascular disease (32.1% vs 21.4%, p=0.006), and prior TIA/stroke (14.5% vs 6.7%, p=0.003). At 90 days after matching, TNK was associated with significantly higher rehabilitation needs (65.3% vs 53.2%; OR 1.66, 95% CI 1.08-2.56; HR 1.47, 95% CI 1.11-1.93; p=0.005). No significant differences were observed in major bleeding (16.8% vs 13.3%, p=0.39), ICH (15.0% vs 11.0%, p=0.28), mortality (24.3% vs 26.0%, p=0.66), functional dependency (26.0% vs 22.0%, p=0.54), or critical illness ED visits (60.7% vs 64.2%, p=0.38). At 180 days after matching, rehabilitation needs remained numerically higher with TNK with borderline significance (66.7% vs 59.1%; HR 1.30, 95% CI 1.00-1.71; p=0.048), while other outcomes remained similar including major bleeding (14.6% vs 14.0%, p=0.91), ICH (13.5% vs 11.7%, p=0.65), mortality (24.6% vs 23.4%, p=0.90), and functional dependency (28.1% vs 22.8%, p=0.37).Conclusion TNK and tPA demonstrated comparable safety and mortality in BAO treated with combined thrombolysis and EVT through 180 days. Higher rehabilitation utilization with TNK likely reflects survivor bias and temporal confounding rather than a difference in functional recovery.Disclosures M. Essibayi: None.