This study aims to compare the therapeutic efficacy and safety of two different thrombolytic agents Tenecteplase and alteplase in patients with acute ischemic stroke.

Tenecteplase, a newer generation tissue plasminogen activator, offers potential advantages over the current standard treatment, Alteplase, for acute ischemic stroke due to its longer half-life and greater fibrin specificity. This systematic review evaluates the effectiveness of these two thrombolytic agents in stroke management.

Electronic databases like PubMed, Cochrane Library, and ScienceDirect were comprehensively searched till September 2024. Risk Ratios (RR) for all the extracted dichotomous outcomes were pooled along with 95% confidence intervals (CI) under the random effects model using Review Manager 5.4.1. The RoB 2.0 tool was used to assess the quality of the included randomized controlled trials, and the Leave-one-out sensitivity analysis was used to investigate the heterogeneity. The risk of publication bias was assessed through funnel plots and Egger's regression test. A GRADE assessment was conducted to determine the certainty of evidence.

Twelve trials, including a total of 7,268 patients, were included in the quantitative analysis. Tenecteplase was comparable to Alteplase regarding excellent functional outcomes (modified Rankin Scale (mRS) 0-1) at 90 days (RR=1.04; 95% CI:[1.00,1.08]; p=0.06; I²=4%), good functional outcomes (mRS 0-2) at 90 days (RR=1.01; 95% CI:[0.96,1.05]; p=0.78; I²=41%), poor functional outcomes (mRS  5-6) at 90 days (RR=0.98; 95% CI:[0.82,1.16]; p=0.81; I²=30%), symptomatic Intracranial hemorrhage (SICH) (RR=1.13; 95% CI:[0.83,1.53]; p=0.43; I²=0%), and major neurological improvement within 72 hours(RR=1.05; 95% CI:[0.94,1.18]; p=0.38; I²=52%).

Tenecteplase demonstrated non-inferiority to Alteplase in treating acute ischemic stroke, with similar efficacy in functional outcomes and safety profiles. This suggests Tenecteplase may serve as a viable alternative to Alteplase for stroke management.