To compare hemorrhagic transformation severity and imaging phenotypes following intravenous tenecteplase versus alteplase in patients with acute ischemic stroke.
Approach:
Study Design: A retrospective real-world cohort study of patients treated with intravenous thrombolysis at a stroke center.
Participants: Included 95 patients (alteplase n = 41; tenecteplase n = 54) with acute ischemic stroke treated between January and December 2025.
Endpoints: Primary endpoint was ordinal shift in hemorrhagic transformation severity using the Heidelberg Bleeding Classification; secondary endpoint was symptomatic intracranial hemorrhage (sICH).
Statistical Analysis: Multivariable logistic regression was performed to identify independent predictors of hemorrhage.
Key Findings:
No significant difference in sICH incidence between tenecteplase and alteplase groups (p = NS).
Higher baseline NIHSS score (OR 1.10, 95% CI 1.02–1.18, p = 0.013) and longer onset-to-needle time (OR 1.12 per 10 min, 95% CI 1.02–1.23, p = 0.016) were independently associated with intracranial hemorrhage.
No significant ordinal shift in hemorrhagic severity was detected between treatment groups (p = NS).
Interpretation:
Limitations:
Small sample size and limited number of severe hemorrhagic events.
Findings should be interpreted as preliminary and hypothesis-generating due to the limited sample size.
Conclusion:
Imaging-based classification using the Heidelberg framework did not reveal a significant shift toward more severe hemorrhagic phenotypes between the two thrombolytic agents.
