A multicenter Japanese randomized trial tested whether standard-dose tenecteplase (0.25 mg/kg) outperforms low-dose alteplase (0.6 mg/kg) in patients with large-vessel occlusion stroke heading into mechanical thrombectomy. Among 218 patients, tenecteplase achieved substantial reperfusion before thrombectomy in 10.3% of patients versus just 3.6% with alteplase — nearly three times the rate. Functional outcomes at 90 days favored tenecteplase (odds ratio 1.47), though this did not reach statistical significance. Critically, safety profiles were comparable: symptomatic brain bleeding occurred in 2.8% vs 1.8%, and 90-day mortality was 6.5% vs 9.9%. The findings support tenecteplase as a superior pre-thrombectomy thrombolytic in regions like Japan where low-dose alteplase remains standard.
