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Kelani, Abdelraouf, Salamah, Berglas, Elboraay, Mahmoud, Abugdida, Albaramony, Elazim, Greene-Chandos, El-Ghanem, Vulkanov, Sunik, Khaneja, Lerner, and Al-Mufti: Efficacy and safety of tenecteplase for acute ischemic stroke within an extended treatment window: a systematic review, meta-analysis, and trial sequential analysis of randomized controlled trials
Review Article

J Neurocrit Care 2025;18(2):52-63.

Published online: 29 December 2025

DOI: https://doi.org/10.18700/jnc.250030

Efficacy and safety of tenecteplase for acute ischemic stroke within an extended treatment window: a systematic review, meta-analysis, and trial sequential analysis of randomized controlled trials

Hesham Kelani, MD1, Mohamed R. Abdelraouf, MBBS2, Hazem Mohamed Salamah, MBBS3, Eli Berglas, BA1, Toka Elboraay, MBBS3, Abdelrahman Mahmoud, MBBS4, Mohamed Abugdida, MBBS4, Nadia Albaramony, MBBS5, Ahmed Abd Elazim, MD6, Diana Greene-Chandos, MD7, Mohammad El-Ghanem, MD8, Volodymyr Vulkanov, MD9, Artem Sunik, MD1, Amit Khaneja, MD1, David P. Lerner, MD1, Fawaz Al-Mufti, MD10

1College of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA

2Faculty of Medicine, Alexandria University, Alexandria, Egypt

3Faculty of Medicine, Zagazig University, Zagazig, Egypt

4Faculty of Medicine, Minia University, Minia, Egypt

5Department of Neurology, Louisiana State University, Shreveport, LA, USA

6Department of Neurology, Sanford USD Medical Center, Sanford, SD, USA

7Department of Neurology, School of Medicine, University of Saint Louis, St. Louis, MO, USA

8Department of Clinical Science, University of Houston, HCA Houston-Northwest Medical Center, Houston, TX, USA

9Department of Neurology, Rutgers New Jersey School of Medicine, Newark, NJ, USA

10Departments of Neurology, Neurosurgery and Radiology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA

Corresponding author: Hazem Mohamed Salamah, MBBS Faculty of Medicine, Zagazig University, Zagazig 7120001, Egypt Tel: +20-10-1120-1851 Email: hazem.salamah@gmail.com

Received 8 September 2025       Revised 22 October 2025       Accepted 20 November 2025

© 2025 The Korean Neurocritical Care Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

In acute ischemic stroke (AIS), the treatment window for thrombolytics is 4.5 hours from symptom onset. Tenecteplase, a modified tissue plasminogen activator, may be effective over an extended treatment window (4.5–24 hours). Hence, a meta-analysis was performed to evaluate tenecteplase use within an extended treatment window.

Methods

Databases were searched for articles published before July 3, 2024. Randomized controlled trials (RCTs) that compared tenecteplase treatment in an extended treatment window with the current standard of care were included. The endpoints were excellent functional outcomes (modified Rankin Scale [mRS] 0–1) at 90 days, National Institutes of Health Stroke Scale (NIHSS) score change at 24 hours and 7 days, and symptomatic intracranial hemorrhage (sICH) at 90 days. The pooled risk ratio (RR) and mean difference (MD) were calculated for categorical and continuous outcomes, respectively.

Results

Four RCTs involving 1,629 patients with AIS were included. High-quality evidence indicated that tenecteplase achieved a higher likelihood of mRS 0–1 at 90 days (RR, 1.21; 95% confidence interval [CI], 1.06 to 1.38; P=0.004) and a lower NIHSS score change at 24 hours (MD, −0.84; 95% CI, −1.40 to −0.27; P=0.003) than that of the placebo. Low-quality evidence showed that tenecteplase reduced the NIHSS score change at 7 days (MD, −0.79; 95% CI, −1.56 to −0.03; P=0.04). No differences in sICH or mortality were observed.

Conclusion

Tenecteplase compared favorably with non-thrombolytic therapy in an extended treatment window. Future RCTs may establish tenecteplase as the standard of care for up to 24 hours.

Keywords: Ischemic stroke, Extended time window, Plasminogen activators, Thrombolytic therapy, Meta-analysis, Tenecteplase

INTRODUCTION

Stroke is a major cause of morbidity and mortality worldwide [1]. Given that acute ischemic stroke (AIS) accounts for the majority of strokes, reperfusion therapies are at the forefront of clinical innovation [2,3]. Despite advancements in endovascular techniques, most AIS cases only require medical therapy [4]. When indicated, thrombolytic agents, namely tissue plasminogen activators (tPA), such as alteplase, are crucial for restoring cerebral blood flow. However, thrombolytic therapy must be initiated quickly to ensure that vessel recanalization occurs rapidly enough to limit hypoxic brain injury. Current guidelines suggest a 4.5-hour treatment window based on the 2008 the European Cooperative Acute Stroke Study trial, which established the benefit of extending the tPA treatment window from 3 to 4.5 hours after stroke onset [5,6]. The prevailing concern is that after a 4.5-hour treatment window, the complications of tPA therapy, namely hemorrhage, outweigh the benefits of restoring blood flow to an already highly damaged brain parenchyma [5,7].
Given the ischemic nature of AIS injury, the benefits of extended thrombolytic use continues to be explored. Recent guidelines suggest that there is moderate evidence supporting alteplase therapy within 9 h of stroke onset if perfusion imaging indicates the presence of salvageable ischemic brain tissue [8,9]. This extended treatment window allows for the treatment of patients who may have missed the initial 4.5-hour treatment window. Given the increasingly aggressive use of tPAs for the treatment of AIS, alternative tPA therapies with various pharmacological properties have been explored. Such an agent is the third-generation tPA tenecteplase, which has enhanced fibrin specificity, increased resistance to plasminogen activator inhibitor 1, and the convenience of single-bolus administration [10-13]. Tenecteplase is at least as effective as alteplase and may lead to better clinical outcomes, such as higher recanalization rates and improved functional recovery [13-15].
Considering that tenecteplase shows promising results in the established 4.5-hour thrombolytic window [13-15], its role as a viable thrombolytic in an extended treatment window (4.5–24 hours after onset) is currently being explored [16-19]. However, given that the use of tenecteplase in an extended treatment window is relatively new, high-quality randomized controlled trials (RCT) are limited. Therefore, this study aimed to conduct a systematic review and meta-analysis of RCTs that evaluated tenecteplase use in an extended treatment window relative to the current standard of care. In doing so, this study will summarize the current evidence to evaluate the efficacy and safety of tenecteplase treatment between 4.5 and 24 hours after AIS symptom onset. The findings of this study will have important clinical implications for further optimization of AIS treatment algorithms for patients eligible for thrombolytic therapy.

METHODS

Protocol documentation

This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines in adherence to the Cochrane Handbook of Systematic Reviews [20,21]. The protocol for this systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42024565984).

Data sources and search strategy

A literature search of PubMed, Cochrane, Scopus, and Web of Science was conducted. The end date was July 3, 2024, and no restrictions on language or year of publication were implemented. The following terms were searched: ("Tenecteplase OR TNK OR TNKase OR Metalyse OR Elaxim) AND (“ischemic stroke” OR “intracranial occlusion” OR “minor stroke” OR “transient ischemic attack” OR stroke* OR “tandem lesion” OR “cerebral infarction” OR “cerebrovascular accident” OR “vessel occlusion”). The full search strategy for each database is presented in Supplementary Table 1.

Eligibility criteria

RCTs that evaluated tenecteplase versus non-thrombolytic therapy in patients with AIS over an extended time window were included. The extended time window was defined as thrombolytic treatment between 4.5 to 24 hours after the time the patient was last seen well, including wake-up stroke.

Study selection

All the records were managed using Rayyan, a web-based software platform. Two reviewers independently screened the records in two stages: title and abstract, followed by full-text review. Article selection was based on the predefined eligibility criteria. Disagreements during the selection process were resolved through discussions with a third reviewer.

Data extraction

Two reviewers independently extracted the data using a standardized extraction form (Microsoft Excel) encompassing the study characteristics, baseline patient data, and study outcomes. Any conflict of interest was resolved through discussion with a third reviewer.

Outcomes

The primary outcome was excellent functional outcome at 90 days as defined by modified Rankin Scale (mRS) scores of 0–1. Secondary outcomes included functional independence (mRS 0–2) at 90 days, National Institutes of Health Stroke Scale (NIHSS) score change at 24 hours and 7 days, reperfusion at 24 hours, symptomatic intracranial hemorrhage (sICH) at 90 days, overall adverse events, serious adverse events, and 90-day mortality. Conference abstracts, observational studies, nonrandomized studies, review articles, and animal studies were excluded from the analysis.

Assessment of bias

The quality of each study was assessed using the Cochrane Risk of Bias Tool version 2 (ROB-2) [22]. The evaluated risk of bias domains included the randomization process, deviation from the intended intervention, missing outcome data, outcome measurements, and selection of the reported results. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines were used to assess the quality of the evidence [23].

Statistical analysis

Data analysis was conducted using RevMan version 5.4. The pooled risk ratio (RR) was calculated for categorical outcomes, and the mean difference was determined for continuous outcomes. Both were calculated with 95% CI. A random-effects model was used to evaluate the outcomes regardless of heterogeneity. Heterogeneity was evaluated using I2 with values >60% and the chi-square test (Cochran’s Q test) with P-values <0.1 representing significant heterogeneity. In cases of significant heterogeneity, leave-one-out sensitivity analysis was performed to investigate the source of heterogeneity. Finally, trial sequential analysis (TSA) was performed using TSA software (Copenhagen Trial Unit, Centre for Clinical Intervention Research) on the primary outcomes of 90-day excellent functional outcome (mRS 0–1), 90-day functional independence (mRS 0–2), NIHSS score change at 24 hours, NIHSS score change at 7 days, and sICH at 90 days. This study used a two-sided conventional boundary with a 5% type-I error rate. Alpha-spending boundaries were established using a two-sided boundary type with type I errors set to 5% and 80% statistical power. The O'Brien-Fleming approach was used for the alpha- and beta-spending functions. To determine the required information size, an estimation method was used, and the model variance was applied for heterogeneity correction. Owing to the limited number of included studies, an assessment of publication bias was not performed, as it is generally recommended that a minimum of ten studies be available to yield reliable and meaningful results [24].

RESULTS

Search results

The systematic search of the four databases yielded 2,100 studies. After removing 1,244 duplicates, the remaining 856 records were screened based on their titles and abstracts. This initial screening process resulted in the exclusion of 842 studies that did not meet the inclusion criteria. Consequently, 14 studies were deemed eligible for full-text evaluation. Of these, 10 studies were excluded following a comprehensive review of their full texts, leaving four studies that met the inclusion criteria and were included in the meta-analysis. A PRISMA flow diagram illustrating the article search and selection process is provided in Fig. 1.

Characteristics of included studies

Four RCTs [16-19] consisting of 1,629 patients with AIS were included in the study. Further details regarding each RCT and its inclusion criteria are presented in Table 1. The baseline characteristics of the patients included in each RCT are shown in Supplementary Table 2.

Risk of bias and quality assessment

Using ROB-2, one study [16] showed an overall low risk of bias. However, the other three studies [17-19] showed signs of bias due to deviation from the intended intervention (Fig. 2). The quality of evidence determined using the GRADE guidelines showed no concerns about quality in the primary outcome of excellent functional outcome (mRS 0–1) at 90 days or in the secondary outcome of an NIHSS score change at 24 hours. Owing to serious imprecision concerns, only moderate certainty of evidence was observed for sICH. Furthermore, owing to very serious imprecision concerns, low certainty of evidence existed for functional independence (mRS 0–2) at 90 days. Low certainty of evidence was also present for NIHSS score change at 7 days owing to serious concerns of inconsistency and imprecision. Lastly, very low certainty was present for the data on reperfusion outcomes at 24 hours owing to serious concerns of inconsistency and imprecision (Table 2).

Efficacy outcomes

Excellent functional outcome (mRS 0–1) at 90 days

High-certainty evidence showed that patients receiving tenecteplase in the extended treatment window were more likely to achieve excellent functional outcomes (mRS 0–1) at 90 days than those receiving the current standard of care (RR, 1.21; 95% CI, 1.06–1.38; P=0.004). The pooled analysis was homogeneous (I2=0%, P for Cochran’s Q=0.76) (Fig. 3A).

Functional independence (mRS 0–2) at 90 days

Low certainty evidence showed no statistically significant difference in functional independence (mRS 0–2) at 90 days between those receiving tenecteplase in the extended treatment window and those receiving the current standard of care (RR, 1.10; 95% CI, 0.99–1.21; P=0.07). The pooled analysis was homogeneous (I2=8%, P for Cochran’s Q=0.35) (Fig. 3B).

NIHSS score change at 24 hours

High-certainty evidence showed that tenecteplase led to an improvement in NIHSS score at 24 hours compared to that under the current standard of care (mean difference [MD], −0.84; 95% CI, −1.40 to −0.27; P=0.003). The pooled analysis was homogeneous (I2=14%, P for Cochran’s Q=0.28) (Fig. 4A).

NIHSS score change at 7 days

Low-certainty evidence indicated that tenecteplase significantly improved the NIHSS score at 7 days compared with that under the current standard of care (MD, −0.79; 95% CI, −1.56 to −0.03; P=0.04). However, the pooled analysis exhibited significant heterogeneity (I2=63%, P for Cochran’s Q=0.06) (Fig. 4B).
The potential sources of heterogeneity were explored by conducting sensitivity analyses. Excluding a single study (TWIST) resulted in a homogenous pooled analysis (I2=0%, P for Cochran’s Q=0.45), and the overall effect remained statistically significant (MD, −1.25; 95% CI, −1.84, −0.65; P<0.0001) (Supplementary Fig. 1).

Reperfusion at 24 hours

Very low certainty evidence showed that tenecteplase did not significantly improve reperfusion at 24 hours compared to that under the current standard of care (RR, 1.25; 95% CI, 0.73–2.12; P=0.41). However, the pooled analysis revealed significant heterogeneity (I2=81%, P for Cochran’s Q=0.02). Sensitivity analysis was not applicable as only two studies reported this outcome (Fig. 4C).

Safety outcomes

Overall adverse effects

No statistically significant difference in overall adverse events was observed between patients receiving tenecteplase in the extended treatment window and those receiving tenecteplase under the current standard of care (RR, 1.26; 95% CI, 0.88–1.82; P=0.21). The pooled analysis was heterogeneous (I2=73%, P for Cochran’s Q=0.02) (Fig. 5A). Heterogeneity was resolved by excluding TRACE-III from the analysis (I2=33%, P for Cochran’s Q=0.22); however, the overall effect remained non-significant (RR, 1.60; 95% CI, 0.94–2.73; P=0.08) (Supplementary Fig. 2).

Serious adverse effects

The analysis revealed no statistically significant difference in serious adverse events between patients receiving tenecteplase in the extended treatment window and those under the current standard of care (RR, 1.22; 95% CI, 0.92–1.62; P=0.16). The pooled analysis was homogeneous (I2=0%, P for Cochran’s Q=0.38) (Fig. 5B).

The sICH at 90 days

Moderate certainty evidence showed no significant difference between tenecteplase treatment in the extended treatment window and treatment under the current standard of care in terms of the incidence of sICH at 90 days (RR, 1.98; 95% CI, 0.93–4.24; P=0.08). The pooled analysis was homogeneous (I2=0%, P for Cochran’s Q=0.58) (Fig. 5C).

Mortality at 90 days

The addition of tenecteplase in the extended treatment window did not lead to significantly greater mortality at 90 days than that under the current standard of care (RR, 1.11; 95% CI, 0.86–1.43; P=0.44). The pooled analysis was homogeneous (I2=0%, P for Cochran’s Q=0.61) (Fig. 5D).

TSA findings

TSA showed that the cumulative z-curve crossed the trial sequential monitoring boundary for the favorable effect of tenecteplase therapy on excellent functional outcome (mRS 0–1), NIHSS score at 24 hours, and NIHSS score at 7 days. The cumulative sample size exceeded the diversity-adjusted required information size for excellent functional outcomes (mRS 0–1) and NIHSS at 24 hours (Supplementary Figs. 3 and 4). This confirms that tenecteplase therapy has a beneficial effect on excellent functional outcome (mRS 0–1) and NIHSS score at 24 hours, and further studies are unlikely to alter these findings. However, the TSA of functional independence (mRS 0–2), NIHSS score at 7 days, and sICH at 90 days revealed insufficient evidence to draw meaningful conclusions, and further investigation is required (Supplementary Figs. 5-7).

DISCUSSION

The optimal treatment window for thrombolytic therapy in AIS remains a topic of debate [6,8]. Although a 4.5-hour treatment window is the current standard of care, introduction of alternative tPAs has incited new trials evaluating the use of thrombolytics up to 24 hours after symptom onset [16-19]. This is because alternative tPAs, such as tenecteplase, have pharmacological properties that may confer greater safety when used outside the 4.5-hour window [10-13]. Considering the massive societal burden of AIS, a more flexible timeline for thrombolytic therapy may lead to a substantial reduction in harm. Therefore, this study conducted a systematic review and meta-analysis of RCTs evaluating tenecteplase treatment in the extended treatment window (4.5–24 hours) to evaluate its efficacy and safety compared to that under the current standard of care.
The primary outcome of this study was an excellent functional outcome (mRS 0–1) at 90 days, which is an important marker of morbidity and mortality in patients with AIS [25]. The meta-analysis found that the group treated with tenecteplase in the extended treatment window was 21% more likely than the standard care group to achieve an excellent functional outcome (mRS 0–1) at 90 days. This result was supported by the high certainty of the evidence and TSA. Furthermore, despite the meta-analyzed RCTs having different inclusion criteria and patient characteristics, all four RCTs favored the addition of tenecteplase in the 4.5–24-hour treatment window. Similar findings were found for functional independence (mRS 0–2) at 90 days, with a lower certainty of evidence. However, the overall effect was not significant. In line with the improved functional outcomes, this meta-analysis found a benefit for the extended-window use of tenecteplase when evaluating NIHSS scores at 24 hours and 7 days. Although the certainty of evidence was stronger for the NIHSS score at 24 hours, which was also validated with TSA, both findings indicate a clear benefit of using tenecteplase in the extended treatment window.
Based on the function of tenecteplase, the likely cause of these improved functional and NIHSS outcomes was the restoration of cerebral blood flow, leading to a shorter duration of parenchymal ischemia [26]. However, this study did not find a significant overall difference in reperfusion rates between patients treated with tenecteplase in the extended treatment window and those treated under the current standard of care. However, reperfusion outcomes had concerning certainty of evidence and were riddled with heterogeneity between the two included trials [16,19]. When assessing each RCT independently, the TRACE-III trial showed a substantially increased likelihood of reperfusion (70%) in patients treated with tenecteplase compared with that under the current standard of care, which was not the case in the TIMELESS trial. One likely factor contributing to the heterogeneity of findings was the use of thrombectomy in both studies. Unlike the TIMELESS trial, patients enrolled in the TRACE-III trial did not undergo thrombectomy. Therefore, the higher reperfusion rates in TRACE III can be explained by the fact that patients are more likely to have a thrombus that leads to an ischemic insult. However, this thrombus could be broken down by tenecteplase, thus restoring perfusion.
The purpose of the thrombolytic window is to establish the time point at which the risk of thrombolysis outweighs the benefits of cerebral perfusion. Logically, the greatest risk consideration is hemorrhagic transformation; however, tPAs also enhance the inflammatory process, which may independently lead to further parenchymal damage [7,10,11,27,28]. The present meta-analysis assessed the total adverse events, serious adverse events, sICH, and 90-day mortality to quantify the risks of tenecteplase treatment in an extended treatment window. Although no significant differences were observed, all adverse events were more likely to occur in the tenecteplase-treated group. When combining the increased likelihood of adverse events in the tenecteplase group with the lack of certainty in the evidence, considerable risks associated with tenecteplase treatment in the extended treatment window must be considered. However, these findings do not disqualify the use of tenecteplase in the extended treatment window. This is because some of these risks, namely, the incidence of sICH, are increased even if tPAs are administered in the established 4.5-hour window [5,7,29]. Therefore, continuing to validate tPAs in an extended treatment window is reasonable. If the benefits continue to be demonstrated across trials, extended-window administration can be an added option for patient-centered decision-making in AIS [30]. Therefore, new clinical trials, such as Extending the Time Window for Tenecteplase by Effective Reperfusion in Patients With Large Vessel Occlusion, have assessed the use of tenecteplase for large-vessel occlusion in the extended treatment window period [31]. Considering that the trials to date have yielded mixed results, even if the guideline-recommended treatment window for tPA therapy expands, it will likely be accompanied by a high level of nuance in decision-making [16-19,32].
To the best of the authors’ knowledge, this study is the most comprehensive meta-analysis that compares and examines the effect of tenecteplase treatment over an extended treatment window with that under the current standard of care. However, the study had some limitations, including significant heterogeneity and a limited sample size for some outcomes. Given that all the included studies were RCTs, the time until treatment initiation did not vary greatly among the studies. However, during meta-analysis of these studies, variation in treatment across a large treatment window period (4.5–24 hours) may have biased the results. Furthermore, methodological differences, such as the presence of thrombectomy, inclusion of wake-up stroke, and baseline NIHSS requirements for inclusion, may have biased the results.

IMPLICATIONS FOR FUTURE RESEARCH

TSA showed that future studies are not required to validate the benefit of extended-window therapy for increasing the likelihood of excellent functional outcome (mRS 0–1) at 90 days and NIHSS score at 24 hours. However, further studies are required to draw more robust conclusions regarding functional independence (mRS 0–2), sICH, and NIHSS score at 7 days. Moreover, additional studies are needed to examine the effects of other thrombolytic agents within an extended treatment window and compare them with tenecteplase and the current standard of care.

CONCLUSION

This study demonstrated that tenecteplase can increase the likelihood of a better functional outcome at 90 days, NIHSS score at 24 hours, and NIHSS score at 7 days. However, further studies are needed to confirm its efficacy in reperfusion at 24 hours and safety when compared to the current standard of care within an extended treatment window.

Notes

Ethics statement

Institutional review board approval and informed consent were not applicable because this study was a meta-analysis of previously published data.

Conflict of interest

No potential conflict of interest relevant to this article.

Funding

None.

Acknowledgments

None.

Author contributions

Conceptualization: HK. Methodology: MRA, TE, AM, MA, NA, AA. Formal analysis: HMS. Data curation: DGC, MEG. Writing - original draft: VV, SAV, AS. Writing - review & editing: DPL, FAM. All authors read and agreed to the published version of the manuscript.

Supplementary materials

Supplementary materials can be found via https://doi.org/10.18700/jnc.250030.
Supplementary Table 1.
Full search strategy for each database.
jnc-250030-Supplementary-Table-1.pdf
Supplementary Table 2.
Baseline characteristics of patients in each study.
jnc-250030-Supplementary-Table-2.pdf
Supplementary Fig. 1.
Sensitivity analysis of NIHSS score change at 7 days.
jnc-250030-Supplementary-Fig-1.pdf
Supplementary Fig. 2.
Sensitivity analysis of overall adverse events.
jnc-250030-Supplementary-Fig-2.pdf
Supplementary Fig. 3.
Trial sequential analysis of Excellent functional outcome (mRS 0-1) at 90 days.
jnc-250030-Supplementary-Fig-3.pdf
Supplementary Fig. 4.
Trial sequential analysis of NIHSS score change at 24 hours.
jnc-250030-Supplementary-Fig-4.pdf
Supplementary Fig. 5.
Trial sequential analysis of Functional independence (mRS 0-2) at 90 days.
jnc-250030-Supplementary-Fig-5.pdf
Supplementary Fig. 6.
Trial sequential analysis of NIHSS score change at 7 days.
jnc-250030-Supplementary-Fig-6.pdf
Supplementary Fig. 7.
Trial sequential analysis of symptomatic intracranial hemorrhage (sICH).
jnc-250030-Supplementary-Fig-7.pdf

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Fig. 1.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart of the screening process. The process included searches of databases, registers, and other sources. RCT, randomized controlled trial.
jnc-250030f1.tif
Fig. 2.
Summary of risk of bias. (A) Review authors' judgments about each risk of bias item for each included study. (B) Review authors' judgments about each risk of bias item presented as percentages across all included studies. TIMELESS, Thrombolysis in Imaging-Eligible, Late-Window Patients to Assess the Efficacy and Safety of Tenecteplase; TWIST, Tenecteplase in Wake-up Ischaemic Stroke Trial; ROSE-TNK, MRI-guided thrOmbolysis for Stroke bEyond Time Window by TNK; TRACE-III, Tenecteplase Reperfusion Therapy in Acute Ischemic Cerebrovascular Events-III.
jnc-250030f2.tif
Fig. 3.
Forest plots showing risk ratios. (A) Excellent functional outcome: mRS 0–1. (B) Functional independence: mRS 0–2. IV, inverse variance method; ROSE-TNK, MRI-guided thrOmbolysis for Stroke bEyond Time Window by TNK; TIMELESS, Thrombolysis in Imaging-Eligible, Late-Window Patients to Assess the Efficacy and Safety of Tenecteplase; TRACE-III, Tenecteplase Reperfusion Therapy in Acute Ischemic Cerebrovascular Events-III; TWIST, Tenecteplase in Wake-up Ischaemic Stroke Trial.
jnc-250030f3.tif
Fig. 4.
Forest plots showing mean differences. (A) National Institutes of Health Stroke Scale (NIHSS) score change from baseline at 24 hours. (B) NIHSS score change at 7 days. (C) Risk ratio of reperfusion at 24 hours. SD, standard deviation; IV, inverse variance method; TWIST, Tenecteplase in Wake-up Ischaemic Stroke Trial; TRACE-III, Tenecteplase Reperfusion Therapy in Acute Ischemic Cerebrovascular Events-III; TIMELESS, Thrombolysis in Imaging-Eligible, Late-Window Patients to Assess the Efficacy and Safety of Tenecteplase.
jnc-250030f4.tif
Fig. 5.
Forest plots showing risk ratios. (A) Overall adverse events. (B) Serious adverse events. (C) Symptomatic intracranial hemorrhage. (D) Ninety-day mortality. IV, inverse variance method; ROSE-TNK, MRI-guided thrOmbolysis for Stroke bEyond Time Window by TNK; TRACE-III, Tenecteplase Reperfusion Therapy in Acute Ischemic Cerebrovascular Events-III; TWIST, Tenecteplase in Wake-up Ischaemic Stroke Trial; TIMELESS, Thrombolysis in Imaging-Eligible, Late-Window Patients to Assess the Efficacy and Safety of Tenecteplase.
jnc-250030f5.tif
Table 1.
Characteristics of the included studies
Study Study design Country Sample size Inclusion criteria Main conclusion
TIMELESS [16] Double-blind, United States and Canada 458 - Patients were at least 18 years old with independent function prior to stroke (pre-stroke modified Rankin Scale score of 0–2). - Tenecteplase therapy initiated 4.5–24 hours after stroke onset (most patients had undergone endovascular thrombectomy) did not improve clinical outcomes compared to placebo.
Randomized controlled trial - Suffered from ischemic stroke and eligible to receive tenecteplase or placebo between 4.5–24 hours after last being seen well. - The incidence of symptomatic intracerebral hemorrhage was similar in both groups.
- Required to have a NIHSS score of at least 5
- Evidence of occlusion in the middle cerebral artery or internal carotid artery
- Salvageable brain tissue identified through perfusion imaging
TWIST [17] Open-label, Randomized controlled trial Denmark, Estonia, Finland, Latvia, Lithuania, New Zealand, Norway, Sweden, Switzerland, and United Kingdom 578 - Patients were 18 years or older and exhibited stroke symptoms upon awakening that were absent before sleep. - In patients with wake-up stroke selected based on non-contrast CT, the primary functional outcome at 90 days was similar between treatment groups.
- Had limb weakness or aphasia with a NIHSS score of ≥3 - The incidence of symptomatic intracerebral hemorrhage was low in both groups, consistent with prior thrombolysis trials in patients with wake-up stroke.
- Eligible for treatment with tenecteplase within 4.5 hours of awakening - Current evidence does not support tenecteplase treatment in patients selected solely based on non-contrast CT.
ROSE-TNK [18] Randomized, blinded endpoint assessment China 80 - Adults aged 18 to 80 years with acute moderate to severe ischemic stroke (NIHSS scores, 6–25 at admission) This phase 2, randomized, multicenter study suggests that intravenous tenecteplase within 4.5–24 hours of onset may be safe and feasible in patients with acute ischemic stroke with a diffusion-weighted imaging–fluid-attenuated inversion recovery mismatch.
- Functioning independently in the community with a pre-stroke mRS score of 0–1
- Enrolled within 4.5–24 hours after stroke symptom onset. If it was a wake-up stroke, the onset time was defined as the last time that the patient was seen well.
TRACE-III [19] Open-label, Randomized, blinded-outcome-assessment China 516 - Patients aged 18 years or older with stroke, including stroke on awakening or unwitnessed stroke In this trial involving Chinese patients with ischemic stroke due to large-vessel occlusion, most of whom did not undergo endovascular thrombectomy, treatment with tenecteplase administered within 4.5–24 hours after stroke onset resulted in:
- Recruited within 4.5–24 hours from last being seen well - Less disability than that under standard medical treatment
- Pre-stroke mRS score of 0–1 - Survival rates were similar between the tenecteplase and standard treatment groups.
- NIHSS score between 6 and 25 - Incidence of symptomatic intracranial hemorrhage appeared higher with tenecteplase.

TIMELESS, Thrombolysis in Imaging-Eligible, Late-Window Patients to Assess the Efficacy and Safety of Tenecteplase; TWIST, Tenecteplase in Wake-up Ischaemic Stroke Trial; ROSE-TNK, MRI-guided thrOmbolysis for Stroke bEyond Time Window by TNK; TRACE-III, Tenecteplase Reperfusion Therapy in Acute Ischemic Cerebrovascular Events-III; NIHSS, National Institutes of Health Stroke Scale; CT, computed tomography.

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Table 2.
GRADE evidence profile
Certainty assessment Certainty
No. of studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations
mRS 0–1 at 90 days 4 Randomized trials Not serious Not serious Not serious Not serious None ⨁⨁⨁⨁
High
mRS 0–2 at 90 days 4 Randomized trials Not serious Not serious Not serious Very seriousa),b) None ⨁⨁◯◯
Low
NIHSS score change at 24 hours 2 Randomized trials Not serious Not serious Not serious Not serious None ⨁⨁⨁⨁
High
NIHSS score change at 7 days 3 Randomized trials Not serious Seriousc) Not serious Seriousd) None ⨁⨁◯◯
Low
Reperfusion at 24 hours 2 Randomized trials Not serious Very seriouse) Not serious Very seriousb) None ⨁◯◯◯
Very low
Symptomatic intracranial hemorrhage at 90 days 3 Randomized trials Not serious Not serious Not serious Seriousa),b) None ⨁⨁⨁◯
Moderate

GRADE, Grading of Recommendations Assessment, Development, and Evaluation; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale.

a)Confidence interval is wide; b)Sample size is much lower than the optimal information size; c)Moderately high heterogeneity; d)Sample size is lower than the optimal information size; e)Very high heterogeneity.

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