The impact of stroke etiology on recanalization and clinical outcome following intravenous thrombolysis with tenecteplase (t-IVT) and endovascular therapy (EVT) has not been investigated. We aimed to compare stroke subtypes in a dataset of acute ischemic stroke (AIS) patients treated with t-IVT + EVT.

Our population was selected from the TETRIS registry, which retrospectively compiled clinical and imaging data on AIS patients treated with t-IVT, with or without EVT, from several French stroke centres. For this study, we only considered patients with anterior circulation large vessel occlusion (acLVO) intended for EVT. Cardioembolic (CE), large artery Atherosclerotic (LAA) and undetermined (UD) subtypes were included and compared; other stroke etiologies and dual causes were excluded. Primary outcome was the 3-month modified Rankin scale (mRS) ordinal distribution. Secondary outcomes were the rates of early recanalization, final successful recanalization, and symptomatic intracranial haemorrhage (sICH). Adjustments on relevant confounding variables were made within multivariate regression models.

Among 1,421 patients included in TETRIS, 789 patients (CE = 454, LAA = 113, UD = 222) met our inclusion criteria. LAA etiology was associated with non-significant trends towards worse 3-month mRS distribution than CE (adjusted common odds ratio [acOR] per 1 mRS level improvement = 0.69; 95% confidence interval [CI] = 0.46–1.02; P = 0.063) and UD (acOR = 0.67; 95% CI = 0.43–1.03; P = 0.067) subtypes, while no difference was found between UD and CE cases (acOR = 1.03; 95% CI = 0.76–1.40; P = 0.84). Compared with CE subtype, LAA etiology was associated with a non-significant trend towards less frequent early recanalization (adjusted OR = 0.51; 95% CI = 0.26–1.01; P = 0.052) and significantly lower chances of final successful recanalization (adjusted OR = 0.43; 95% CI = 0.23–0.78; P = 0.005). No significant difference was found regarding sICH.

In the context of bridging therapy with tenecteplase for acLVO AIS, LAA etiology might be associated with less favourable clinical and angiographic outcomes than CE subtype. Whether tenecteplase efficacy varies according to thrombi's composition and origin can only be conjectured and should be further investigated.