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Comparative efcacy and safety of tissue plasminogen activators (tPA) in
acute ischemic stroke: A systematic review and network meta-analysis of
randomized controlled trials
Sufyan Shahid, MBBS
a
, Humza Saeed, MBBS
b
, Minahil Iqbal, MBBS
c
, Ayesha Batool, MBBS
c
,
Muhammad Bilal Masood, MBBS
d
, Muhammad Husnain Ahmad, MD
e,*
,
Aqeeb Ur Rehman, MD
f
, Muhammad Aemaz Ur Rehman, MD
f
, Fahd Sultan, MD
g
a
Khawaja Muhammad Safdar Medical College, Sialkot, Pakistan
b
Rawalpindi Medical University, Rawalpindi, Pakistan
c
Allama Iqbal Medical College, Lahore, Pakistan
d
Wah Medical College, Wah Cantt, Pakistan
e
Tentishev Satkynbai Memorial Asian Medical Institute, Kant, Bishkek, Kyrgyzstan
f
University of Alabama at Birmingham, Birmingham, AL, USA
g
University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
ARTICLE INFO
Keywords:
Acute ischemic stroke
Tissue plasminogen activator
Alteplase
Tenecteplase
Reteplase
Network meta-analysis
ABSTRACT
Background: Intravenous alteplase (ALT) is the standard treatment for acute ischemic stroke (AIS). However,
recent trials comparing other tissue plasminogen activators (tPAs) like tenecteplase (TNK) and reteplase with
ALT have yielded conicting results. This necessitated a network meta-analysis to compare the efcacy and
safety of various tPAs in AIS patients.
Methods: We searched MEDLINE, Embase, and CENTRAL (until September 15, 2024) for randomized controlled
trials (RCTs) comparing TNK or reteplase (any dose) with ALT (0.9 mg/kg) in AIS patients. A frequentist network
meta-analysis was performed using risk ratio (RR) and 95 % CI for each comparison, and P-scores ranked
treatments. Analyses were done using R Software 4.4.1.
Results: Sixteen RCTs (9259 patients, 62.1 % males) were included. Reteplase 18+18 mg signicantly improved
excellent functional recovery (mRS 0-1) (RR: 1.13; p <0.01) and independent ambulation (mRS 0-2) at 3 months
(RR: 1.07; p <0.01) compared to ALT. The 0.25 mg/kg TNK group also showed improved functional recovery
(mRS 0-1) (RR: 1.06; p <0.01). For safety, 0.1 mg/kg TNK was associated with a higher incidence of symp-
tomatic intracranial hemorrhage (s-ICH) (RR: 7.27; p <0.01). No signicant differences in ICH or all-cause
mortality were found between ALT and other treatments. Reteplase 18+18 mg ranked highest for functional
recovery (P-score=0.9638) and ambulation (P-score=0.9749), while ALT ranked highest for s-ICH (P-
score=0.8060). No signicant differences were observed between reteplase and TNK.
Conclusion: Reteplase 18+18 mg and TNK 0.25 mg/kg demonstrated higher efcacy and comparable safety to
ALT. Larger trials are needed to further explore these agents as alternatives to ALT.
Introduction
Stroke is a signicant global health concern, affecting approximately
15 million individuals worldwide each year, with an estimated 87 % of
all strokes being ischemic.
1
Acute Ischemic Stroke (AIS) occurs when a
sudden blockage of a cerebral artery interrupts blood ow, leading to
rapid neuronal damage and severe neurological decits. Reperfusion
therapy with tissue Plasminogen Activators (tPA) is an extremely
effective evidence-based intervention for AIS in the early stages, with
intravenous alteplase (ALT) considered as the standard thrombolytic
* Corresponding author.
E-mail addresses: sufyanshahid09@gmail.com (S. Shahid), hamzasaeed309@gmail.com (H. Saeed), minahil.iqbal131@gmail.com (M. Iqbal), ayeshabinteakbar@
gmail.com (A. Batool), bilal.masood23.bm@gmail.com (M.B. Masood), husnainahmad601@gmail.com (M.H. Ahmad), aqeebrehman57@gmail.com (A.U. Rehman),
maemazurrehman@uabmc.edu (M. Aemaz Ur Rehman), Fahd-sultan@ouhsc.edu (F. Sultan).
Contents lists available at ScienceDirect
Journal of Stroke and Cerebrovascular Diseases
journal homepage: www.elsevier.com/locate/jstroke
https://doi.org/10.1016/j.jstrokecerebrovasdis.2025.108230
Received 12 December 2024; Received in revised form 2 January 2025; Accepted 8 January 2025
Journal of Stroke and Cerebrovascular Diseases 34 (2025) 108230
Available online 9 January 2025
1052-3057/© 2025 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-
nc-nd/4.0/ ).
agent used within 4.5 h of symptom onset. ALT is given in a dose of 0.9
mg/kg, 10 % of which is administered as a bolus, and the rest is given as
a continuous infusion over the subsequent hour.
2
Despite a signicant
surge in thrombolysis demand, marked by a 60.3 % increase from 2015
to 2019, with 22.9 % of patients receiving treatment within 4.5 h of
symptom onset, there remains a pressing need for more effective and
affordable thrombolytic agents to meet this growing demand.
3
Comparative analysis reveals that tenecteplase (TNK) and reteplase
possess superior pharmacological and practical proles relative to ALT.
Notably, TNK treatment is associated with reduced lifetime costs and
enhanced clinical outcomes, versus ALT.
4
Despite ALT being the long-recommended treatment in international
guidelines, only a small percentage (5.64–16.3 %) of stroke patients
globally receive intravenous thrombolysis (IVT) due to a strict time
window and high costs.
3
Recent studies show TNK, a modied version of
ALT, provides similar benets without an increased incidence of adverse
outcomes, leading to its recommendation alongside ALT in guidelines.
5
Reteplase, another tPA delivered in a double-bolus regimen, has also
been gaining popularity. Reteplase offers a simpler administration
method, is more affordable, and has an extended plasma half-life.
6,7
Reteplase has also been approved for acute myocardial infarction (AMI)
treatment in several regions.
8
Meta-analyses have found no signicant
differences in mortality or incidence of disabling stroke incidence be-
tween reteplase and ALT in acute myocardial infarction patients.
9
The contradictory and inconsistent ndings from randomized
controlled trials (RCTs) comparing the efcacy and safety of TNK,
reteplase, and ALT in patients with AIS warrant a comprehensive meta-
analysis to resolve these uncertainties, which could have a signicant
impact on real-world stroke outcomes and clinical decision-making. Our
meta-analysis offers a comprehensive comparison of ALT, TNK, and
reteplase, incorporating the latest trials and addressing signicant
knowledge gaps. We include the most recent TNK versus ALT studies and
are the rst to meta-analyze reteplase versus ALT. Our network meta-
analysis compares all three tPAs at different doses, providing the most
up-to-date understanding of their relative efcacy. This study distin-
guishes itself from previous research, providing valuable insights for
clinicians, researchers, and guideline developers.
Methods
This study followed the guidelines of the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA), NMA extension.
10
The protocol for this study has been registered with the International
Prospective Register of Systematic Reviews, PROSPERO database (ID
CRD42024565938).
Search Strategy
Three extensive databases i.e. MEDLINE (via PubMed), Embase and
the Cochrane Controlled Register of Trials (CENTRAL) (via the Cochrane
Library) were searched from their inception to September 15, 2024
without any language restrictions using the following keywords com-
bined by the Boolean operators “AND” and “OR”: “reteplase,” “ten-
ecteplase,” “alteplase,” “TNK,” “ALT,” “tPA,” “tissue plasminogen
activators,” "cerebrovascular disease," “acute ischemic stroke” and
“stroke”. The detailed search strategy is available in the supplementary
le. Additionally, reference lists of relevant studies were also manually
curated to identify any potential studies.
Eligibility criteria and outcomes
We included randomized controlled trials in our meta-analysis if they
included adult patients (i.e. age ≥18) undergoing thrombolysis within
4.5 h of AIS, compared one or more tPA at any dose, and had at least one
outcome of interest concerning the efcacy and/or safety of tPAs.
Studies other than RCTs i.e. non-randomized trials, single arm trials,
observational studies, case reports, review articles, study protocols and
pre-clinical studies were excluded.
The primary efcacy and safety outcomes included functional status
at three months/90 days [modied Rankin Scale (mRS) score of 0–1 and
modied Rankin Scale (mRS) score of 0–2] and symptomatic intracra-
nial hemorrhage (sICH) within 36 h. Secondary outcomes included early
neurological improvement, intracranial hemorrhage (ICH), and mor-
tality. The denitions of outcomes were the same as in the included
RCTs. Excellent functional outcome was dened as a score of 0 or 1 on
the mRS and good functional outcome was dened as a score of 0, 1 or 2
on the mRS at 3 months. Early neurological improvement was dened
by a reduction of 8 or more points from the baseline NIHSS score at 24 h
(or closest to 24 h).
The different doses of TNK and reteplase employed by included trials
were categorized into different tiers: three (0.1 mg/kg, 0.25 mg/kg, 0.4
mg/kg) in case of TNK and two for reteplase (18+18 mg, 12+12 mg).
Study selection and data extraction
The search results were transferred to Rayyan software, where after
removing the duplicates, two reviewers (SS and AB) independently
screened the remaining studies based on their titles and abstracts. They
selected potentially eligible RCTs and went for their full-text review.
Any disagreements between the two reviewers were settled by discus-
sion and a third reviewer (HS) in case a consensus could not be reached.
Following data was extracted from the included studies as recommended
in the guidelines of the Cochrane Collaboration: the authors, year of
publication, the country of the study where the RCT was conducted,
study design, total number, mean age and sex of participants, in-
terventions (with doses) received by the participants, and various ef-
cacy and safety outcomes at that dose.
Quality assessment
The revised Cochrane “Risk of Bias” assessment tool for randomized
controlled trials (RCTs) version 2 (RoB 2.0) was used to evaluate the risk
of bias in the included trials by two authors (AB and SS) with dis-
agreements resolved by consensus. The RoB-2 graded the risk of bias of
the included studies as low risk, some concerns, or high risk and assessed
studies across ve domains: bias arising from the randomization process,
bias due to deviations from intended interventions, bias due to missing
outcome data, bias in the measurement of the outcome, and bias in the
selection of the reported result
11
. Additionally, the risk of bias for the
network estimates was evaluated and presented using bar graphs,
illustrating the percentage of information for each comparison derived
from studies with low, moderate, or high risk of bias, considering both
randomization and compliance to treatment for all direct comparisons.
Two authors (SS and AB) independently assessed the certainty of
evidence using the minimally contextualized Grading of Recommenda-
tions, Assessment, Development, and Evaluation (GRADE) framework.
12
Any disagreements were resolved through a consensus discussion
involving a third author (HS). Certainty of evidence for each comparison
was evaluated based on factors such as risk of bias, inconsistency,
indirectness, publication bias, intransitivity, incoherence, and impreci-
sion. Each outcome’s certainty was categorized as very low, low, mod-
erate, or high.
Statistical analysis
We performed a random-effects frequentist network meta-analysis
(NMA) to compare the efcacy and safety of different tPAs in patients
of AIS. This approach allowed us to simultaneously compare different
therapies and doses and therefore accommodate trials with multiple
groups. The network plots generated using the NMA studio software
showed different therapies as nodes, and the connected nodes indicated
that the two therapies were directly compared. The number of studies
S. Shahid et al.
Journal of Stroke and Cerebrovascular Diseases 34 (2025) 108230
2
that made direct comparison between therapies were shown on the lines
that connected the nodes. Dichotomous outcomes were evaluated using
risk ratios (RR) and 95 % condence intervals (CIs) within a frequentist
network meta-analysis framework. This analysis included direct, indi-
rect and overall network effect sizes, and inconsistencies were tested
globally and locally. Between-study variance using
τ
2\tau^2 was esti-
mated to assess heterogeneity across the network for each outcome,
assuming a common random-effects variance for all comparisons within
that outcome. Data was presented in the form of league tables (summary
statistics) for all possible network comparisons along with effect sizes for
all direct comparisons. The three tPAs at different doses were ranked
based on their probability of being the best using the probability score
(P-score) values. Potential publication bias was evaluated by visually
inspecting the symmetry of the funnel plots and by calculating p-values
of egger’s test. All statistical analyses were performed using R Software
version 4.4.1 (R Foundation for Statistical Computing, Vienna, Austria).
The signicance threshold for all tests was set at p <0.05.
Results
Study selection
Our extensive database search yielded 2155 records, which was
narrowed down to 1688 unique records after duplicate removal (n =
467). Upon title and abstract screening, 1561 studies were excluded,
leaving 127 articles for full-text evaluation. After applying the pre-
dened inclusion criteria, 16 randomized controlled trials (RCTs) were
identied and selected for quantitative analysis
6,7,13–25
, as illustrated in
the PRISMA owchart (Fig. 1).
Study and patient characteristics
After an extensive literature review, we included sixteen studies with
9259 patients (about 62.1 % male) from 2010 to 2024.
6,7,13–25
The mean
age across the studies varied, with a general age range between 54 and
75 years. The prevalence of hypertension also varied across the studies,
with some studies reporting up to 79.5 % and others without available
data. The time from symptom onset to intervention was within 4.5 h and
follow-up duration was 3 years for all included trials. Table 1 summa-
rizes the characteristics of included trials.
Primary outcomes
1. Excellent functional recovery (mRS 0-1):
All sixteen included trials, involving 9,254 patients, described the
outcome of excellent functional recovery (mRS 0-1) at 3 months and
included a total of six interventions, with non-signicant global
inconsistency (p=0.39). The network evidence plot is presented in
Fig. 2A. Compared to ALT, excellent functional recovery (mRS 0-1)
was signicantly better in the 0.25 mg/kg TNK (RR: 1.06; 95% CI:
Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) owchart for the included studies.
S. Shahid et al.
Journal of Stroke and Cerebrovascular Diseases 34 (2025) 108230
3
Table 1
Baseline characteristics of the included trials.
Study Intervention and
dose
Control
and dose
No. of Patients, n Age of patients, Mean years (SD) Hypertension,
%
Prior Stroke
or TIA, %
Needle
Time
Male
patients, %
NIHSS Score, median (range) Maximum
Follow-up
Intervention Control Intervention Control Intervention Control
Haley 2010 0.1/0.25/0.4 mg/
kg TNK
0.9 mg/kg
ALT
31/31/19 31 67 (19)/ 69 (15)/ 68
(16)
72 (16) 79.5 22.3 <3 hrs 52 8 (5-11)/ 10 (6-
15)/ 9 (5-17)
13 (5-17) 3 months
Parsons
2012
0.1/0.25 mg/kg
TNK
0.9 mg/kg
ALT
25/25 25 72 (6.9)/ 68 (9.4) 70 (8.4) 62.7 nr <3 hrs 51 14.5 (2.3)/ 14.6
(2.3) (mean)
14.0 (2.3)
(mean)
3 months
ATTEST 2015 0.25 mg/kg TNK 0.9 mg/kg
ALT
47 49 71 (13) 71 (12) 50 24 <4.5 hrs 63.5 12 (9-18) 11 (8-16) 3 months
NOR-TEST
2017
0.4 mg/kg TNK 0.9 mg/kg
ALT
549 551 70.8 (14.4) 71.2
(13.2)
43.8 12.7 <3 hrs 60 4 (2-7) 4 (2-8) 3 months
Campbell
2018
0.25 mg/kg TNK 0.9 mg/kg
ALT
101 101 70.4 (15.1) 71.9
(13.7)
nr nr <3 hrs 54.5 17 (12-22) 17 (12-22) 3 months
Rajappa
2018
0.2 mg/kg TNK 0.9 mg/kg
ALT
42 84 54 (median) 54
(median)
nr nr <3 hrs nr 11.2 11.2 3 months
TASTE-A
2022
0.25 mg/kg TNK 0.9 mg/kg
ALT
55 49 75.3 (5.3) 72.6 (4.2) 58.6 24 <4.5 hrs 60.5 8 (5-14) 8 (5-14) 3 months
AcT 2022 0.25 mg/kg TNK 0.9 mg/kg
ALT
806 771 74 (3.2) 73 (3.3) nr nr <3 hrs 52 9 (6-16) 10 (6-17) 3 months
NOR-TEST 2
2022
0.4 mg/kg TNK 0.9 mg/kg
ALT
100 104 73.2 (12.6) 68.6
(15.6)
51 13.2 <4.5 hrs 48 11.5 (8-17) 11.5 (8-
17)
3 months
TRACE 2022 0.1/0.25/0.32 mg/
kg TNK
0.9 mg/kg
ALT
60/57/60 59 62.4 (11.1)/ 64.3
(12.8)/ 64.8 (12.1)
66.5
(12.6)
66.5 nr <3 hrs 72 7/8/7.5 8 3 months
Campbell
2020
0.4 mg/kg TNK 0.25 mg/
kg TNK
150 150 71.7 (11.3) 73.8
(12.8)
65.7 nr <3 hrs 53 17 (11-21) 16 (9-20) 3 months
Trace-2 2023 0.25 mg/kg TNK 0.9 mg/kg
ALT
710 707 67 (2.4) 65 (2.2) 72 nr <4.5 hrs 68.5 7 (5-10) 7 (6-10) 3 months
Li 2023 18 +18mg/ 12 +
12 mg reteplase
0.9 mg/kg
ALT
66/60 50 62.8 (10.1)/ 61.9
(9.5)
63.3 (9.5) 67 35.8 <4.5 hrs 73.9 6.0 (5.0–8.5)/ 6.0
(5.0–8.0)
8 (5-10) 3 months
Raise 2024 18 +18 mg
reteplase
0.9 mg/kg
ALT
707 705 63 (2.2) 63 (2.2) 74.8 nr <4.5 hrs 70.5 6 (5-8) 6 (5-8) 3 months
TASTE 2024 0.25 mg/kg TNK 0.9 mg/kg
ALT
339 341 75 (2.9) 73 (3.1) 62.9 11.6 <4.5 hrs 61.8 7 (4-11) 7 (5-10) 3 months
ORIGINAL
2024
0.25 mg/kg TNK 0.9 mg/kg
ALT
732 733 66 (3.75) 65 (4.0) nr 1.8 <4.5 hrs 69.6 6 (5-8.5) 6 (5-9) 3 months
TNK: Tenecteplase; ALT: alteplase; TIA: transient ischemic stroke: NIHSS: National Institute of Health Stroke Scale; SD: standard deviation; nr: not reported.
S. Shahid et al.
Journal of Stroke and Cerebrovascular Diseases 34 (2025) 108230
4
1.02 to 1.11; p<0.01) and 18 +18 mg reteplase (RR: 1.13; 95% CI:
1.06 to 1.20; p<0.01) groups (Fig. 3A). All other comparisons be-
tween the six interventions (including between TNK and reteplase)
yielded non-signicant results (Table 2A) in addition to the non-
signicant local inconsistencies between direct and indirect com-
parisons (Supplementary Table 2). Among the six interventions, 18 +
18 mg reteplase had the highest probability of being the best treat-
ment (P-score=0.9638), while 0.1 mg/kg TNK had the least proba-
bility of being the best (P-score=0.1523) (Table 3, Supplementary
Fig. 1A). The between-study variance (
τ
2\tau^2 =0.0020) indicates
low heterogeneity, suggesting consistent treatment effects across
studies with minimal unexplained variability (Supplementary
Table 3).
2. Independent Ambulation (mRS 0-2)
Fourteen trials, involving 9,016 patients, described the outcome of
Independent Ambulation (mRS 0-2) at 3 months and included a total
of six interventions, with non-signicant global inconsistency (p =
0.17). The network evidence plot is presented in Fig. 2B. Compared
to ALT, Independent Ambulation (mRS 0-2) was signicantly better
in the 18 +18 mg reteplase (RR: 1.07; 95 % CI: 1.02 to 1.12; p <
0.01) group (Fig. 3B). All other comparisons between the six in-
terventions (including between TNK and reteplase) yielded non-
Fig. 2. The network evidence plots generated using the NMA studio software showing different therapies as nodes, and the connected nodes indicating that the two
therapies were directly compared. a. Excellent functional recovery (mRS 0-1) b. Independent ambulation (mRS 0-2) c. Symptomatic intracranial hemorrhage (s-ICH)
d. Any intracranial hemorrhage (any ICH) e. All-cause mortality f. Early neurological improvement g. Excellent functional recovery (mRS 0-1)
S. Shahid et al.
Journal of Stroke and Cerebrovascular Diseases 34 (2025) 108230
5
signicant results (Table 2B) in addition to the non-signicant local
inconsistencies between direct and indirect comparisons (Supple-
mentary Table 2). Among the six interventions, 18 +18 mg reteplase
had the highest probability of being the best treatment (P-
score=0.9749), while 0.1 mg/kg TNK had the least probability of
being the best (P-score=0.1995) (Table 3, Supplementary Fig. 1B).
The between-study variance for the outcome of independent ambu-
lation (
τ
2\tau^2 =0.0025) reects low heterogeneity, indicating
minimal unexplained variability and consistent treatment effects
across the included studies (Supplementary Table 3).
3. Symptomatic Intracranial Hemorrhage (s-ICH)
All sixteen trials, involving 9,259 patients, described the outcome
of S-ICH within 36 h and included a total of six interventions, with
non-signicant global inconsistency (p =0.12). The network evi-
dence plot is presented in Fig. 2C. Compared to ALT, the incidence of
S-ICH was signicantly higher in the 0.1 mg/kg TNK group (RR:
7.27; 95 % CI: 2.77 to 19.06; p <0.01) (Fig. 3C). In addition, 0.1 mg/
kg ALT had a higher risk of incidence of s-ICH compared to 0.25 mg/
kg TNK (RR: 7.28; 95 % CI: 2.68 to 19.78; p <0.05), 0.4 mg/kg TNK
(RR: 4.18; 95 % CI: 1.57 to 11.13; p <0.05) and 18 +18 mg reteplase
(RR: 5.50; 95 % CI: 1.51 to 19.98; p <0.05) (Table 2C). All other
comparisons between the six interventions (including between TNK
and reteplase) yielded non-signicant results (Table 2C) in addition
to the non-signicant local inconsistencies between direct and
Fig. 2. (continued).
S. Shahid et al.
Journal of Stroke and Cerebrovascular Diseases 34 (2025) 108230
6
indirect comparisons (Supplementary Table 2). ALT had the highest
probability of being the best treatment (P-score=0.8060), while 0.1
mg/kg TNK had the lowest (P-score=0.0227) (Table 3, Supplemen-
tary Fig. 1C). For the outcome of s-ICH, the between-study variance
(
τ
2\tau^2 =0.0945) indicates low to moderate heterogeneity across
the included studies (Supplementary Table 3).
Secondary outcomes
1. Any Intracranial Hemorrhage:
Twelve trials, involving 6,705 patients, described the outcome of
any ICH and included a total of six interventions, with non-
signicant global inconsistency (p =0.62). The network evidence
plot is presented in Fig. 2D. All comparisons of any ICH between the
six interventions yielded non-signicant results (Fig. 3D, Table 2D)
in addition to the non-signicant local inconsistencies between
direct and indirect comparisons (Supplementary Table 2). Among
the six interventions, 12 +12 mg reteplase had the highest proba-
bility of being the best treatment (P-score=0.7917), while 0.4 mg/kg
TNK had the least probability of being the best (P-score=0.0701)
(Table 3, Supplementary Fig. 1D). The between-study variance was
τ
2\tau^2 =0.0439, indicating low heterogeneity (Supplementary
Table 3).
2. All-cause Mortality:
All sixteen trials, involving 9,234 patients, described the outcome
of all-cause mortality and included a total of six interventions, with
Fig. 2. (continued).
S. Shahid et al.
Journal of Stroke and Cerebrovascular Diseases 34 (2025) 108230
7
non-signicant global inconsistency (p =0.73). The network evi-
dence plot is presented in Fig. 2E. All comparisons of any ICH be-
tween the six interventions yielded non-signicant results (Fig. 3E,
Table 2E) in addition to the non-signicant local inconsistencies
between direct and indirect comparisons (Supplementary Table 2).
Among the six interventions, 0.1 mg/kg TNK had the highest prob-
ability of being the best treatment (P-score=0.6471), while 0.4 mg/
kg TNK had the least probability of being the best (P-score=0.2796)
(Table 3, Supplementary Fig. 1E). For the outcome of all-cause
mortality, the between-study variance was
τ
2\tau^2 =0.0631,
indicating low to moderate heterogeneity (Supplementary Table 3).
3. Early Neurological Improvement:
Twelve trials, involving 5,906 patients, described the outcome of
early neurological improvement and included a total of six in-
terventions, with a signicant global inconsistency among the com-
parisons (p =0.02). The network evidence plot is presented in
Fig. 2F. All network comparisons of any ICH between the six in-
terventions yielded non-signicant results; however, the comparison
of direct and indirect evidence showed signicant inconsistency for
the comparisons of 0.1 mg/kg TNK with 0.25 mg/kg TNK and 12+12
mg reteplase (p-values for inconsistency <0.05) (Fig. 3F, Table 2F).
Among the six interventions, 0.25 mg/kg TNK had the highest
probability of being the best treatment (P-score=0.8543), while 0.1
mg/kg TNK had the least probability of being the best (P-
score=0.1098) (Table 3, Supplementary Fig. 1F). For the outcome of
early neurological development, the between-study variance was
τ
2
\tau^2 =0.0045, indicating low heterogeneity (Supplementary
Table 3).
Quality assessment, condence rating and publication bias
All included trials, except one
17
, which showed some concerns due to
deviations from intended interventions, were assessed as having a low
risk of bias across all ve key domains (Supplementary Table 4). Sup-
plementary Fig. 2A–F present bar graphs illustrating the percentage of
information for each comparison derived from studies based on their
risk of bias, showing that the majority of comparisons for each outcome
originated from studies with a low risk of bias. The condence or cer-
tainty of evidence across all GRADE domains for all comparisons of each
outcome are reported in Supplementary Tables 5A-5F, which highlight
variable condence ratings across comparisons, ranging from very low
to high. Visual inspection of the funnel plots revealed no notable
asymmetry, a nding further supported by non-signicant p-values from
Egger’s tests for all outcomes, except early neurological improvement (p
=0.0116). Collectively, these results suggest minimal to no risk of
publication bias (Supplementary Fig. 3A–F).
Fig. 3. Network analysis plots compared to alteplase (ALT) 0.9 mg/kg for: a. Excellent functional recovery (mRS 0-1) b. Independent ambulation (mRS 0-2) c.
Symptomatic intracranial hemorrhage (s-ICH) d. Any intracranial hemorrhage (any ICH) e. All-cause mortality f. Early neurological improvement
S. Shahid et al.
Journal of Stroke and Cerebrovascular Diseases 34 (2025) 108230
8
Discussion
To our knowledge, this is the rst and largest meta-analysis to sys-
tematically evaluate reteplase trials and compare the efcacy and safety
of reteplase and TNK with ALT in AIS. Pharmacologically, TNK and
reteplase offer several pharmacological and practical advantages over
ALT, making them promising alternatives for AIS treatment. They offer
longer half-lives, greater brin specicity, and reduced binding afnity
to Plasminogen Activator Inhibitor (PAI). Specically, reteplase has a
half-life of 13–16 min, nearly twice that of ALT’s 6–7 min, and a lower
afnity for PAI-1, enhancing its thrombolytic effect and reducing sys-
temic bleeding risk. These pharmacological advantages, combined with
simplied administration regimens, provide practical benets for hos-
pital staff and patients. TNK’s single-bolus administration and rete-
plase’s two-bolus regimen streamline treatment, reducing needle time,
bleeding risk, and monitoring needs. Additionally, reteplase longer shelf
life and simpler storage requirements facilitate handling and storage.
Overall, reteplase’s unique prole makes it a valuable treatment option
for patients with acute myocardial infarction or AIS, particularly those
at high risk of bleeding, positioning it as a benecial alternative to ALT
in clinical settings.
3,26
This network meta-analysis, encompassing 16 randomized
controlled trials, systematically compared the efcacy of six distinct
interventions for AIS. The primary ndings indicate that treatment with
0.25 mg/kg TNK and 18 +18 mg reteplase yielded signicantly superior
excellent functional recovery rates (modied Rankin Scale [mRS] 0-1) at
three months compared to ALT. Furthermore, 18 +18 mg reteplase
demonstrated improved Independent Ambulation (mRS 0-2) outcomes.
Conversely, the 0.1 mg/kg TNK regimen was associated with a sub-
stantially higher incidence of Symptomatic Intracerebral Hemorrhage
(S-ICH) within 36 h. In addition, ALT exhibited the highest probability
of minimizing S-ICH risk. Notably, no signicant interventional differ-
ences were observed in all-cause mortality rates. Ranking the treat-
ments’ efcacy, 18 +18 mg reteplase emerged as the top option for
excellent functional recovery and Independent Ambulation, while ALT
proved optimal for S-ICH prevention. Additionally, 0.25 mg/kg TNK
showed the highest probability of achieving early neurological
improvement.
Contrary to previous meta-analysis by Rehman et al. comparing TNK
to ALT showing no signicant difference in S-ICH rates between TNK
and ALT
27
, our study found higher incidence of S-ICH with 0.1 mg/kg
TNK. Recent meta-analyses by Wu et al. and Srisurapanont et al. also
compared TNK and ALT in AIS, sharing similarities in safety and func-
tional outcomes, but differing in objectives and populations.
28,29
Our
study uniquely compared six interventions involving TNK, reteplase,
and ALT in the general AIS population, revealing that 0.25 mg/kg TNK
and 18+18 mg reteplase outperformed ALT for excellent functional re-
covery. Notably, our ndings align with Wu et al.’s results showing
TNK’s superiority to ALT for successful recanalization, and Srisur-
apanont et al.’s identication of 0.25 mg/kg TNK as the optimal dose.
Fig. 3. (continued).
S. Shahid et al.
Journal of Stroke and Cerebrovascular Diseases 34 (2025) 108230
9
Fig. 3. (continued).
S. Shahid et al.
Journal of Stroke and Cerebrovascular Diseases 34 (2025) 108230
10
Table 2
League Tables (Summary statistics) of each outcome showing direct evidence effect sizes above the diagonal while network evidence effect sizes below the
diagonal. Each statistically signicant (p <0.05) effect size is highlighted in bold format.
S. Shahid et al.
Journal of Stroke and Cerebrovascular Diseases 34 (2025) 108230
11
However, safety proles varied: our study linked 0.1 mg/kg TNK to
higher S-ICH risk, whereas Wu et al. found no increased risk, and Sri-
surapanont et al. noted higher TNK doses increase S-ICH and paren-
chymal hemorrhage risk. Importantly, our study was the rst to compare
reteplase with ALT, revealing signicant improvement in excellent
functional recovery with 18+18 mg reteplase.
Our study utilized a random-effects model within a frequentist sta-
tistical framework, thereby minimizing potential biases associated with
subjective prior assumptions and yielding more objective and reliable
outcomes. By employing network meta-analysis (NMA), we integrated
both direct and indirect evidence, providing a more comprehensive
comparison of various tPAs beyond what traditional meta-analysis of-
fers. However, it is essential to acknowledge that NMA’s reliance on
indirect evidence necessitates cautious interpretation of the results, as
indirect evidence may introduce potential biases. Consequently, future
head-to-head clinical trials will play a critical role in validating and
rening these ndings.
Our study pioneers a comprehensive comparison of reteplase, TNK,
and ALT dosing regimens, offering new perspectives for clinicians and
researchers. This meta-analysis provides the rst systematic dose-based
comparison of reteplase and TNK with ALT across outcomes, a distinc-
tion that sets it apart from previous research. Notably, it represents the
largest and most up-to-date pooling of RCTs data on this topic. A key
strength lies in the consistent absence of signicant differences between
direct and indirect comparisons across most outcomes, including mor-
tality, functional outcomes, and adverse events, which demonstrates the
robustness and reliability of our ndings. This consistency enhances the
validity and generalizability of our results, underscoring the study’s
contribution to understanding treatment effects.
Limitations
Despite the robustness of our results, there are certain limitations.
First, the limited number of studies evaluating reteplase restricts the
generalizability of its ndings, despite its promising efcacy. Second,
the lack of long-term outcome data prevents a comprehensive under-
standing of the sustained benets and risks of the treatments. Third, the
analysis excluded observational studies, which could provide valuable
insights into real-world effectiveness. Fourth, while subgroup analyses
by comorbidities and other baseline characteristics were not performed
owing to limited data available, these could further rene the under-
standing of treatment efcacy and safety. Lastly, signicant in-
consistencies and publication bias for certain outcomes, such as early
neurological improvement, highlight the need for cautious interpreta-
tion and validation through future research.
Conclusion
This network meta-analysis demonstrates that 18+18 mg reteplase
and 0.25 mg/kg TNK offer superior efcacy compared to ALT in
achieving excellent functional recovery and independent ambulation at
three months in AIS patients, with comparable safety proles for most
outcomes. However, 0.1 mg/kg TNK was associated with a signicantly
higher risk of sICH, highlighting ALT as the safest option for minimizing
sICH. While the ndings emphasize the potential of reteplase and TNK as
alternatives to ALT, further large-scale trials, long-term outcome studies,
and cost-effectiveness analyses are necessary to validate these results
and optimize stroke management strategies globally.
Financial support and sponsorship
This research received no specic grant from any funding agency in
the public, commercial, or not-for-prot sectors.
Ethical considerations
No ethical approval was required for this study design, as all data
were obtained from publicly available sources.
CRediT authorship contribution statement
Sufyan Shahid: Writing – review & editing, Writing – original draft,
Project administration, Methodology, Investigation, Formal analysis,
Data curation, Conceptualization. Humza Saeed: Writing – review &
editing, Writing – original draft, Supervision, Software, Methodology,
Investigation, Formal analysis, Data curation. Minahil Iqbal: Writing –
review & editing, Writing – original draft, Supervision, Project admin-
istration, Investigation, Formal analysis, Data curation. Ayesha Batool:
Writing – review & editing, Writing – original draft, Validation, Soft-
ware, Methodology, Formal analysis. Muhammad Bilal Masood:
Writing – review & editing, Writing – original draft, Resources, Project
administration, Methodology, Formal analysis, Data curation.
Muhammad Husnain Ahmad: Writing – review & editing, Writing –
original draft, Visualization, Methodology, Investigation, Formal anal-
ysis, Data curation. Aqeeb Ur Rehman: Writing – review & editing,
Writing – original draft, Visualization, Validation, Supervision, Meth-
odology, Investigation, Formal analysis, Data curation. Muhammad
Aemaz Ur Rehman: Writing – review & editing, Writing – original draft,
Visualization, Validation, Software, Resources, Formal analysis, Data
curation. Fahd Sultan: Writing – review & editing, Validation, Soft-
ware, Project administration, Methodology, Formal analysis, Data
curation, Conceptualization.
Declaration of competing interest
The authors declare that they have no known competing nancial
interests or personal relationships that could have appeared to inuence
the work reported in this paper.
Table 3
P-scores for each intervention and endpoint.
Intervention Excellent functional
recovery (mRS 0-1)
Independent
Ambulation (mRS 0-2)
Symptomatic Intracranial
Hemorrhage (s-ICH)
Any Intracranial
Hemorrhage (ICH)
Early Neurological
Development
All-cause
mortality
18þ18 mg
Reteplase
0.9638 0.9749 0.5978 0.6503 0.4241 0.3497
0.25 mg/kg
TNK
0.7405 0.7161 0.7982 0.6504 0.8543 0.5964
0.4 mg/kg TNK 0.4210 0.3097 0.4052 0.0701 0.5763 0.2796
0.9 mg/kg ALT 0.3865 0.5519 0.8060 0.3861 0.5430 0.6168
12þ12 mg
Reteplase
0.3358 0.2480 0.3701 0.7917 0.4924 0.5103
0.1 mg/kg TNK 0.1523 0.1995 0.0227 0.4515 0.1098 0.6471
*The interventions with the highest P-scores for each endpoint are highlighted in bold, indicating the highest probability of being the best option.
mRS: modied ranking scale; TNK: tenecteplase; ALT: alteplase.
S. Shahid et al.
Journal of Stroke and Cerebrovascular Diseases 34 (2025) 108230
12
Acknowledgments
The authors have no acknowledgments to declare.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.jstrokecerebrovasdis.2025.108230.
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