Mild acute ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤ 5 points) accounts for approximately 50 % of all strokes [1], [2]. Owing to its mild symptoms or rapid resolution at onset, it is often overlooked by both patients and clinicians. However, mild stroke can progress to disabling strokes, with up to 30 % of patients being left with varying degrees of disability upon discharge [3]. The recent ATAMIS study, which aimed to evaluate antiplatelet therapy in acute mild-to-moderate ischemic stroke, indicated that 4.8 % of patients experienced early neurological deterioration (END) even after dual antiplatelet therapy [4].

Intravenous thrombolysis (IVT) with tenecteplase and alteplase administered within 4.5 h of onset in acute ischemic stroke patients improves both short- and long-term prognoses and is the preferred treatment, as recommended by guidelines [5], [6], [7]. However, the efficacy and safety of intravenous thrombolytic therapy for patients with mild stroke remain a topic of debate [8]. The PRISMS study revealed that, in patients with mild, nondisabling acute ischemic stroke, alteplase treatment did not improve the likelihood of favorable functional outcome at 90 days compared with aspirin, and alteplase treatment was associated with an increased risk of symptomatic intracranial hemorrhage (sICH) [9]. The ARAMIS study conducted in China demonstrated that for mild, nondisabling stroke patients who received treatment within 4.5 h of onset, the dual antiplatelet treatment group achieved a similar or better functional prognosis (modified Rankin score [mRS]) at 90 days than did the alteplase IVT group [10]. An observational study revealed that while alteplase thrombolysis is safe, it does not significantly improve the prognosis of patients with nondisabling stroke [11]. A recent systematic review and meta-analysis revealed that, compared with optimal pharmacological treatments, IVT did not notably improve functional outcomes or increase the risk of sICH in patients with mild stroke [12]. Distinguishing between disabling and nondisabling strokes is challenging, and mild strokes may worsen over time. Therefore, it is vital to evaluate the short-term efficacy and safety of IVT in real-world patients with mild strokes, providing a dependable basis for clinical treatment decisions.

Thrombolysis with tenecteplase and alteplase has beneficial effects on outcomes and is safe within 4.5 h [11], [12], [13], [14], [15], [16], [17], [18]. The most recent meta-analysis confirmed a similar safety profile between 0.25 mg/kg tenecteplase and alteplase. Moreover, tenecteplase was superior to alteplase in terms of excellent functional outcomes and reduced disability at 3 months [15]. However, evidence on the treatment effect of tenecteplase in Chinese patients with mild acute ischemic stroke is limited [19]. Despite the safety and effectiveness of IVT in patients with mild stroke [5], [20], [21], the short-term outcomes of intravenous tenecteplase compared with alteplase in the treatment of patients remain unclear.

In the present study, we aimed to compare the short-term outcomes of intravenous tenecteplase with those of alteplase in patients with mild stroke treated within 4.5 h of symptom onset.