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Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke.

Bruce C V Campbell1, Peter J Mitchell1, Leonid Churilov1

  • 1From the Departments of Medicine and Neurology, Melbourne Brain Centre (B.C.V.C., N.Y., B.Y., T.Y.W., D.G.S., E.R., H.Z., P.S., G.S., M.W.P., S.M.D.), and the Department of Radiology (P.J.M., R.J.D., S.J.B., P.M.D.), Royal Melbourne Hospital, and the Florey Institute of Neuroscience and Mental Health (L.C., N.Y., V.T., H.A., H.M., C.F.B., G.A.D.), University of Melbourne, Parkville, VIC, the Departments of Neurology (T.J.K.) and Radiology (R.S.), Royal Adelaide Hospital, and the Department of Neurology, Lyell McEwin Hospital (D.F.), Adelaide, SA, the Department of Neurosciences, Eastern Health and Eastern Health Clinical School (H.M.D., C.F.B.), and the Departments of Neurology (H.M., T.G.P.) and Radiology (W. Chong, R.V.C., L.-A.S.), Monash Medical Centre, Monash University, Clayton, VIC, the Departments of Neurology (V.T., M.S.) and Radiology (M.B., H.A.), Austin Hospital, Austin Health, Heidelberg, VIC, School of Medicine, Faculty of Health, Deakin University, Melbourne, VIC (H.A.), and the Departments of Medicine and Neurology, Melbourne Medical School, University of Melbourne and Western Health, Sunshine Hospital, St. Albans, VIC (T.W.), the Departments of Neurology (D.G.S., H.B.) and Radiology (K.R., D.L.), Princess Alexandra Hospital, and the Departments of Neurology (A.A.W., C.M.) and Radiology (A.C., K. Mitchell, J.C., K. Mahady), Royal Brisbane and Women's Hospital and the University of Queensland, Brisbane, the Departments of Neurology (P.B.) and Radiology (H.R., L.V.), Gold Coast University Hospital, Southport, QLD, and the Department of Neurology, Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, NSW (T.A., F.M., C.R.L., C.G.-E., M.W.P.), the Department of Neurology, Royal North Shore Hospital and Kolling Institute, University of Sydney (M.K.), and the Department of Radiology, Royal North Shore Hospital (T.J.H., K.C.F., B.S.S.), St. Leonards, and the Department of Radiology, Westmead Hospital, Sydney (T.J.H., K.C.F., B.S.S.) - all in Australia; and the Departments of Neurology (T.Y.W., J.N.F.) and Radiology (W. Collecutt), Christchurch Hospital, Christchurch, New Zealand.

The New England Journal of Medicine
|April 26, 2018
PubMed
Summary

Tenecteplase, a fibrinolytic drug, improved reperfusion and functional outcomes in ischemic stroke patients undergoing thrombectomy compared to alteplase. This study demonstrates tenecteplase

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Area of Science:

  • Neuroscience
  • Cardiovascular Medicine
  • Pharmacology

Background:

  • Alteplase infusion is standard for thrombolysis before endovascular thrombectomy in ischemic stroke.
  • Tenecteplase offers advantages like higher fibrin specificity and longer activity, administered as a bolus.

Purpose of the Study:

  • To compare the efficacy and safety of tenecteplase versus alteplase in ischemic stroke patients undergoing thrombectomy.
  • To assess reperfusion rates and functional outcomes at 90 days post-treatment.

Main Methods:

  • Randomized trial involving 202 ischemic stroke patients eligible for thrombectomy.
  • Patients received either tenecteplase (0.25 mg/kg) or alteplase (0.9 mg/kg) within 4.5 hours of symptom onset.
  • Primary outcome: reperfusion >50% or absence of retrievable thrombus; secondary outcomes: 90-day functional status (modified Rankin Scale), death, and symptomatic intracerebral hemorrhage.

Main Results:

  • Tenecteplase achieved significantly higher reperfusion rates (22% vs. 10%, P=0.002 for noninferiority, P=0.03 for superiority).
  • Patients receiving tenecteplase showed better 90-day functional outcomes (median mRS score 2 vs. 3, P=0.04).
  • Symptomatic intracerebral hemorrhage occurred in 1% of patients in both groups.

Conclusions:

  • Tenecteplase administration prior to thrombectomy is associated with increased reperfusion and improved functional outcomes in acute ischemic stroke.
  • Tenecteplase represents a potentially superior alternative to alteplase for thrombolysis in this patient population.