Comparing mismatch strategies for patients being considered for ischemic stroke tenecteplase trials

Area of Science:

• Neurology
• Radiology
• Clinical Trials

Background:

• Ischemic stroke patient selection involves various imaging-based mismatch methods.
• Comparing common mismatch criteria is crucial for optimizing treatment strategies.

Purpose of the Study:

• To compare DAWN and DEFUSE 2 mismatch criteria in ischemic stroke.
• To evaluate the impact of these criteria on patient outcomes in a randomized trial comparing tenecteplase and alteplase.

Main Methods:

• Pooled data from randomized trials of intravenous tenecteplase versus alteplase.
• Patients categorized using DAWN (NIHSS ≥ 10, core volume) or DEFUSE 2 (mismatch volume > 15 mL, ratio > 1.8, core < 70 mL) criteria.
• Assessed odds of less disability (mRS 0-1) for tenecteplase vs. alteplase based on mismatch criteria.

Main Results:

• Overall, tenecteplase did not significantly improve outcomes compared to alteplase (mRS 0-1, OR 1.77, p=0.102).
• However, tenecteplase showed favorable outcomes (mRS 0-1) when patients met imaging mismatch criteria (OR 2.33, p=0.032) or clinical mismatch criteria (OR 2.15, p=0.027).
• Proportions meeting criteria varied: 27% met both, 17% imaging only, 25% clinical only, 31% neither.

Conclusions:

• Target mismatch selection is more inclusive.
• Imaging and clinical mismatch criteria identified subgroups with larger treatment effects for tenecteplase over alteplase.
• Mismatch criteria significantly influence treatment effect size in ischemic stroke trials.