Tenecteplase Versus Alteplase for First-Pass Reperfusion in Basilar Artery Occlusion Stroke Thrombectomy

Area of Science:

• Neurology
• Cardiovascular Diseases
• Pharmacology

Background:

• First-pass effect (FPE) is crucial for favorable outcomes in large vessel occlusion stroke.
• Intravenous thrombolytics like tenecteplase (TNK) and alteplase (TPA) are used for stroke treatment.
• Basilar artery occlusion (BAO) presents unique challenges for reperfusion.

Purpose of the Study:

• To compare the efficacy of intravenous tenecteplase (TNK) versus alteplase (TPA) in achieving first-pass effect (FPE) in patients with basilar artery occlusion (BAO).
• To assess the association between FPE and 90-day functional outcomes in BAO patients.

Main Methods:

• A retrospective analysis of 163 BAO patients treated with TNK or TPA within 4.5 hours of last known well.
• Exclusion of patients with early reperfusion or aborted procedures.
• Multivariable regression analysis to identify predictors of FPE (eTICI 2c-3) and modified FPE (mFPE, eTICI 2b-3), and their association with 90-day outcomes (mRS 0-3).

Main Results:

• First-pass effect (FPE) occurred in 41.4% of patients, being significantly more frequent with TNK (51.7%) than TPA (32.9%).
• TNK was independently associated with higher odds of achieving FPE (aOR 2.37) and mFPE (aOR 2.74) compared to TPA.
• Both FPE and mFPE were independently associated with improved ambulatory outcomes at 90 days (aORs 2.94 and 5.11, respectively).

Conclusions:

• Intravenous tenecteplase (TNK) significantly increases the likelihood of achieving first-pass effect (FPE) in basilar artery occlusion (BAO) compared to alteplase (TPA).
• FPE is a strong predictor of functional recovery, suggesting TNK may offer a reperfusion advantage in BAO.
• While a direct outcome benefit of TNK was not demonstrated, the improved FPE suggests potential clinical benefits warranting further investigation.