Penumbral Imaging-Based Thrombolysis with Tenecteplase Is Feasible up to 24 Hours after Symptom Onset

Abstract

Background and Purpose Thrombolysis >4.5 hours after ischemic stroke onset is unproven. We assessed the feasibility of tenecteplase (TNK) treatment in patients with evidence of an ischemic penumbra 4.5 to 24 hours after onset.Methods Acute ischemic stroke patients underwent perfusion computed tomography (CT)/magnetic resonance imaging. Patients with cerebral blood volume (CBV) or diffusion weighted imaging Alberta Stroke Program Early CT Scores (ASPECTS) >6 and mismatch score >2 (defined as >2 ASPECTS regions with delay on mean transit time maps and normal CBV) were eligible for treatment with TNK (0.25 mg/kg). Patients with mismatch patterns enrolled in non-endovascular/non-thrombolysis trials and those without mismatch patterns served as comparators.Results The median (interquartile range) baseline National Institutes of Health Stroke Scale (NIHSS) in TNK treated patients (n=16) was 12 (range, 8 to 15). In the untreated mismatch (n=18) and nonmismatch (n=23) groups, the baseline NIHSS was 12 (range, 7 to 12) and 16 (range, 8 to 20; P=0.09) respectively. There was one symptomatic hemorrhage each in the TNK group (parenchymal hematoma [PH] 2) and non-mismatch group (PH 2). Penumbral salvage volumes were higher in TNK treated patients (48.3 mL [range, 24.9 to 80.4]) than the non-mismatch (–90.8 mL [range, –197 to –20]; P<0.0001) patients.Conclusions This prospective, non-randomized study supports the feasibility of TNK therapy in patients with evidence of ischemic penumbra 4 to 24 hours after onset.

Intravenous thrombolysis for acute ischemic stroke with extended time window

“…Michel et al [ 14 ] randomly assigned stroke patients occurring in the middle cerebral artery territory to alteplase venous thrombolysis, with an average last proof of well-being time point of 564 min (9.4 h), or placebo, and an average last proof of well-being of 437.5 min (7.3 h), and the results showed that thrombolytic therapy is feasible in patients with unknown stroke. Kate et al [ 15 ] reported patients were treated with tenecteplase at a median of 9.6 h after symptom onset with a range of 5.1 to 23.7 h and supported the feasibility of tenecteplase treatment in patients with 4 to 24 h of ischemic penumbral onset. In addition, we also performed subgroup analysis through different ages, NIHSS scores, and time windows and demonstrated that patients in the IVT group had better favorable functional outcomes at age ≤70 years, NIHSS ≤10, and time windows >9 h than the patients in the CG.…”

Trombolisis endovenosa con tenecteplase en ventana extendida tras selección por CT y AngioCT: Caso clínico

“…La mayoría de los centros no cuentan con imágenes avanzadas por lo que la CT de cerebro con ASPECTS ≥ 7 y buen estado de colaterales al CTA orientan a que hay tejido cerebral que puede ser reperfundido a pesar de estar fuera de la ventana terapéutica [14][15][16] . TNK se ha usado en ventana extendida con beneficios hasta 24 horas desde el inicio de los síntomas, con alta tasa de recanalización y baja tasa de complicaciones hemorrágicas 17 .…”

Tenacity of Collateral Perfusion in Proximal Cerebral Arterial Occlusions 6–12 h after Onset

“…The efficacy of EVT treatment for such patients that was proven in recent randomized clinical trials was replicated in our predominantly Asian cohort. Further experience and reports are warranted in implementation of ischemic penumbra quantification and application of recanalization treatments in the era of extended time window [25]. …”