Tenecteplase versus alteplase before mechanical thrombectomy: experience from a US healthcare system undergoing a system-wide transition of primary thrombolytic

Hendrix, Philipp; Collins, Malie; Griessenauer, Christoph J.; Goren, Oded; Melamed, Itay; Weiner, Gregory M.; Dalal, Shamsher; Kole, Matthew J; Noto, Anthony; Schirmer, Clemens M.

doi:10.1136/jnis-2022-019662

Cited by 20 publications

(16 citation statements)

References 34 publications

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“…37 We observed no differential effect of tenecteplase versus alteplase on the incidence of ER across IVT-to-ER eval intervals in our analyses. This finding stands apart from some previous data that support that, while the ER rate quickly reaches about 20% with tenecteplase, even for short IVT-to-ER eval times, 18,21,27,37,39 it increases more slowly with alteplase. 28,39 While Figure 2 seems visually in favor of tenecteplase among patients with short IVT-to-ER eval times, the relevance of this trend is questionable given that nonlinear association was checked for in the continuous variable and that the interaction analysis was negative.…”

Section: Discussioncontrasting

confidence: 99%

“…[19][20][21][22][23] Reduced process times have also been reported, owing to its simpler administration. [24][25][26] More recently, 2 nonrandomized studies reported higher ER rates with tenecteplase compared with alteplase, 27,28 while in the AcT trial (Alteplase Compared to Tenecteplase), both thrombolytics achieved similar ER rates. 29 Hence, there are conflicting data on whether tenecteplase actually yields higher ER rates than alteplase, and little data on potential differences in terms of ER predictors between the 2 agents.…”

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confidence: 99%

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Early Recanalization Among Patients Undergoing Bridging Therapy With Tenecteplase or Alteplase

Checkouri,

Gerschenfeld,

Seners

et al. 2023

Stroke

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BACKGROUND: Intravenous thrombolysis (IVT) with alteplase or tenecteplase before mechanical thrombectomy is the recommended treatment for large-vessel occlusion acute ischemic stroke. There are divergent data on whether these agents differ in terms of early recanalization (ER) rates before mechanical thrombectomy, and little data on their potential differences stratified by ER predictors such as IVT to ER evaluation (IVT-to-ER eval ) time, occlusion site and thrombus length. METHODS: We retrospectively compared the likelihood of ER after IVT with tenecteplase or alteplase in anterior circulation large-vessel occlusion acute ischemic stroke patients from the PREDICT-RECANAL (alteplase) and Tenecteplase Treatment in Ischemic Stroke (tenecteplase) French multicenter registries. ER was defined as a modified Thrombolysis in Cerebral Infartion score 2b-3 on the first angiographic run, or noninvasive vascular imaging in patients with early neurological improvement. Analyses were based on propensity score overlap weighting (leading to exact balance in patient history, stroke characteristics, and initial management between groups) and confirmed with adjusted logistic regression (sensitivity analysis). A stratified analysis based on pre-established ER predictors (IVT-to-ER eval time, occlusion site, and thrombus length) was conducted. RESULTS: Overall, 1865 patients were included. ER occurred in 156/787 (19.8%) and 199/1078 (18.5%) patients treated with tenecteplase or alteplase, respectively (odds ratio, 1.09 [95% CI, 0.83–1.44]; P =0.52). A differential effect of tenecteplase versus alteplase on the probability of ER according to thrombus length was observed ( P interaction =0.003), with tenecteplase being associated with higher odds of ER in thrombi >10 mm (odds ratio, 2.43 [95% CI, 1.02–5.81]; P =0.04). There was no differential effect of tenecteplase versus alteplase on the likelihood of ER according to the IVT-to-ER eval time ( P interaction =0.40) or occlusion site ( P interaction =0.80). CONCLUSIONS: Both thrombolytics achieved ER in one-fifth of patients with large-vessel occlusion acute ischemic stroke without significant interaction with IVT-to-ER eval time and occlusion site. Compared with alteplase, tenecteplase was associated with a 2-fold higher likelihood of ER in larger thrombi.

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Section: Discussioncontrasting

confidence: 99%

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confidence: 99%

Early Recanalization Among Patients Undergoing Bridging Therapy With Tenecteplase or Alteplase

Checkouri,

Gerschenfeld,

Seners

et al. 2023

Stroke

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“…A retrospective study evaluated the system-wide impact in the USA of the transition from alteplase to TNK in patients with planned EVT. The study reported a significantly higher spontaneous recanalization rate in the TNK compared with the alteplase group (20 vs. 10%) [27].…”

Section: Current Evidence For Tenecteplase In Ischemic Strokementioning

confidence: 84%

Advances in the management of acute ischemic stroke

Nair

Wagner

Buck

2023

Current Opinion in Neurology

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Purpose of reviewThis review aims to summarize the therapeutic advances and evidence in the medical management of acute ischemic stroke (AIS). Recent evidence comparing the efficacy and safety of tenecteplase (TNK) with alteplase for intravenous thrombolysis (IVT) in AIS will be highlighted. Recent advances and evidence on improving micro-circulation following endovascular procedures and neuroprotection will be reviewed.Recent findingsA significant number of randomized control studies now support the use of tenecteplase for IVT in AIS. TNK 0.25 mg/kg single bolus is as effective and well tolerated as alteplase 0.9 mg/kg infusion for IVT in AIS. Evidence from randomized control trials (RCTs) has shown effective and well tolerated expansion of the therapeutic window of IVT in the wake-up stroke and up to 9 h after last seen well, using advanced neuroimaging with computed tomography perfusion/MRI. Early evidence suggests that intra-arterial alteplase may help improve microcirculation in patients with large vessel occlusion following successful thrombectomy. However, more trials are required to confirm the results. Similarly, early evidence from a recent RCT showed that remote ischemic conditioning confers potential neuroprotection and improves outcomes in AIS.SummaryConverging evidence has demonstrated that for patients with ischemic stroke presenting at under 4.5 h from the onset, TNK is comparable to alteplase. These data along with the practical advantages of TNK have resulted in a shift to replace intravenous TNK as the standard for thrombolysis. Ongoing studies of IVT with TNK are focussed on defining the optimal dose, expanding the time window with multimodal imaging and defining the role of thrombolysis for bridging patients with stroke due to large vessel occlusion.

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“…Recently, tenecteplase, a newer thrombolytic agent that can be administered as a single bolus due to its longer half-life, has become more popular worldwide due to its ease of use. Past studies have suggested that tenecteplase may lead to a higher rate of LVR compared with alteplase 8 19. Thus, patients treated with tenecteplase may achieve LVR faster and/or more often than patients treated with alteplase, and future studies are needed to tailor the HALT score for predicting LVR in patients treated with tenecteplase.…”

Section: Discussionmentioning

confidence: 99%

Predictors for large vessel recanalization before stroke thrombectomy: the HALT score

Colasurdo

Chen

Schrier

et al. 2023

J NeuroIntervent Surg

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BackgroundLarge vessel recanalization (LVR) before endovascular therapy (EVT) for acute large vessel ischemic strokes is a poorly understood phenomenon. Better understanding of predictors for LVR is important for optimizing stroke triage and patient selection for bridging thrombolysis.MethodsIn this retrospective cohort study, consecutive patients presenting to a comprehensive stroke center for EVT treatment were identified from 2018 to 2022. Demographic information, clinical characteristics, intravenous thrombolysis (IVT) use, and LVR before EVT were recorded. Factors independently associated with different rates of LVR were identified, and a prediction model for LVR was constructed.Results640 patients were identified. 57 (8.9%) patients had LVR before EVT. A minority (36.4%) of LVR patients had significant improvements in National Institutes of Health Stroke Scale. Independent predictors for LVR were identified and used to construct the 8-point HALT score: hyperlipidemia (1 point), atrial fibrillation (1 point), location of vascular occlusion (internal carotid: 0 points, M1: 1 point, M2: 2 points, vertebral/basilar: 3 points), and thrombolysis at least 1.5 hours before angiography (3 points). The HALT score had an area under the receiver-operating curve (AUC) of 0.85 (95% CI 0.81 to 0.90, P<0.001) for predicting LVR. LVR before EVT occurred in only 1 of 302 patients (0.3%) with low (0–2) HALT scores.ConclusionsIVT at least 1.5 hours before angiography, site of vascular occlusion, atrial fibrillation, and hyperlipidemia are independent predictors for LVR. The 8-point HALT score proposed in this study may be a valuable tool for predicting LVR before EVT.

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Tenecteplase versus alteplase before mechanical thrombectomy: experience from a US healthcare system undergoing a system-wide transition of primary thrombolytic

Cited by 20 publications

References 34 publications

Early Recanalization Among Patients Undergoing Bridging Therapy With Tenecteplase or Alteplase

Early Recanalization Among Patients Undergoing Bridging Therapy With Tenecteplase or Alteplase

Advances in the management of acute ischemic stroke

Predictors for large vessel recanalization before stroke thrombectomy: the HALT score

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