J Stroke.  2024 May;26(2):280-289. 10.5853/jos.2023.03713.

Tenecteplase Versus Alteplase in Medium Vessel Occlusion Ischemic Stroke: A Secondary Analysis of the Alteplase Compared to Tenecteplase Randomized Trial

• Bala F
• Singh N
• Ignacio K
• Alhabli I
• Ademola A
• Alrohimi A
• Khosravani H
• Tkach A
• Catanese L
• Dowlatshahi D
• Field T
• Hunter G
• Benali F
• Horn M
• Demchuk A
• Hill M
• Sajobi T
• Buck B
• Swartz R
• Almekhlafi M
• Menon BK

• KMID: 2556048
• DOI: http://doi.org/10.5853/jos.2023.03713

Abstract

Background and Purpose
The safety and efficacy of tenecteplase in patients with ischemic stroke due to medium vessel occlusion (MeVO) are not well studied. We aimed to compare tenecteplase with alteplase in stroke due to MeVO.
Methods
Patients with baseline M2-middle cerebral artery (MCA), M3/M4-MCA, P2/P3/P4-posterior cerebral artery (PCA), A2/A3/A4-anterior cerebral artery (ACA) occlusions from the Alteplase Compared to Tenecteplase (AcT) trial were included. Primary outcome was the proportion of 90-day modified Rankin Scale (mRS) 0–1. Secondary outcomes were 90-day mRS 0–2, ordinal mRS, mortality, quality of life measures (EuroQol 5-Dimension 5-Level, EuroQol visual analog scale), and symptomatic intracerebral hemorrhage (sICH). Initial and final successful reperfusion were reported in patients undergoing endovascular thrombectomy (EVT).
Results
Among 1,558 patients with available baseline computed tomography angiography; 455 (29.2%) had MeVO of which 27.5% (125/455) were proximal M2; 16.3% (74/455) were distal M2; 35.2% (160/455) were M3/M4; 7.5% (34/455) were A2/A3/A4; and 13.6% (62/455) were P2/P3/P4 occlusions. EVT was performed in 87/455 (19.1%) patients. mRS 0–1 at 90 days was achieved in 37.9% in the tenecteplase versus 34.7% in the alteplase group (adjusted risk ratio [aRR] 1.07; 95% confidence interval [CI] 0.91–1.25). Rates of 90-day mRS 0–2, sICH, and mortality were similar in both groups. No statistical difference was noted in initial successful reperfusion rates (13.0% vs. 7.5%) among the 87 patients who underwent endovascular thrombectomy. However, final successful reperfusion was higher in the tenecteplase group (71.7% vs. 60.0%, aRR 1.29, 95% CI 1.04–1.61).
Conclusion
Intravenous tenecteplase had comparable safety, functional outcomes and quality of life compared to intravenous alteplase among patients with MeVO. Among those treated with EVT, tenecteplase was associated with higher successful reperfusion rates than alteplase.

Keyword

Stroke; Occlusion; Mechanical thrombectomy; Alteplase; Thrombolysis; Ischemic

Figure

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  Figure 1. Study flowchart. AcT, Alteplase Compared to Tenecteplase; ICA, internal carotid artery; CTA, computed tomography angiography; IVT, intravenous thrombolysis; EVT, endovascular thrombectomy.

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  Figure 2. Distribution of the modified Rankin Scale (mRS) scores at 90 days. No significant difference was seen between the tenecteplase and alteplase groups in the ordinal analysis of the mRS score, adjusted for age, sex, baseline stroke severity, symptom onset-to-needle as fixed-effects variables, and site as a random-effects variable (adjusted common odds ratio, 0.87 [0.62 to 1.20], P=0.39). The mRS score ranges from 0 to 6, with 0 indicating no symptoms, 1 no clinically significant disability, 2 slight disability, 3 moderate disability, 4 moderately severe disability, 5 severe disability, and 6 death.

Reference

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