Tenecteplase versus alteplase in acute ischemic stroke: systematic review and meta-analysis

Tenecteplase versus alteplase for the treatment of acute ischemic stroke: a meta-analysis of randomized controlled trials

OBJECTIVES

Tenecteplase, a modified variant of alteplase with greater fibrin specificity and longer plasma half-life, may have better efficacy and safety than alteplase in patients with acute ischemic stroke (AIS). We aimed to compare the benefits and risks of tenecteplase versus alteplase in the treatment of AIS.

METHODS

Electronic databases were searched up to 10 February 2023 for randomized controlled trials evaluating the effect of tenecteplase versus alteplase in the treatment of AIS. The primary outcome was functional outcome at 90 days, and secondary outcomes including the symptomatic intracranial haemorrhage (SICH), and major neurological improvement. Subgroup analysis was performed based on the different dosage of tenecteplase.

RESULTS

Ten studies with a total of 5123 patients were analysed in this meta-analysis. Overall, no significant difference between tenecteplase and alteplase was observed for functional outcome at 90 days (excellent: OR 1.08, 95%CI 0.93-1.26, I2 = 26%; good: OR 1.04, 95%CI 0.83-1.30, I2 = 56%; poor: OR 0.95, 95%CI 0.75-1.21, I2 = 31%), SICH (OR 1.12, 95%CI 0.79-1.59, I2 = 0%), and early major neurological improvement (OR 1.26, 95%CI 0.80-1.96, I2 = 65%). The subgroup analysis suggested that the 0.25 mg/kg dose of tenecteplase had potentially greater efficacy and lower symptomatic intracerebral haemorrhage risk compared with 0.25 mg/kg dose tenecteplase.

CONCLUSIONS

Among AIS patients, there was no significant difference on clinical outcomes between tenecteplase and alteplase. Subgroup analysis demonstrated that 0.25 mg/kg doses of tenecteplase were more beneficial than 0.4 mg/kg doses of tenecteplase. Further studies are required to identify the optimal dosage of tenecteplase.

Tenecteplase versus alteplase for acute ischemic stroke: a systematic review and meta-analysis of randomized and non-randomized studies

OBJECTIVE

Alteplase is the current standard of care for acute ischemic stroke. Tenecteplase is a newer fibrinolytic agent with preferable administration and lower costs; however, its comparative effectiveness to alteplase remains uncertain. We set out to perform a systematic review and meta-analysis to establish the benefits and harms of tenecteplase versus alteplase for acute ischemic stroke.

METHODS

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov from inception to April 2023 for randomized and non-randomized studies that compared tenecteplase versus alteplase for acute ischemic stroke. Paired reviewers independently assessed risk of bias and extracted data. We performed both conventional meta-analyses and Bayesian network meta-analyses (NMA) with random-effects models and used the GRADE approach to evaluate the certainty of evidence. Our primary efficacy outcome was excellent functional outcome at 3 months, defined as a score of 0-1 on the modified Rankin Scale. Our primary safety outcomes were symptomatic intracranial hemorrhage and all-cause mortality.

RESULTS

Thirty-six studies were eligible for review, including 12 randomized (n = 5533) and 24 non-randomized studies (n = 44,956). Moderate certainty evidence showed that there was no difference between tenecteplase and alteplase in increasing the proportion of patients achieving excellent functional outcome at 3 months (odds ratio [OR], 1.10; 95% CI 0.98-1.23; risk difference [RD] 2.4%, 95% CI - 0.5 to 5.2), while moderate certainty evidence from NMA suggested that 0.25 mg/kg tenecteplase significantly improved excellent functional outcome at 3 months (OR, 1.16; 95% credible interval 1.02-1.32). Moderate certainty evidence showed that, compared to alteplase, tenecteplase may make little to no difference in the prevalence of symptomatic intracranial hemorrhage (OR, 1.12; 95% CI 0.79-1.59; RD 0.3%, 95% CI - 0.5 to 1.4), and probably reduces all-cause mortality (adjusted odds ratio [aOR], 0.44; 95% CI 0.30-0.64; RD - 4.6%; 95% CI - 5.8 to - 2.9).

CONCLUSIONS

Moderate certainty evidence suggested that there was little to no difference between tenecteplase and alteplase in increasing the proportion of patients achieving excellent functional outcome at 3 months and the risk of symptomatic intracranial hemorrhage, while compared to alteplase, tenecteplase probably reduce all-cause mortality. Administration of 0.25 mg/kg tenecteplase after acute ischemic stroke is suggestive of increasing the proportion of patients that achieve excellent functional outcome at 3 months.

Observation of efficacy of rt-PA thrombolysis combined with Solitaire AB stent mechanical thrombectomy in patients with acute ischemic stroke: a retrospective analysis

OBJECTIVE

To observe and analyze the efficacy of recombinant tissue-plasminogen activator (rt-PA) thrombolysis combined with Solitaire AB stent mechanical thrombectomy in patients with acute ischemic stroke.

METHODS

Clinical efficacy, neurological function, oxidative stress response, adverse reactions, and quality of life were compared between the two groups.

RESULTS

Lower NIHSS scores were observed among patients who received treatment within 2 h after stroke onset when compared with those in a timeframe of 2-6 h, suggesting better neurological function recovery of the patients with early intervention and thus emphasizing the importance of early treatment for patients with stroke onset. Clinical efficacy in the combination group was significantly higher than in the control group (p < 0.05). After treatment, Paraoxonase-1 (PON-1) levels were higher, while lipoprotein-associated phospholipase A2 (Lp-PLA2) and Serum Amyloid A (SAA) levels were lower in the combination group compared to the control group (p < 0.05). The incidence of adverse reactions was significantly lower in the combination group (p < 0.05). At discharge, we observed significantly more patients with good recovery in the combination group when compared to the control group (p < 0.05), suggesting better quality of life of the patients, while this statistical significance was no longer observable at 90 days after discharge (p > 0.05).

CONCLUSION

For acute ischemic stroke patients, rt-PA thrombolysis combined with Solitaire AB stent mechanical thrombectomy treatment is effective. It promotes neurological function recovery, improves vascular stenosis, reduces inflammation and adverse reactions, and enhances quality of life, showing promising clinical applications.

Tenecteplase versus Alteplase in Acute Ischemic Stroke: A Systematic Review and Meta-analysis

Background

A number of clinical trials have compared tenecteplase (TNK) and alteplase for the management of acute ischemic stroke (AIS) and the results are inconsistent.

Purpose

Present systematic review and meta-analysis is undertaken to analyse the efficacy and safety of TNK in AIS compared to alteplase.

Summary

A thorough literature search was performed through the databases Embase, Cochrane Library, PubMed, and clinicaltrials.gov, for a period from inception to September 2022, with the keywords i.e., "tenecteplase" and "alteplase" and "acute ischemic stroke." Clinical trials published in English that compared the efficacy and safety of TNK to alteplase in AIS were included. The major outcomes of this meta-analysis were proportion of patients free from disability and functional independence at 90 days, early neurological improvement at 24 hours, all-cause mortality at 90 days, patients with intra cranial hemorrhage (ICH), and patients with severe disability at 90 days. A total of nine studies with 3,573 patients were included in the analysis. The proportion of patients with freedom from disability was comparable in both groups (relative risk [RR] = 1.04, 95 per cent CI = 0.92-1.17; p = .53). Similarly, proportion of patients with functional independence was comparable (RR = 1.12, 95 per cent CI = 0.96-1.31; p = .14). TNK group had a higher rate of early neurological recovery (RR = 1.56, 95 per cent CI = 0.96-2.54; p = .07). All-cause mortality at 90 days was comparable in both groups (RR = 0.97; 95 per cent CI = 0.72-1.29; p = .82). The proportion of patients with ICH was higher in TNK group (RR = 1.14, 95 per cent CI = 0.77-1.68; p = .52). The proportion of patients with severe disability was less in TNK group (RR =0.84, 95 per cent CI = 0.53-1.32; p = .44).

Key Message

TNK was similar to alteplase in terms of efficacy and safety. The patients in TNK group showed early neurological improvement but were simultaneously at higher risk of ICH. The TNK can be an alternative to alteplase if the benefits outweigh the risks.

RE-OPEN: Randomised trial of biosimilar TNK versus TPA during endovascular therapy for acute ischaemic stroke due to large vessel occlusions

Rationale

Rapid and timely treatment with intravenous thrombolysis and endovascular treatment (EVT) in patients with acute ischaemic stroke (AIS) and large vessel occlusion (LVO) significantly improves patient outcomes. Bridging therapy is the current standard of care in these patients. However, an incompletely answered question is whether one thrombolytic agent is better than another during bridging therapy.

Aim

The current study aims to understand if one thrombolytic agent is superior to the other during bridging therapy in the treatment of AIS and LVO.

Sample size estimates

Using 80% power and an alpha error of 5 %, presuming a 10% drop out rate, a total of 372 patients will be recruited for the study.

Methods and design

This study is a prospective, randomised, multicentre, open-label trial with blinded outcome analysis design.

Study outcomes

The primary outcomes include proportion of patients who will be independent at 3 months (modified Rankin score (mRS) ≤2 as good outcome) and proportion of patients who achieve recanalisation modified thrombolysis in cerebral infarction grade 2b/3 at first angiography run at the end of EVT. Secondary outcomes include proportion of patients with early neurological improvement, rate of symptomatic intracerebral haemorrhage (ICH), rate of any ICH, rate of any systemic major or minor bleeding and duration of hospital stay. Safety outcomes include any intracranial bleeding or symptomatic ICH.

Discussion

This trial is envisioned to confirm the theoretical advantages and increase the strength and quality of evidence for use of tenecteplase (TNK) in practice. Also, it will help to generate data on the efficacy and safety of biosimilar TNK.

Trial registration number

CTRI/2022/01/039473.

Efficacy of urokinase and alteplase intravenous thrombolysis in the treatment of acute phase cerebral infarction and impact on serum S-100β and nerve growth factor levels

OBJECTIVE

To compare the efficacy of urokinase and alteplase intravenous thrombolysis in the treatment of acute phase cerebral infarction and investigate their impact on serum S-100β and nerve growth factor (NGF) levels.

METHODS

Parameters assessed included NIHSS score reduction, vascular recanalization rates, mRS, Barthel Index, and adverse reactions. Post-treatment blood samples were also collected for further analysis.

RESULTS

The clinical treatment effectiveness and Vascular recanalization rate in Group A was higher than in Group B, with p < 0.05. After treatment, the NIHSS score in Group A was lower than in Group B (p < 0.05), and the mRS score was slightly lower, but the difference was not significant (p > 0.05). After treatment, the levels of IL-6, TNF-α, and CRP in Group A were lower than in the control group (p < 0.05). The S-100β level in Group A was lower than in Group B, and NGF level was higher than in Group B (p < 0.05). Group A had better prognosis.

CONCLUSION

The efficacy and safety of both urokinase and alteplase intravenous thrombolysis for acute phase cerebral infarction have been demonstrated, yet disparities exist in neurological function recovery and regulation of biochemical indicators. Alteplase intravenous thrombolysis emerges as the superior option, displaying greater effectiveness and safety, alongside improved regulation of serum S-100β and NGF levels. Tailoring treatment plans to individual patient characteristics and drug mechanisms is essential. Given these findings, the promotion of alteplase intravenous thrombolysis in the management of acute phase cerebral infarction is justified.

The efficacy and safety of intravenous thrombolysis with tenecteplase versus alteplase for acute ischemic stroke: a systematic review and meta-analysis

OBJECTIVES

We aimed to evaluate the available evidence on the efficacy and safety outcomes of intravenous tenecteplase (TNK) compared with intravenous alteplase(ALT) for patients with acute ischemic stroke (AIS) in randomized controlled trials (RCTs).

METHODS

The MEDLINE/PubMed, Embase, Springer, Web of Science, Cochrane Collaboration database, China National Knowledge Infrastructure (CNKI) database, and Wanfang database were comprehensively searched for RCTs regarding the effects of TNK versus ALT among AIS patients in these English and Chinese electronic databases from inception dates to August 1, 2022. This meta-analysis followed PRISMA guidelines. Two reviewers independently retrieved RCTs and extracted relevant information. The methodological quality of the included trials was estimated using the Cochrane risk of bias tool. The pooled analyses were performed using RevMan 5.3 software. The primary outcome was functional outcome on the modified Rankin Scale (mRS) (range 0 to 5) and mortality at 90 days. The secondary outcomes included successful recanalization, early neurologic improvement < 48 h, any intracranial hemorrhage (ICH), and symptomatic ICH. The follow-up time of all studies was at least 3 months.

RESULTS

A total of nine RCTs involving 1958 patients in TNK group and 1731 patients in ALT group were finally included. For the efficacy outcomes, there were no significant differences between the two groups in terms of mRS score 0 ~ 2 (RR 1.00; 95% CI 0.88-1.13; P = 0.96), mRS score 0 ~ 1 (RR 1.03; 95% CI 0.96-1.10; P = 0.36), successful recanalization (RR 1.25; 95% CI 0.88-1.76; P = 0.21), and early neurologic improvement < 48 h (RR 1.08; 95% CI 0.92-1.26; P = 0.37). Similar results were seen for the safety outcomes, which have no statistical differences in terms of any ICH (RR 1.01; 95% CI 0.72-1.41; P = 0.96), symptomatic ICH (RR 1.19; 95% CI 0.81-1.76; P = 0.37), and mortality at 90 days (RR 0.99; 95% CI 0.83-1.19; P = 0.94).

CONCLUSION

Overall, the efficacy and safety outcomes of intravenous thrombolysis with TNK versus ALT for AIS were not statistically different. However, TNK at a dose of 0.25 mg/kg may be a reasonable alternative to ALT for thrombolysis.

Complications of Intravenous Tenecteplase Versus Alteplase for the Treatment of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

Prior systematic reviews have compared the efficacy of intravenous tenecteplase and alteplase in acute ischemic stroke, assigning their relative complications as a secondary objective. The objective of the present study is to determine whether the risk of treatment complications differs between patients treated with either agent.

METHODS

We performed a systematic review including interventional studies and prospective and retrospective, observational studies enrolling adult patients treated with intravenous tenecteplase for ischemic stroke (both comparative and noncomparative with alteplase). We searched MEDLINE, Embase, the Cochrane Library, Web of Science, and the www.

CLINICALTRIALS

gov registry from inception through June 3, 2022. The primary outcome was symptomatic intracranial hemorrhage, and secondary outcomes included any intracranial hemorrhage, angioedema, gastrointestinal hemorrhage, other extracranial hemorrhage, and mortality. We performed random effects meta-analyses where appropriate. Evidence was synthesized as relative risks, comparing risks in patients exposed to tenecteplase versus alteplase and absolute risks in patients treated with tenecteplase.

RESULTS

Of 2226 records identified, 25 full-text articles (reporting 26 studies of 7913 patients) were included. Sixteen studies included alteplase as a comparator, and 10 were noncomparative. The relative risk of symptomatic intracranial hemorrhage in patients treated with tenecteplase compared with alteplase in the 16 comparative studies was 0.89 ([95% CI, 0.65-1.23]; I2=0%). Among patients treated with low dose (<0.2 mg/kg; 4 studies), medium dose (0.2-0.39 mg/kg; 13 studies), and high dose (≥0.4 mg/kg; 3 studies) tenecteplase, the RRs of symptomatic intracranial hemorrhage were 0.78 ([95% CI, 0.22-2.82]; I2=0%), 0.77 ([95% CI, 0.53-1.14]; I2=0%), and 2.31 ([95% CI, 0.69-7.75]; I2=40%), respectively. The pooled risk of symptomatic intracranial hemorrhage in tenecteplase-treated patients, including comparative and noncomparative studies, was 0.99% ([95% CI, 0%-3.49%]; I2=0%, 7 studies), 1.69% ([95% CI, 1.14%-2.32%]; I2=1%, 23 studies), and 4.19% ([95% CI, 1.92%-7.11%]; I2=52%, 5 studies) within the low-, medium-, and high-dose groups. The risks of any intracranial hemorrhage, mortality, and other studied outcomes were comparable between the 2 agents.

CONCLUSIONS

Across medium- and low-dose tiers, the risks of complications were generally comparable between those treated with tenecteplase versus alteplase for acute ischemic stroke.

Feasibility of switching from alteplase to tenecteplase for stroke thrombolysis – a retrospective cohort analysis

Introduction

Tenecteplase (TNK-tPA) has several benefits over alteplase (tPA) in treatment of acute ischaemic stroke. Randomised controlled trials have shown promising results. In June 2017, the Stroke Unit at Sundsvall County Hospital switched from tPA to TNK-tPA in standard clinical practice. This study examines the effects of that shift.

Methods

All thrombolysis treatments performed during the first twenty-four months with TNK-tPA (168) were compared to the last twenty-four months with tPA (191). Data were collected from patient records. Follow-up time was 30 days. Co-primary outcomes were death and symptomatic intracranial haemorrhage (SICH). Secondary outcomes were types of intracerebral bleeding and cause of death. Tertiary outcome was door-to-needle time (DNT).

Results

Treatment groups were of comparable age (75.7 ± 0.2 years). tPA-treated patients had an NIHSS (National Institutes of Health Stroke Scale) score of 9.2 versus 7.5 for TNK-tPA. Patients older than 80 had more severe strokes (median NIHSS 9 versus 5). SICH occurred in 6 (3.6 %) patients in the TNK-tPA group and in 2 (1.0 %) treated with tPA, odds ratio (OR) 3.41 (0.70-16.7). Numbers for death were 21 (12.5 %) and 31 (15.2 %), OR 0.77 (0.46-1.29), meaning no statistically significant differences in primary outcomes. There were no significant differences in secondary outcomes. Predominant cause of death was cerebral infarction. DNT with tenecteplase was shorter: mean 44 versus 26, and median 35 versus 19 min.

Conclusions

Switching from alteplase to tenecteplase was associated with shorter time to treatment. To draw certain conclusions regarding safety or efficacy would require a larger material.

Tenecteplase in managing acute ischemic stroke: a long-term cost-utility analysis in Iran

BACKGROUND & AIMS

The advantage of tenecteplase (TNK) over alteplase (ALT) in managing acute ischemic stroke (AIS) has been reported, but the cost-effectiveness of these two strategies has not received as much attention. The objective of this study was to compare TNK and ALT for the management of AIS patients in Iran in terms of cost-effectiveness.

METHODS

This study was carried out from the payer's perspective in Iran, with a lifetime horizon. A full economic evaluation model was designed as a decision tree and a Markov model. After defining different Markov states, each health state was assigned a utility value, and quality-adjusted life year (QALY) was estimated using that value. The incremental cost-effectiveness ratio (ICER) was ultimately used for evaluating the comparative cost-effectiveness. Both deterministic and probabilistic sensitivity analyses were carried out.

RESULTS

Compared to ALT, TNK can save approximately 4333.81 USD, and is able to increase one unit of QALY while saving approximately 17,450.29 USD. So, Base-case results showed that TNK strongly dominates ALT. Moreover, the base case results were strongly confirmed by deterministic and probabilistic sensitivity analysis.

CONCLUSIONS

Base-case and sensitivity analysis showed that TNK is the dominant strategy compared to ALT for the management of AIS patients.

Effectiveness and Safety of Tecneplase vs. Alteplase in the Acute Treatment of Ischemic Stroke

Not all hospitals have interventional radiology services. This fact implies that in centers where this resource is not available, the treatment of stroke in the acute phase must be adapted and individualized. The aim of the study is to determine and compare the combined effect of thrombolysis and thrombectomy effectiveness and safety of tenecteplase versus alteplase in the acute treatment of ischemic stroke in patients who are candidates for endovascular therapy according to clinical practice guidelines. This paper details a retrospective multicenter cohort study of patients with ischemic stroke admitted in three hospitals between 2018 and 2020. The main outcome variables were the degree of recanalization and the functional outcome at 3 months; safety variables were mortality and the occurrence of intracranial hemorrhage (ICH). In total, 100 patients were included, 20 of which were treated with tenecteplase (TNK) and 80 with alteplase (rtPA). Of those treated with TNK, 75% obtained a successful recanalization compared to 83.8% in those treated with rtPA (OR 0.58; 95% CI 0.18–1.88; p = 0.56). No differences were found in obtaining an excellent functional result at 3 months (35% TNK vs. 58.8% rtPA; p = 0.38). Tenecteplase showed worse neurological results after 24 h (unfavorable result of 70% with TNK vs. 45% with rtPA; OR = 5.4; 95% CI 1.57–18.6). No significant differences were identified in mortality; 17.5% with rtPA and 20% with TNK (p = 0.79), nor in the appearance of intracranial hemorrhage ICH (15.2% with rtPA vs. 30% with TNK (p = 0.12). In our series, there were not significant differences shown regarding effectiveness and safety between tenecteplase and alteplase.

The Efficacy and Safety of Ischemic Stroke Therapies: An Umbrella Review

Background: Ischemic stroke is a leading cause of morbidity and mortality in neurological diseases. Numerous studies have evaluated the efficacy and safety of ischemic stroke therapies, but clinical data were largely inconsistent. Therefore, it is necessary to summarize and analyze the published clinical research data in the field.

Objective: We aimed to perform an umbrella review to evaluate the efficacy and safety of ischemic stroke therapies.

Methods: We conducted a search for meta-analyses and systematic reviews on PubMed, the Cochrane Library, and the Web of Science to address this issue. We examined neurological function deficit and cognitive function scores, quality of life, and activities of daily living as efficacy endpoints and the incidence of adverse events as safety profiles.

Results: Forty-three eligible studies including 377 studies were included in the umbrella review. The results showed that thrombolytic therapy (tPA; alteplase, tenecteplase, and desmoteplase), mechanical thrombectomy (MTE), edaravone with tPA, stem cell-based therapies, stent retrievers, acupuncture with Western medicines, autologous bone marrow stromal cells, antiplatelet agents (aspirin, clopidogrel, and tirofiban), statins, and Western medicines with blood-activating and stasis-dispelling herbs (NaoShuanTong capsule, Ginkgo biloba, Tongqiao Huoxue Decoction, Xuesaitong injection) can improve the neurological deficits and activities of daily living, and the adverse effects were mild for the treatment of ischemic stroke. Moreover, ligustrazine, safflower yellow, statins, albumin, colchicine, MLC601, salvianolic acids, and DL-3-n-butylphthalide showed serious adverse events, intracranial hemorrhage, or mortality in ischemic stroke patients.

Conclusion: Our study demonstrated that tPA, edaravone and tPA, tPA and MTE, acupuncture and Western medicines, and blood-activating and stasis-dispelling herbs with Western medicines are the optimum neurological function and activities of daily living medication for patients with ischemic stroke.

Systematic Review Registration: https://inplasy.com/, identifier [INPLASY202250145].

Ethical Justification for Deferral of Consent in the AcT Trial for Acute Ischemic Stroke

The AcT trial (Alteplase Compared to Tenecteplase) compares alteplase or tenecteplase for patients with acute ischemic stroke. All eligible patients are enrolled by deferral of consent. Although the use of deferral of consent in the AcT trial meets the requirements of Canadian policy, we sought to provide a more explicit and rigorous approach to the justification of deferral of consent organized around 3 questions. Ultimately, the approach we outline here could become the foundation for a general justification for deferral of consent.

A practice game changer: Impact of tenecteplase for acute ischemic stroke in a multicenter quality improvement project

PURPOSE

Tenecteplase is a thrombolytic that is more fibrin specific, has a longer half-life, and is easier to administer than alteplase for acute ischemic stroke (AIS). This article outlines the pharmacy experience and perspective on implementation of tenecteplase as the treatment of choice for AIS.

SUMMARY

Tenecteplase has been of increasing interest for AIS and is currently being studied in several clinical trials. Although it is not indicated by the Food and Drug Administration for AIS, several published studies and an update to stroke guidelines from the American Heart Association and American Stroke Association support its use in this setting. In January 2021, Cedars-Sinai Health System made the decision to add tenecteplase to the formulary for AIS in addition to keeping alteplase for patients who met the criterion of being outside the 4.5-hour window following stroke onset. Along with the added benefits of having tenecteplase on formulary come challenges of managing multiple thrombolytics for the same indication. Identifying key stakeholders and creating an interdisciplinary team are critical to ensure safe transitions.

CONCLUSION

Institutions can safely transition from alteplase to tenecteplase as a thrombolytic of choice for AIS.

Low-cost alternatives for the management of acute ischemic stroke in low and middle-income countries

Acute ischemic stroke (AIS) patients arriving within a suitable time frame are treated with recanalization therapy i.e. intravenous thrombolysis (IVT) with alteplase and/or mechanical thrombectomy (MT). IVT with alteplase is indicated in AIS patients presenting within 4.5 hours of onset regardless of vascular territory involved. MT is indicated in AIS patients presenting within 24 hours of onset with large vessel occlusion in the anterior circulation. However, MT is ludicrously expensive and requires exorbitant setup, devices, and expertise which is not currently feasible in LMICs. Therefore, in LMICs the only feasible recanalization option left for AIS patients is IVT. The cost of IVT varies across the LMICs, however, most of them cost around 2000-5000 USD. Apart from IVT, patients with AIS often have other significant medical costs including those for neuroimaging, intensive care, and prolonged rehabilitative treatment. In LMICs, these costs can only be afforded by a handful of patients. The majority of the LMICs have health insurance in their infancy and family members of AIS patients opt-out IVT due to the economic burden. In general, the current treatment guidelines for AIS are not very useful in LMICs because of cost-related issues among several other factors. In this editorial, we discuss evidence for alternative treatment strategies that can help tackle the rising epidemic of AIS in poor countries by improvising on existing clinical guidelines and seeking alternative treatment regimens.

Functional Outcome, Recanalization, and Hemorrhage Rates After Large Vessel Occlusion Stroke Treated With Tenecteplase Before Thrombectomy

BACKGROUND AND OBJECTIVES

To investigate in routine care the efficacy and safety of IV thrombolysis (IVT) with tenecteplase prior to mechanical thrombectomy (MT) in patients with large vessel occlusion acute ischemic strokes (LVO-AIS), either secondarily transferred after IVT or directly admitted to a comprehensive stroke center (CSC).

METHODS

We retrospectively analyzed clinical and procedural data of patients treated with 0.25 mg/kg tenecteplase within 270 minutes of LVO-AIS who underwent brain angiography. The main outcome was 3-month functional independence (modified Rankin Scale score ≤2). Recanalization (revised Treatment in Cerebral Ischemia score 2b-3) was evaluated before (pre-MT) and after MT (final).

RESULTS

We included 588 patients (median age 75 years [interquartile range (IQR) 61-84]; 315 women [54%]; median NIH Stroke Scale score 16 [IQR 10-20]), of whom 520 (88%) were secondarily transferred after IVT. Functional independence occurred in 47% (n = 269/570; 95% confidence interval [CI] 43.0-51.4) of patients. Pre-MT recanalization occurred in 120 patients (20.4%; 95% CI 17.2-23.9), at a similar rate across treatment paradigms (direct admission, n = 14/68 [20.6%]; secondary transfer, n = 106/520 [20.4%]; p > 0.99) despite a shorter median IVT to puncture time in directly admitted patients (38 [IQR 23-55] vs 86 [IQR 70-110] minutes; p < 0.001). Final recanalization was achieved in 492 patients (83.7%; 95%CI 80.4-86.6). Symptomatic intracerebral hemorrhage occurred in 2.5% of patients (n = 14/567; 95% CI 1.4-4.1).

DISCUSSIONS

Tenecteplase before MT is safe, effective, and achieves a fast recanalization in everyday practice in patients secondarily transferred or directly admitted to a CSC, in line with published results. These findings should encourage its wider use in bridging therapy.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that tenecteplase within 270 minutes of LVO-AIS increases the probability of functional independence.

Icariin, an Up-and-Coming Bioactive Compound Against Neurological Diseases: Network Pharmacology-Based Study and Literature Review

Icariin is a biologically active substance in Epimedii herba that is used for the treatment of neurologic disorders. However, a comprehensive analysis of the molecular mechanisms of icariin is lacking. In this review, we present a brief history of the use of icariin for medicinal purposes; describe the active chemical components of Epimedii herba; and examine the evidence from experimental studies that have uncovered molecular targets of icariin in different diseases. We also constructed a protein–protein interaction network and carried out Gene Ontology and Kyoto Encyclopedia of Genes and Genomes functional enrichment analyses to predict the therapeutic actions of icariin in nervous system diseases including Alzheimer disease, Parkinson disease, ischemic stroke, depressive disorder, multiple sclerosis, glioblastoma, and hereditary spastic paraplegias. The results of our analyses can guide future studies on the application of icariin to the treatment of neurologic disorders.

Comparison of thrombolytic agents in treatment of patients with acute ischemic stroke; findings from a single centre follow up study in real-life settings

BACKGROUND AND OBJECTIVES

Health outcome data of thrombolysis in patients with acute ischemic stroke in real life-settings in India are scarce. We studied the clinical profile, risk factors and functional outcome of patients with acute ischemic stroke (AIS) who were thrombolysed.

METHODS

In a single centre retrospective study from January 2017 to June 2020, we analysed the data of adult patients with AIS presented within 4.5 h of symptom onset. We included patients if they had NIHSS score ≥4, modified Rankin score of 2 or less before the stroke onset and without evidence of haemorrhage. Modified Rankin score of two or less at the end of three months was defined as the primary efficacy outcome. The development of symptomatic intracerebral haemorrhage was considered as the primary safety outcome. We tried to analyse the primary safety and efficacy outcomes between two thrombolytic agents.

RESULTS

Ninety patients (Tenecteplase = 61; Alteplase, n = 29) underwent stroke thrombolysis during the study period. The mean age was 64.3 years in Tenecteplase group and 63.2 years in Alteplase group. Twenty patients were aged more than 75 years. Hypertension was the most common comorbidity in both the groups (72% and 72.4%). Median mRS score at 3-months was 1 in Tenecteplase group and 0.5 in Alteplase group (p < 0.001), however there was no statistically significant difference between both treatment groups in terms of NIHS score at 24 h (70.4% vs 51.7%, p = 0.08), functional recovery calculated with mRS at 3-month (83.6% vs 79.3%, p = 0.62) or in terms of symptomatic ICH (9.8% and 17.2% p = 0.36).

CONCLUSION

Tenecteplase appears to have similar clinical outcomes as Alteplase for stroke thrombolysis. Given the relatively low-cost and ease of administration, Tenecteplase may be better than Alteplase for management of acute ischemic stroke.

The net benefit of thrombolysis in the management of intermediate risk pulmonary embolism: Systematic review and meta‐analysis

Background

Benefit of thrombolytic therapy in patients with massive pulmonary embolism (PE) is evident. However, evidence supporting benefit in clinical outcomes of this approach in intermediate risk PE is lacking.

Objective

To determine the impact of thrombolysis on overall survival in intermediate risk PE patients.

Methods

We searched in MEDLINE (OVID), EMBASE, LILACS, and the Cochrane Central Register of Controlled Trials (CENTRAL) from present day. We also searched in other databases and unpublished literature. We included clinical trials without language restrictions. The risk of bias was evaluated with the Cochrane Collaboration's tool. The primary outcome was overall survival. Secondary outcomes were adverse events, including major bleeding, and all‐cause mortality. The measure of the effect was the risk ratio with a 95% confidence interval (CI).

Results

We included 11 studies in the qualitative and quantitative analysis, with a total of 1855 patients. Risk of bias was variable among the study items. There were no results reported about overall survival in any of the studies. The risk ratio (RR) for all‐cause mortality was 0.68 95% CI (0.40 to 1.16). The RR of overall bleeding, major bleeding and stroke were 2.72 95% CI (1.58 to 4.69), 2.17 95% CI (1.03 to 4.55), and 2.22 95% CI (0.17 to 28.73), respectively. Additionally, the RR for recurrent PE was 0.56 95% CI (0.23 to 1.37).

Conclusions

In patients with intermediate risk PE, the risk of bleeding is higher when thrombolysis is used. There was no significant difference between thrombolysis and anticoagulation in recurrence of PE, stroke, and all‐cause mortality.

Clinical outcomes and safety profile of Tenecteplase in wake-up stroke

BACKGROUND

Tenecteplase has probably pharmacological and clinical advantages in the treatment of acute ischemic stroke. There are lacking data about safety and efficacy of tenecteplase in wake-up stroke (WUPS).

AIMS

To investigate safety and efficacy of tenecteplase compared to alteplase in WUPS patients included in NOR-TEST.

METHODS

WUPS patients in NOR-TEST were included in the study based on DWI-FLAIR mismatch. Included patients randomly assigned (1:1) to receive intravenous tenecteplase 0.4 mg/kg (to a maximum of 40 mg) or alteplase 0.9 mg/kg (to a maximum of 90 mg). Neurological improvement was defined as 1) favorable functional outcome at 90 days modified Rankin Scale (mRS) of 0 or 1 and 2) neurological improvement measured with the National Institutes of Health Stroke Scale (NIHSS) of 4 points within 24 hours as compared to admission NIHSS or NIHSS 0 at 24 hours.

RESULTS

Of 1100 patients from 13 stroke centers included in NOR-TEST, 45 were WUPS patients. Of these, 5 patients were stroke mimics and excluded. Of the remaining 40 patients (3.6%), 24 were treated with alteplase (60%). There was no difference in the number of patients achieving a good clinical outcome (mRS 0-1) in either treatment group. Patients treated with tenecteplase showed a better early neurological improvement (87.5% vs 54.2%, P = 0.027). No ICH was detected on MRI/CT 24-28 hours after thrombolysis.

CONCLUSIONS

In WUPS patients treated in NOR-TEST, there was no difference in clinical outcomes at 90 days and no ICH events or deaths were observed in either alteplase- or tenecteplase-treated patients. Clinical Trial Registration-URL: https://www.clinicaltrials.gov. Unique identifier: NCT01949948.

Border Zones of Evidence: How Non-evidence Based Factors Influence Evidence Generation and Clinical Practice in Stroke Medicine

The interpretation of the results of clinical trials should be done by examining the finer prints of extraneous factors such as stopping rules, interim analysis, intricacies of patient selection, and the rationale of decisions that lead to non-prespecified termination. This can be done only by critical education in the art and science of interpretation of evidence emerging from clinical trials. The pioneering pivotal studies, namely, NINDS rtPA and ECASS III trials, hold disproportionate influence in determining the contours of the subsequent fate of clinical trials and treatment guidelines. It needs to be recognized that the pooling of studies using dissimilar trial designs, notwithstanding similar patient profiles, would undermine the positive signal emerging from the studies that have used better selection methodologies to homogenize the study population.

Using Tenecteplase for Acute Ischemic Stroke: What Is the Hold Up?

Alteplase is the only Food and Drug Administration-approved intravenous (IV) thrombolytic medication for acute ischemic stroke. However, multiple recent studies comparing tenecteplase and alteplase suggest that tenecteplase is at least as efficacious as alteplase with regards to neurologic improvement. When given at 0.25 milligrams per kilogram (mg/kg), tenecteplase may have less bleeding complications than alteplase as well. This narrative review evaluates the literature and addresses the practical issues with regards to the use of tenecteplase versus alteplase for acute ischemic stroke, and it recommends that physicians consider tenecteplase rather than alteplase for thrombolysis of acute ischemic stroke.

Status of prehospital delay and intravenous thrombolysis in the management of acute ischemic stroke in Nepal

BACKGROUND

Intravenous thrombolysis has been recently introduced in Nepal for the management of acute ischemic stroke. Pre-hospital delay is one of the main reasons that hinder thrombolytic therapy. The objective of this study was to evaluate the status of prehospital delay and thrombolysis in Nepal.

METHODS

Data were prospectively collected from patients of both genders, age >  18 years who arrived at the emergency department (ED) with symptoms and neuroimaging findings consistent with an ischemic stroke. Patient data were obtained from ED form and standard questionnaires were used to assess factors resulting in prehospital delay. Modified Rankin scale and National Institute of Health stroke scale were used to assess the degree of disability and severity of stroke respectively.

RESULTS

A total of 228 patients were enrolled in the study between August 2017 and August 2018. Only 46 (20.17%) patients arrived within the time frame for thrombolysis. Onset at daytime (OR: 4.07; 95% CI: 1.65-10.1; p = 0.001), stroke symptoms facial deviation (OR: 5.03; 95% CI: 2.47 to 10.26; p = 0.000) and speech disturbances (OR: 2.34; 95% CI: 1.06 to 5.1; p = 0.021), identification of stroke (OR: 22.36; 95% CI: 9.42-53.04;p = 0.000), rushing to ED after onset of symptoms (OR: 2.93; 95% CI: 1.5-5.7; p = 0.001), awareness of treatment of stroke (OR: 10.21; 95% CI: 4.8-21.6; p = 0.000), direct presentation (OR: 4.2; 95% CI: 2.09-8.66; p = 0.000), the distance less than 20 km (OR: 7.9; 95% CI: 3.8-16.5; p = 0.000), and education above high school (OR:4.85; 95% CI: 2.2-10.5; p = 0.000) were associated with early arrival. Heavy traffic, income below 1000 USD per annum and diabetes mellitus were associated with delayed arrival to ED. Out of 46 early arrival patients, only 30 patients (13.15%) received tissue plasminogen activator during the study period, while others were deprived because of their inability to afford the treatment cost.

CONCLUSION

Community-based intervention to spread awareness, establishing comprehensive stroke centers, training specialists, improving emergency services, establishment of telestroke facilities and encouraging the use of low-cost tenecteplase as an alternative to alteplase can help improve care for stroke patients in Nepal.

Innovations in Acute Stroke Reperfusion Strategies

Vascular neurology is witnessing unprecedented innovations in the management of acute ischemic stroke, especially in reperfusion strategies. The emergence of mechanical thrombectomy with new generation devices has revolutionized the treatment of acute ischemic stroke with large vessel occlusion. The reperfusion strategies are evolving with the extension of the window period for thrombolysis and endovascular therapy through the concept of “tissue clock” in addition to the established “time clock.” The newer generation of thrombolytic drugs like tenecteplase are promising exciting times ahead in acute stroke care. In this “viewpoint,'” the evolution of reperfusion therapy in acute ischemic stroke will be discussed followed by recent innovations in reperfusion strategies.