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Huang J, Zheng H, Zhu X, Zhang K, Ping X. Tenecteplase versus alteplase for the treatment of acute ischemic stroke: a meta-analysis of randomized controlled trials. Ann Med 2024; 56:2320285. [PMID: 38442293 PMCID: PMC10916912 DOI: 10.1080/07853890.2024.2320285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 02/13/2024] [Indexed: 03/07/2024] Open
Abstract
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.
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Affiliation(s)
- Jian Huang
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Hui Zheng
- Department of Emergency Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Xianfeng Zhu
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaofeng Ping
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
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Parsons MW, Yogendrakumar V, Churilov L, Garcia-Esperon C, Campbell BCV, Russell ML, Sharma G, Chen C, Lin L, Chew BL, Ng FC, Deepak A, Choi PMC, Kleinig TJ, Cordato DJ, Wu TY, Fink JN, Ma H, Phan TG, Markus HS, Molina CA, Tsai CH, Lee JT, Jeng JS, Strbian D, Meretoja A, Arenillas JF, Buck BH, Devlin MJ, Brown H, Butcher KS, O'Brien B, Sabet A, Wijeratne T, Bivard A, Grimley RS, Agarwal S, Munshi SK, Donnan GA, Davis SM, Miteff F, Spratt NJ, Levi CR. Tenecteplase versus alteplase for thrombolysis in patients selected by use of perfusion imaging within 4·5 h of onset of ischaemic stroke (TASTE): a multicentre, randomised, controlled, phase 3 non-inferiority trial. Lancet Neurol 2024:S1474-4422(24)00206-0. [PMID: 38880118 DOI: 10.1016/s1474-4422(24)00206-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/05/2024] [Accepted: 05/07/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Intravenous tenecteplase increases reperfusion in patients with salvageable brain tissue on perfusion imaging and might have advantages over alteplase as a thrombolytic for ischaemic stroke. We aimed to assess the non-inferiority of tenecteplase versus alteplase on clinical outcomes in patients selected by use of perfusion imaging. METHODS This international, multicentre, open-label, parallel-group, randomised, clinical non-inferiority trial enrolled patients from 35 hospitals in eight countries. Participants were aged 18 years or older, within 4·5 h of ischaemic stroke onset or last known well, were not being considered for endovascular thrombectomy, and met target mismatch criteria on brain perfusion imaging. Patients were randomly assigned (1:1) by use of a centralised web server with randomly permuted blocks to intravenous tenecteplase (0·25 mg/kg) or alteplase (0·90 mg/kg). The primary outcome was the proportion of patients without disability (modified Rankin Scale 0-1) at 3 months, assessed via masked review in both the intention-to-treat and per-protocol populations. We aimed to recruit 832 participants to yield 90% power (one-sided alpha=0·025) to detect a risk difference of 0·08, with an absolute non-inferiority margin of -0·03. The trial was registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613000243718, and the European Union Clinical Trials Register, EudraCT Number 2015-002657-36, and it is completed. FINDINGS Recruitment ceased early following the announcement of other trial results showing non-inferiority of tenecteplase versus alteplase. Between March 21, 2014, and Oct 20, 2023, 680 patients were enrolled and randomly assigned to tenecteplase (n=339) and alteplase (n=341), all of whom were included in the intention-to-treat analysis (multiple imputation was used to account for missing primary outcome data for five patients). Protocol violations occurred in 74 participants, thus the per-protocol population comprised 601 people (295 in the tenecteplase group and 306 in the alteplase group). Participants had a median age of 74 years (IQR 63-82), baseline National Institutes of Health Stroke Scale score of 7 (4-11), and 260 (38%) were female. In the intention-to-treat analysis, the primary outcome occurred in 191 (57%) of 335 participants allocated to tenecteplase and 188 (55%) of 340 participants allocated to alteplase (standardised risk difference [SRD]=0·03 [95% CI -0·033 to 0·10], one-tailed pnon-inferiority=0·031). In the per-protocol analysis, the primary outcome occurred in 173 (59%) of 295 participants allocated to tenecteplase and 171 (56%) of 306 participants allocated to alteplase (SRD 0·05 [-0·02 to 0·12], one-tailed pnon-inferiority=0·01). Nine (3%) of 337 patients in the tenecteplase group and six (2%) of 340 in the alteplase group had symptomatic intracranial haemorrhage (unadjusted risk difference=0·01 [95% CI -0·01 to 0·03]) and 23 (7%) of 335 and 15 (4%) of 340 died within 90 days of starting treatment (SRD 0·02 [95% CI -0·02 to 0·05]). INTERPRETATION The findings in our study provide further evidence to strengthen the assertion of the non-inferiority of tenecteplase to alteplase, specifically when perfusion imaging has been used to identify reperfusion-eligible stroke patients. Although non-inferiority was achieved in the per-protocol population, it was not reached in the intention-to-treat analysis, possibly due to sample size limtations. Nonetheless, large-scale implementation of perfusion CT to assist in patient selection for intravenous thrombolysis in the early time window was shown to be feasible. FUNDING Australian National Health Medical Research Council; Boehringer Ingelheim.
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Affiliation(s)
- Mark W Parsons
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia; Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia.
| | - Vignan Yogendrakumar
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Leonid Churilov
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Carlos Garcia-Esperon
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Bruce C V Campbell
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Michelle L Russell
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia
| | - Gagan Sharma
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia; Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Chushuang Chen
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Longting Lin
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Beng Lim Chew
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia
| | - Felix C Ng
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Austin Health, Melbourne, VIC, Australia
| | | | - Philip M C Choi
- Department of Neuroscience, Box Hill Hospital, Eastern Health, Melbourne, VIC, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dennis J Cordato
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - John N Fink
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Henry Ma
- Schools of Clinical Science at Monash Health, Department of Medicine and Neurology, Monash University, Melbourne, VIC, Australia
| | - Thanh G Phan
- Schools of Clinical Science at Monash Health, Department of Medicine and Neurology, Monash University, Melbourne, VIC, Australia
| | - Hugh S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Carlos A Molina
- Vall d'Hebron Stroke Center, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Chon-Haw Tsai
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Juan F Arenillas
- Department of Neurology, Hospital Clínico Universitario, Valladolid Health Research Institute, University of Valladolid, Valladolid, Spain
| | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Michael J Devlin
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Helen Brown
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Ken S Butcher
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Arman Sabet
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Tissa Wijeratne
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, Western Health, Sunshine Hospital, St Albans, VIC, Australia
| | - Andrew Bivard
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Rohan S Grimley
- Sunshine Coast University Hospital, School of Medicine and Dentistry, Griffith University, Birtinya, QLD, Australia
| | - Smriti Agarwal
- Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge, UK
| | - Sunil K Munshi
- Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Geoffrey A Donnan
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Stephen M Davis
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Ferdinand Miteff
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Neil J Spratt
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Christopher R Levi
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
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Xiong Y, Wang L, Pan Y, Wang M, Schwamm LH, Duan C, Campbell BCV, Li S, Hao M, Wu N, Cao Z, Wu S, Li Z, Wang Y. Tenecteplase versus alteplase for acute ischaemic stroke in the elderly patients: a post hoc analysis of the TRACE-2 trial. Stroke Vasc Neurol 2024:svn-2023-003048. [PMID: 38858097 DOI: 10.1136/svn-2023-003048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 05/20/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND The benefit-risk profile of tenecteplase in the elderly patients with acute ischaemic stroke (AIS) is uncertain. We sought to investigate the efficacy and safety of 0.25 mg/kg tenecteplase compared with alteplase for AIS patients aged ≥80 years. METHODS We performed a post hoc analysis of the Tenecteplase Reperfusion Therapy in Acute Ischaemic Cerebrovascular Events-2 Trial, a randomised, phase 3, non-inferiority clinical trial. Disabling AIS patients aged ≥80 years who initiated intravenous thrombolytics within 4.5 hours of symptom onset were enrolled from June 2021 to May 2022 across 53 centres in China and were randomly allocated to receive 0.25 mg/kg tenecteplase or 0.9 mg/kg alteplase. The primary efficacy outcome was the proportion of participants with a modified Rankin Scale (mRS) score of 0-1 at 90 days. Symptomatic intracranial haemorrhage (sICH) within 36 hours was the safety outcome. RESULTS Of 137 participants, mRS 0-1 at 90 days occurred in 37 (49.3%) of 75 in the tenecteplase group vs 20 (33.9%) of 59 in the alteplase group (risk ratio (RR) 1.47, 95% CI 0.96 to 2.23). sICH within 36 hours was observed in 3 (4.0%) of 76 in the tenecteplase group and two (3.3%) of 61 in the alteplase group (RR 1.30, 95% CI 0.20 to 8.41). CONCLUSIONS The risk-benefit profile of tenecteplase thrombolysis was preserved in the elderly patients, which lends further support to intravenous 0.25 mg/kg tenecteplase as an alternative to alteplase in these patients.
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Affiliation(s)
- Yunyun Xiong
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liyuan Wang
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Mengxing Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lee H Schwamm
- Yale New Haven Health System, Yale School of Medicine, New Haven, Connecticut, USA
| | - Chunmiao Duan
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Neurology, Beijing Daxing Hospital, Capital Medical University, Beijing, China
| | - Bruce C V Campbell
- Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Shuya Li
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Manjun Hao
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Na Wu
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhixin Cao
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuangzhe Wu
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
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Xu Y, Liu C, Zhou Q, Gu H, Jia Y, Meng D, Wang J, Li W, Liu J, Li Z, Yang X, Guo L. Thrombocytopenia and In-hospital outcomes in patients with acute ischemic stroke undergoing intravenous thrombolysis: Findings from a nationwide registry study in China. J Stroke Cerebrovasc Dis 2024; 33:107805. [PMID: 38839025 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 05/28/2024] [Accepted: 06/02/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Our study aimed to evaluate the associations between platelet count (PC) and in-hospital outcomes for patients with stroke after rt-PA intravenous thrombolysis. METHODS We identified patients who had been hospitalized with a primary diagnosis of stroke and had received rt-PA intravenous thrombolysis from June 2015 to July 2019 at participating hospitals in the Chinese Stroke Center Alliance. PC measured before intravenous thrombolysis was categorized into the following four groups: severe thrombocytopenia (PC < 100 × 109/L), mild thrombocytopenia (100 ≤ PC < 150 × 109/L), normal PC (150 ≤ PC ≤ 450 × 109/L), and thrombocythemia (PC > 450 × 109/L). Outcomes were determined from clinical data collected during hospitalization. The primary clinical outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes were mortality, bleeding events, gastrointestinal (GI) hemorrhage, and in-hospital stroke recurrence. We used multivariate logistic regression models to evaluate the associations between PC and outcomes. RESULTS We included 44,882 individuals with a median age of 66 years, of whom 34.7 % were female, 951 (2.1 %) had severe thrombocytopenia, 7218 (16.1 %) had mild thrombocytopenia, 36,522 (81.4 %) had a normal PC, and 191 (0.4 %) had thrombocythemia. Both severe and mild thrombocytopenia groups had higher risks of bleeding events (adjusted OR 1.30; 95 % CI,1.01-1.67; p = 0.045; adjusted OR 1.32; 95 % CI,1.19-1.46; p < 0.001) and sICH (adjusted OR 1.48;95 % CI,1.13-1.94; p = 0.005; adjusted OR 1.43;95 % CI,1.27-1.60; p < 0.001) than the normal PC group. Patients with 100 ≤ PC < 150 × 109/L also had a higher risk of in-hospital stroke recurrence (adjusted OR 1.12; 95 % CI,1.02-1.22; p = 0.02). CONCLUSIONS Intravenous thrombolysis brings a high risk of sICH given PC < 150 × 109/L, especially PC < 100 × 109/L. It indicated that PC < 100 × 109/L is a reasonable contraindication to thrombolysis.
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Affiliation(s)
- Yuzhu Xu
- Department of Neurology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, PR China
| | - Cuicui Liu
- Department of Neurology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, PR China
| | - Qi Zhou
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, PR China
| | - Hongqiu Gu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, PR China
| | - Yanan Jia
- Department of Neurology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, PR China
| | - Danlin Meng
- Department of Neurology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, PR China
| | - Jinyang Wang
- Department of Neurology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, PR China
| | - Wenjun Li
- Department of Neurology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, PR China
| | - Junyan Liu
- Department of Neurology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, PR China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, PR China
| | - Xin Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, PR China
| | - Li Guo
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, PR China.
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Zarzour A, Batot C, Boisseau W, Cho TH, Guillon B, Richard S, Marnat G, Arquizan C, Lapergue B, Weisenburger Lile D. Tenecteplase versus Alteplase before thrombectomy: A comprehensive evaluation of clinical and angiographic impact: Insights from the ETIS registry. J Neuroradiol 2024; 51:101189. [PMID: 38462131 DOI: 10.1016/j.neurad.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Data on prior use of Tenecteplase versus Alteplase in acute stroke management by mechanical thrombectomy are controversial. Our primary objective was to make a comprehensive comparative assessment of clinical and angiographic efficacy and safety outcomes in a large prospective observational study. METHODS We included stroke patients who were eligible for intravenous thrombolysis and endovascular thrombectomy between 2019 and 2021, from an ongoing registry in twenty comprehensive stroke centers in France. We divided patients into two groups based on the thrombolytic agent used (Alteplase vs Tenecteplase). We then compared their treatment times, and their angiographic (TICI scale), clinical (mRS at three months and sICH) and safety outcomes after controlling for potential confounders using propensity score methods. RESULTS We evaluated 1131 patients having undergone thrombectomy for the final analysis, 250 received Tenecteplase and 881 Alteplase. Both groups were of the same median age (75 vs 74 respectively), and had the same baseline NIHSS score (16) and ASPECTS (8). There was no significant difference for First Pass Effect (OR 0.93, 95 % CI 0.76-1.14, p = 0.75), time required for reperfusion (OR 0.03, 95 % CI 0.09-0.16, p = 0.49), or for final reperfusion status. Clinically, functional independence at 90 days was similar in both groups (OR 0.82, 95 % CI 0.61-1.10, p = 0.18) with the same risk of sICH (OR 1.36, 95 % CI 0.77-2.41, p = 0.28). However, Tenecteplase patients had shorter imaging-to-groin puncture times (99 vs 142 min, p < 0.05). CONCLUSIONS Tenecteplase showed no better clinical or angiographic impact on thrombectomy compared to Alteplase. Nevertheless, it appeared associated with a shorter thrombolysis-to-groin puncture time.
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Affiliation(s)
- Amine Zarzour
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France.
| | - Cedric Batot
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - William Boisseau
- Stroke Unit Neurology, Hôpital Fondation A. de Rothschild, Université Paris-Cité, Université, Paris-Cité and Université Sorbonne Paris Nord (J.P.D.), INSERM, LVTS, F-75018 Paris, France
| | - Tae-Hee Cho
- From the Department of Stroke Medicine, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1044, INSA-Lyon, Hospices Civils de Lyon, Lyon, France
| | - Benoit Guillon
- Department of Neurology, Stroke Center, University Hospital of Nantes, Nantes, France
| | - Sébastien Richard
- Neurology, Stroke Unit, Université, CIC-P 1433, INSERM U1116, CHRU-Nancy, F-54000 Nancy, France
| | - Gaultier Marnat
- Department of Interventional Neuroradiology, University Hospital of Bordeaux, France
| | - Caroline Arquizan
- Department of Neurology, Stroke center, Hôpital Gui de Chauliac, Montpellier Neuroradiology, France
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
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Qu HL, Sun XY, He C, Chen HS. Sex Differences in the Dual Antiplatelet Therapy Versus Alteplase for Patients with Minor Nondisabling Acute Ischemic Stroke: A Secondary Analysis of the ARAMIS Study. CNS Drugs 2024:10.1007/s40263-024-01096-x. [PMID: 38806883 DOI: 10.1007/s40263-024-01096-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND AND PURPOSE Sex is associated with clinical outcome in stroke. The present study aimed to determine the effect of sex on efficacy of dual antiplatelet (DAPT) versus alteplase in ischemic stroke based on Antiplatelet versus recombinant tissue plasminogen activator (R-tPA) for Acute Mild Ischemic Stroke (ARAMIS) trial. METHODS In this secondary analysis of the ARAMIS study, eligible patients aged 18 years or older with minor nondisabling stroke who received dual antiplatelet therapy or intravenous alteplase within 4.5 h of stroke onset were divided into two groups: men and women. The primary endpoint was an excellent functional outcome, defined as a modified Rankin Scale (mRS) 0-1 at 90 days. Binary logistic regression analyses and generalized linear models were used. RESULTS Of the 719 patients who completed the study, 31% (223) were women, and 69% (496) were men. There were no significant sex differences in excellent functional outcome (unadjusted p = 0.304 for men and p = 0.993 for women; adjusted p = 0.376 for men and p = 0.918 for women) and favorable functional outcome (mRS score of 0-2; unadjusted p = 0.968 for men and p = 0.881 for women; adjusted p = 0.824 for men and p = 0.881 for women). But for the secondary outcomes, compared with alteplase, DAPT was associated with a significantly decreased proportion of early neurological deterioration within 24 h in men {unadjusted odds ratio [OR] = 0.440 [95% confidence interval (CI), 0.221-0.878]; p = 0.020; adjusted OR = 0.436 [95% CI, 0.216-0.877]; p = 0.020}, but not in women [unadjusted OR = 0.636 (95% CI, 0.175-2.319), p = 0.490; adjusted OR = 0.687 (95% CI, 0.181-2.609), p = 0.581]. For the safety outcomes, compared with the DAPT group, alteplase was associated with a significantly increased proportion of any bleeding events in men [unadjusted OR = 3.110 (95% CI, 1.103-8.770); p = 0.032], but not in women [unadjusted OR = 5.333 (95% CI, 0.613-46.407), p = 0.129; adjusted OR = 5.394 (95% CI, 0.592-49.112), p = 0.135]. CONCLUSION Sex did not influence the effect of dual antiplatelet therapy versus intravenous alteplase in minor nondisabling stroke, but more early neurological deterioration and bleeding events occurred in men who received alteplase.
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Affiliation(s)
- Hui-Ling Qu
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, 110016, China
| | - Xiao-Yu Sun
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, 110016, China
| | - Chao He
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, 110016, China
| | - Hui-Sheng Chen
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, 110016, China.
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Hilkens NA, Casolla B, Leung TW, de Leeuw FE. Stroke. Lancet 2024:S0140-6736(24)00642-1. [PMID: 38759664 DOI: 10.1016/s0140-6736(24)00642-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 05/19/2024]
Abstract
Stroke affects up to one in five people during their lifetime in some high-income countries, and up to almost one in two in low-income countries. Globally, it is the second leading cause of death. Clinically, the disease is characterised by sudden neurological deficits. Vascular aetiologies contribute to the most common causes of ischaemic stroke, including large artery disease, cardioembolism, and small vessel disease. Small vessel disease is also the most frequent cause of intracerebral haemorrhage, followed by macrovascular causes. For acute ischaemic stroke, multimodal CT or MRI reveal infarct core, ischaemic penumbra, and site of vascular occlusion. For intracerebral haemorrhage, neuroimaging identifies early radiological markers of haematoma expansion and probable underlying cause. For intravenous thrombolysis in ischaemic stroke, tenecteplase is now a safe and effective alternative to alteplase. In patients with strokes caused by large vessel occlusion, the indications for endovascular thrombectomy have been extended to include larger core infarcts and basilar artery occlusion, and the treatment time window has increased to up to 24 h from stroke onset. Regarding intracerebral haemorrhage, prompt delivery of bundled care consisting of immediate anticoagulation reversal, simultaneous blood pressure lowering, and prespecified stroke unit protocols can improve clinical outcomes. Guided by underlying stroke mechanisms, secondary prevention encompasses pharmacological, vascular, or endovascular interventions and lifestyle modifications.
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Affiliation(s)
- Nina A Hilkens
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Barbara Casolla
- Université Nice Cote d'Azur UR2CA-URRIS, Stroke Unit, CHU Pasteur 2, Nice, France
| | - Thomas W Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.
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8
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Wang L, Hao M, Wu N, Wu S, Fisher M, Xiong Y. Comprehensive Review of Tenecteplase for Thrombolysis in Acute Ischemic Stroke. J Am Heart Assoc 2024; 13:e031692. [PMID: 38686848 PMCID: PMC11179942 DOI: 10.1161/jaha.123.031692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 02/20/2024] [Indexed: 05/02/2024]
Abstract
Although intravenous thrombolysis with alteplase remains the primary treatment for acute ischemic stroke, tenecteplase has shown potential advantages over alteplase. Animal studies have demonstrated the favorable pharmacokinetics and pharmacodynamics of tenecteplase. Moreover, it is easier to administer. Clinical trials have demonstrated that tenecteplase is not inferior to alteplase and may even be superior in cases of acute ischemic stroke with large vessel occlusion. Current evidence supports the time and cost benefits of tenecteplase, suggesting that it could potentially replace alteplase as the main option for thrombolytic therapy, especially in patients with large vessel occlusion.
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Affiliation(s)
- Liyuan Wang
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University Beijing China
| | - Manjun Hao
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University Beijing China
| | - Na Wu
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University Beijing China
| | - Shuangzhe Wu
- Chinese Institute for Brain Research Beijing China
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center Harvard Medical School Boston MA USA
| | - Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University Beijing China
- Chinese Institute for Brain Research Beijing China
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9
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Ma Y, Xiang H, Busse JW, Yao M, Guo J, Ge L, Li B, Luo X, Mei F, Liu J, Wang Y, Liu Y, Li W, Zou K, Li L, Sun X. Tenecteplase versus alteplase for acute ischemic stroke: a systematic review and meta-analysis of randomized and non-randomized studies. J Neurol 2024; 271:2309-2323. [PMID: 38436679 DOI: 10.1007/s00415-024-12243-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 03/05/2024]
Abstract
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.
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Affiliation(s)
- Yu Ma
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Hunong Xiang
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Jason W Busse
- Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Anaesthesia, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Minghong Yao
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Jian Guo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Long Ge
- Evidence Based Social Science Research Centre, School of Public Health, Lanzhou University, Lanzhou, 730000, China
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, 730000, China
| | - Bo Li
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300381, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Xiaochao Luo
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Fan Mei
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Jiali Liu
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Yuning Wang
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Yanmei Liu
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Wentao Li
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300381, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Kang Zou
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Ling Li
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China.
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China.
| | - Xin Sun
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China.
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China.
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Geraghty JR, Testai FD. Advances in neurovascular research: Scientific highlights from the 15th world stroke congress. J Stroke Cerebrovasc Dis 2024; 33:107617. [PMID: 38307467 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 01/30/2024] [Indexed: 02/04/2024] Open
Affiliation(s)
- Joseph R Geraghty
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Fernando D Testai
- Department of Neurology & Rehabilitation, University of Illinois College of Medicine, Chicago, IL, USA
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11
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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. Tenecteplase Versus Alteplase in Medium Vessel Occlusion Ischemic Stroke: A Secondary Analysis of the Alteplase Compared to Tenecteplase Randomized Trial. J Stroke 2024; 26:280-289. [PMID: 38836275 PMCID: PMC11164589 DOI: 10.5853/jos.2023.03713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/24/2024] [Accepted: 03/11/2024] [Indexed: 06/06/2024] Open
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.
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Affiliation(s)
- Fouzi Bala
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Internal Medicine (Neurology Division), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Katrina Ignacio
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ayoola Ademola
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Anas Alrohimi
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
- Department of Medicine (Neurology), King Saud University, Riyadh, Saudi Arabia
| | - Houman Khosravani
- Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Canada
| | | | - Luciana Catanese
- Hamilton Health Sciences Centre and McMaster University, Hamilton, Canada
| | - Dariush Dowlatshahi
- Department of Medicine, University of Ottawa, and the Ottawa Heart Research Institute, Ottawa, Canada
| | - Thalia Field
- Vancouver Stroke Program and the Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Gary Hunter
- University of Saskatchewan, Saskatoon, Canada
| | - Faysal Benali
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
| | - MacKenzie Horn
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Andrew Demchuk
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Michael Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Tolulope Sajobi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Richard Swartz
- Department of Medicine (Neurology), King Saud University, Riyadh, Saudi Arabia
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Bijoy K. Menon
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
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Singh A, Singh MP, Gaikwad NR, Kannauje PK. Tenecteplase versus Alteplase in Acute Ischemic Stroke: A Systematic Review and Meta-analysis. Ann Neurosci 2024; 31:132-142. [PMID: 38694719 PMCID: PMC11060130 DOI: 10.1177/09727531231193242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/14/2023] [Indexed: 05/04/2024] Open
Abstract
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.
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Affiliation(s)
- Alok Singh
- Department of Pharmacology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Madhusudan Prasad Singh
- Department of Pharmacology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Nitin R. Gaikwad
- Department of Pharmacology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Pankaj Kumar Kannauje
- Department of General Medicine, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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Yang J, Cai H, Liu N, Huang J, Pan Y, Zhang B, Tong M, Zhang Z. Application of radiomics in ischemic stroke. J Int Med Res 2024; 52:3000605241238141. [PMID: 38565321 PMCID: PMC10993685 DOI: 10.1177/03000605241238141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 02/20/2024] [Indexed: 04/04/2024] Open
Abstract
In recent years, radiomics has emerged as a novel research methodology that plays a crucial role in the diagnosis and treatment of ischemic stroke. By integrating multimodal medical imaging techniques such as computed tomography and magnetic resonance imaging, radiomics offers in-depth insights into aspects such as the extent of brain tissue damage and hemodynamics. These data help physicians to accurately assess patient condition, select optimal treatment strategies, and predict recovery trajectories and long-term prognoses, thereby enhancing treatment efficacy and reducing the risk of complications. With the anticipated further advancements in radiomic technology, this methodology has great potential for expanded applications in the early detection, treatment, and prognosis of ischemic stroke. The present narrative review explores the burgeoning field of radiomics and its transformative impact on ischemic stroke.
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Affiliation(s)
- Jie Yang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Huabo Cai
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ning Liu
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiajie Huang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yun Pan
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bo Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Minfeng Tong
- Department of Neurosurgery, Department of Neuro Intensive Care Unit, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Wang Y, Cai X, Fang Q, Zhu J. Efficacy and safety outcomes of Tenecteplase versus Alteplase for thrombolysis of acute ischemic stroke: A meta-analysis of 9 randomized controlled trials. J Neurol Sci 2024; 458:122912. [PMID: 38325064 DOI: 10.1016/j.jns.2024.122912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/20/2024] [Accepted: 02/01/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND In recent years, Tenecteplase (TNK), a genetically modified variant of alteplase, has been verified as a potential substitute for alteplase in the reperfusion therapy of acute ischemic stroke (AIS). Given the emergence of new randomized controlled trials (RCTs) of this subject, a meta-analysis was conducted to evaluate the present comparative evidence regarding the efficacy and safety outcomes of TNK and alteplase in thrombolysis for AIS. METHODS Following predefined inclusion criteria, we searched the databases of PubMed, Web of Science, and Cochrane Library. RCTs satisfying our inclusion criteria were selected for meta-analysis. Outcome indicators were categorized into efficacy outcomes (early vessel recanalization, excellent recovery, good recovery and early neurological improvement) and safety outcomes (poor recovery, symptomatic intracerebral hemorrhage, parenchymal hemorrhage type 2(PH2) post thrombolysis, and mortality). We extracted data on efficacy outcomes and safety outcomes for patients with AIS in the TNK group at a dose of 0.25 mg/kg and the alteplase group at a dose of 0.9 mg/kg, and expressed the relative risks between the 2 groups as odds ratios (ORs) and 95% confidence intervals (CIs) using the Mantel-Haenszel method. For further insight, we performed a network meta-analysis using a Bayesian framework to compare different doses of TNK (0.1, 0.25, 0.32, and 0.4 mg/kg) with alteplase (0.9 mg/kg). RESULTS A total of 2994 patients in 9 RCTs comparing efficacy and safety outcomes in patients with AIS treated with TNK and alteplase were included. In a pairwise analysis of TNK 0.25 mg/kg and alteplase 0.9 mg/kg, regarding efficacy outcomes, the aggregated results show that TNK 0.25 mg/kg statistically significant increased early vessel recanalization (N = 368, TNK vs. alteplase, OR: 2.07,95%CI: [1.19,3.59], I2 = 0%) and excellent recovery (N = 3548, TNK vs. alteplase, OR: 1.15,95%CI: [1.01,1.32], I2 = 0%). There was no significant difference in good recovery (N = 3486, TNK vs. alteplase, OR: 1.38,95%CI: [0.89,2.15], I2 = 84%) or early neurological improvement (N = 1686, TNK vs. alteplase, OR: 1.06,95%CI: [0.87,1.28], I2 = 24%) between the TNK 0.25 mg/kg group and the alteplase 0.9 mg/kg group. In the safety outcomes, pooled results showed no significant difference in poor recovery (N = 3548, TNK vs. alteplase, OR: 0.94,95%CI: [0.81,1.10], I2 = 0%) and symptomatic intracerebral hemorrhage (N = 3567, TNK vs. alteplase, OR: 1.06,95%CI: [0.70,1.60], I2 = 0%) and PH2(N = 3103, TNK vs. alteplase, OR: 1.26,95%CI:[0.39,4.07], I2 = 56%)and mortality (N = 3447, TNK vs. alteplase, OR: 0.99,95%CI: [0.80,1.23], I2 = 33%) between the TNK group and the alteplase group. In a network meta-analysis, competing treatments were not significantly different from one another (TNK 0.1 mg/kg, TNK 0.25 mg/kg, TNK 0.32 mg/kg, TNK 0.4 mg/kg, alteplase 0.9 mg/kg) in either efficacy outcomes or safety outcomes. CONCLUSION In this analysis of 9 RCTs in patients with AIS, TNK 0.25 mg/kg was comparable to alteplase 0.9 mg/kg from the perspective of efficacy outcomes and safety outcomes after thrombolysis within 4.5 h of AIS occurrence.
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Affiliation(s)
- Yue Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou 215300, China
| | - Xiuying Cai
- Department of Neurology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou 215300, China
| | - Qi Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou 215300, China
| | - Juehua Zhu
- Department of Neurology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou 215300, China.
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15
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Stanton K, Philippou H, Ariëns RA. Ischaemic Stroke, Thromboembolism and Clot Structure. Neuroscience 2024:S0306-4522(24)00088-5. [PMID: 38453129 DOI: 10.1016/j.neuroscience.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/19/2024] [Accepted: 02/23/2024] [Indexed: 03/09/2024]
Abstract
Ischaemic stroke is a major cause of morbidity and mortality worldwide. Blood clotting and thromboembolism play a central role in the pathogenesis of ischaemic stroke. An increasing number of recent studies indicate changes in blood clot structure and composition in patients with ischaemic stroke. In this review, we aim to summarise and discuss clot structure, function and composition in ischaemic stroke, including its relationships with clinical diagnosis and treatment options such as thrombolysis and thrombectomy. Studies are summarised in which clot structure and composition is analysed both in vitro from patients' plasma samples and ex vivo in thrombi obtained through interventional catheter-mediated thrombectomy. Mechanisms that drive clot composition and architecture such as neutrophil extracellular traps and clot contraction are also discussed. We find that, while in vitro clot structure in plasma samples from ischaemic stroke patients are consistently altered, showing denser clots that are more resistant to fibrinolysis, current data on the composition and architecture of ex vivo clots obtained by thrombectomy are more variable. With the potential of advances in technologies underpinning both the imaging and retrieving of clots, we expect that future studies in this area will generate new data that is of interest for the diagnosis, optimal treatment strategies and clinical management of patients with ischaemic stroke.
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Affiliation(s)
- Katherine Stanton
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Helen Philippou
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Robert As Ariëns
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
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16
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Correa-Paz C, Pérez-Mato M, Bellemain-Sagnard M, González-Domínguez M, Marie P, Pérez-Gayol L, López-Arias E, Del Pozo-Filíu L, López-Amoedo S, Bugallo-Casal A, Alonso-Alonso ML, Candamo-Lourido M, Santamaría-Cadavid M, Arias-Rivas S, Rodríguez-Yañez M, Iglesias-Rey R, Castillo J, Vivien D, Rubio M, Campos F. Pharmacological preclinical comparison of tenecteplase and alteplase for the treatment of acute stroke. J Cereb Blood Flow Metab 2024:271678X241237427. [PMID: 38436292 DOI: 10.1177/0271678x241237427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Alteplase (rtPA) remains the standard thrombolytic drug for acute ischemic stroke. However, new rtPA-derived molecules, such as tenecteplase (TNK), with prolonged half-lives following a single bolus administration, have been developed. Although TNK is currently under clinical evaluation, the limited preclinical data highlight the need for additional studies to elucidate its benefits. The toxicities of rtPA and TNK were evaluated in endothelial cells, astrocytes, and neuronal cells. In addition, their in vivo efficacy was independently assessed at two research centers using an ischemic thromboembolic mouse model. Both therapies were tested via early (20 and 30 min) and late administration (4 and 4.5 h) after stroke. rtPA, but not TNK, caused cell death only in neuronal cultures. Mice were less sensitive to thrombolytic therapies than humans, requiring doses 10-fold higher than the established clinical dose. A single bolus dose of 2.5 mg/kg TNK led to an infarct reduction similar to perfusion with 10 mg/kg of rtPA. Early administration of TNK decreased the hemorrhagic transformations compared to that by the early administration of rtPA; however, this result was not obtained following late administration. These two independent preclinical studies support the use of TNK as a promising reperfusion alternative to rtPA.
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Affiliation(s)
- Clara Correa-Paz
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - María Pérez-Mato
- Neuroscience and Cerebrovascular Research Laboratory, Department of Neurology and Stroke Center, La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Universidad Autónoma de Madrid, Madrid, Spain
| | - Mathys Bellemain-Sagnard
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
| | - Marco González-Domínguez
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - Pauline Marie
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
| | - Lara Pérez-Gayol
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - Esteban López-Arias
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - Lucia Del Pozo-Filíu
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - Sonia López-Amoedo
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - Ana Bugallo-Casal
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - María Luz Alonso-Alonso
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
| | - María Candamo-Lourido
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
| | - María Santamaría-Cadavid
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, A Coruña, Spain
| | - Susana Arias-Rivas
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, A Coruña, Spain
| | - Manuel Rodríguez-Yañez
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, A Coruña, Spain
| | - Ramón Iglesias-Rey
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - José Castillo
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - Denis Vivien
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
- Department of Clinical Research, Caen Normandie University Hospital, Caen, France
| | - Marina Rubio
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
| | - Francisco Campos
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
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17
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Brown CS, Manuel FC, Mattson AE, Schmitt CJ, Hellickson JD, Clark SL, Wieruszewski ED. Implementation of Tenecteplase for Acute Ischemic Stroke Treatment. J Emerg Nurs 2024; 50:171-177. [PMID: 38069957 DOI: 10.1016/j.jen.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 10/04/2023] [Accepted: 11/08/2023] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Acute ischemic stroke is a neurologic emergency, requiring rapid recognition and treatment with intravenous thrombolysis. Since the publication of the 2019 American Heart Association/American Stroke Association Guidelines that recommend tenecteplase as an alternative agent, several centers across the United States are transitioning from alteplase to tenecteplase as the agent of choice for thrombolysis in acute ischemic stroke. METHODS Our health system transitioned to tenecteplase for the treatment of acute ischemic stroke in 2021 due to increasing evidence for efficacy and potential for improved door-to-needle time. Herein we describe our experience and provide guidance for other institutions to implement this change. CONCLUSION Emergency nurses are vital to the care of acute ischemic stroke patients. There are several pharmacologic and logistical differences between alteplase and tenecteplase for this indication. This paper outlines these key differences.
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18
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Sajobi TT, Arimoro OI, Ademola A, Singh N, Bala F, Almekhlafi MA, Deschaintre Y, Coutts SB, Thirunavukkarasu S, Khosravani H, Appireddy R, Moreau F, Gubitz GJ, Tkach A, Catanese L, Dowlatshahi D, Medvedev G, Mandzia J, Pikula A, Shankar JS, Williams H, Field TS, Manosalva A, Siddiqui M, Zafar A, Imoukhuede O, Hunter G, Demchuk AM, Mishra SM, Gioia LC, Jalini S, Cayer C, Phillips SJ, Elamin E, Shoamanesh A, Subramaniam S, Kate MP, Jacquin G, Camden MC, Benali F, Alhabli I, Horn M, Stotts G, Hill MD, Gladstone DJ, Poppe AY, Sehgal A, Zhang Q, Lethebe B, Doram C, Shamy M, Kenney C, Buck BH, Swartz RH, Menon BK. Quality of Life After Intravenous Thrombolysis for Acute Ischemic Stroke: Results From the AcT Randomized Controlled Trial. Stroke 2024; 55:524-531. [PMID: 38275116 DOI: 10.1161/strokeaha.123.044690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 11/30/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Recent evidence from thrombolysis trials indicates the noninferiority of intravenous tenecteplase to intravenous alteplase with respect to good functional outcomes in patients with acute stroke. We examined whether the health-related quality of life (HRQOL) of patients with acute stroke differs by the type of thrombolysis treatment received. In addition, we examined the association between the modified Rankin Scale score 0 to 1 and HRQOL and patient-reported return to prebaseline stroke functioning at 90 days. METHODS Data were from all patients included in the AcT trial (Alteplase Compared to Tenecteplase), a pragmatic, registry-linked randomized trial comparing tenecteplase with alteplase. HRQOL at 90-day post-randomization was assessed using the 5-item EuroQOL questionnaire (EQ5D), which consists of 5 items and a visual analog scale (VAS). EQ5D index values were estimated from the EQ5D items using the time tradeoff approach based on Canadian norms. Tobit regression and quantile regression models were used to evaluate the adjusted effect of tenecteplase versus alteplase treatment on the EQ5D index values and VAS score, respectively. The association between return to prebaseline stroke functioning and the modified Rankin Scale score 0 to 1 and HRQOL was quantified using correlation coefficient (r) with 95% CI. RESULTS Of 1577 included in the intention-to-treat analysis patients, 1503 (95.3%) had complete data on the EQ5D. Of this, 769 (51.2%) were administered tenecteplase and 717 (47.7%) were female. The mean EQ5D VAS score and EQ5D index values were not significantly higher for those who received intravenous tenecteplase compared with those who received intravenous alteplase (P=0.10). Older age (P<0.01), more severe stroke assessed using the National Institutes of Health Stroke Scale (P<0.01), and longer stroke onset-to-needle time (P=0.004) were associated with lower EQ5D index and VAS scores. There was a strong association (r, 0.85 [95% CI, 0.81-0.89]) between patient-reported return to prebaseline functioning and modified Rankin Scale score 0 to 1 Similarly, there was a moderate association between return to prebaseline functioning and EQ5D index (r, 0.45 [95% CI, 0.40-0.49]) and EQ5D VAS scores (r, 0.42 [95% CI, 0.37-0.46]). CONCLUSIONS Although there is no differential effect of thrombolysis type on patient-reported global HRQOL and EQ 5D-5L index values in patients with acute stroke, sex- and age-related differences in HRQOL were noted in this study. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03889249.
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Affiliation(s)
- Tolulope T Sajobi
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Olayinka I Arimoro
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
| | - Ayoola Ademola
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Nishita Singh
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada (N.S., J.S.S.)
- University of Manitoba, Winnipeg, Canada (N.S., J.S.S.)
| | - Fouzi Bala
- Department of Diagnostic and Interventional Neuroradiology, Tours University Hospital, France (F. Bala)
| | - Mohammed A Almekhlafi
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
| | - Yan Deschaintre
- Département of Neurosciences, Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
- Centre Hospitalier de l'Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
| | - Shelagh B Coutts
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
| | - Sibi Thirunavukkarasu
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (S.T., S.M.M., M.P.K., B.H.B.)
| | - Houman Khosravani
- Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (H.K., D.J.G., R.H.S.)
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada (R.A., S.J.)
| | | | - Gordon J Gubitz
- Queen Elizabeth Health Sciences Centre, Halifax, NS, Canada (G.J.G., S.J.P., A. Shoamanesh)
| | | | - Luciana Catanese
- Hamilton Health Sciences Centre, McMaster University, Hamilton, ON, Canada (L.C.)
| | - Dar Dowlatshahi
- Department of Medicine, Ottawa Heart Research Institute, University of Ottawa, ON, Canada (D.D., M. Shamy)
| | - George Medvedev
- Department of Medicine, University of British Columbia & Fraser Health Authority, New Westminster, BC, Canada (G.M., G.S.)
- University of British Columbia, Fraser Health Authority, New Westminster, BC, Canada (G.M., G.S.)
| | - Jennifer Mandzia
- London Health Sciences Centre and Western University, ON, Canada (J.M.)
| | | | - Jai Shiva Shankar
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada (N.S., J.S.S.)
- University of Manitoba, Winnipeg, Canada (N.S., J.S.S.)
| | | | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, The University of British Columbia, Vancouver, Canada (T.S.F.)
| | | | | | - Atif Zafar
- St. Michael's Hospital, Toronto, ON, Canada (A.Z.)
| | | | - Gary Hunter
- University of Saskatchewan, Saskatoon, Canada (G.H.)
| | - Andrew M Demchuk
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Sachin M Mishra
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (S.T., S.M.M., M.P.K., B.H.B.)
| | - Laura C Gioia
- Département of Neurosciences, Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
- Centre Hospitalier de l'Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
| | - Shirin Jalini
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada (R.A., S.J.)
| | - Caroline Cayer
- Centre de recherche du CHUS, Centre intégré Universitaire de Santé et des Services Sociaux de l'Estrie, Sherbrooke, QC, Canada (C.C.)
| | - Stephen J Phillips
- Queen Elizabeth Health Sciences Centre, Halifax, NS, Canada (G.J.G., S.J.P., A. Shoamanesh)
| | | | - Ashkan Shoamanesh
- Queen Elizabeth Health Sciences Centre, Halifax, NS, Canada (G.J.G., S.J.P., A. Shoamanesh)
| | - Suresh Subramaniam
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Mahesh P Kate
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (S.T., S.M.M., M.P.K., B.H.B.)
| | - Gregory Jacquin
- Département of Neurosciences, Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
- Centre Hospitalier de l'Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
| | - Marie-Christine Camden
- Enfant-Jésus Hospital, Centre Hospitalier Universitaire de Québec, Laval University, Canada (M.-C.C.)
| | - Faysal Benali
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - MacKenzie Horn
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Grant Stotts
- Department of Medicine, University of British Columbia & Fraser Health Authority, New Westminster, BC, Canada (G.M., G.S.)
- University of British Columbia, Fraser Health Authority, New Westminster, BC, Canada (G.M., G.S.)
| | - Michael D Hill
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
| | - David J Gladstone
- Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (H.K., D.J.G., R.H.S.)
| | - Alexandre Y Poppe
- Département of Neurosciences, Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
- Centre Hospitalier de l'Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
| | - Arshia Sehgal
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Qiao Zhang
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Brendan Lethebe
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
| | - Craig Doram
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Michel Shamy
- Department of Medicine, Ottawa Heart Research Institute, University of Ottawa, ON, Canada (D.D., M. Shamy)
| | - Carol Kenney
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (S.T., S.M.M., M.P.K., B.H.B.)
| | - Richard H Swartz
- Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (H.K., D.J.G., R.H.S.)
| | - Bijoy K Menon
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
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Geraghty JR, Testai FD. WITHDRAWN: Advances in Neurovascular Research: Scientific Highlights from the 15 th World Stroke Congress. J Stroke Cerebrovasc Dis 2024:107614. [PMID: 38301748 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2024.107614. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.
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Affiliation(s)
- Joseph R Geraghty
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Fernando D Testai
- Department of Neurology & Rehabilitation, University of Illinois College of Medicine, Chicago, IL, USA
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20
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Streib C. Tenecteplase for Acute Ischemic Stroke Thrombolysis: Practical Considerations and Real-World Implementation. Neurol Clin Pract 2024; 14:e200221. [PMID: 38223783 PMCID: PMC10786601 DOI: 10.1212/cpj.0000000000200221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/13/2023] [Indexed: 01/16/2024]
Abstract
The only FDA-approved medical treatment for acute ischemic stroke (AIS) is alteplase (commonly referred to as "tPA"). The utilization of a newer fibrinolytic agent, tenecteplase, in routine stroke care is increasing because of recent clinical trial findings, streamlined clinical workflows, and cost-effectiveness. The stroke community is monitoring this development with considerable interest and special attention to the following questions: (1) Does the current evidence support superiority or noninferiority of tenecteplase compared with standard-of-care alteplase? (2) What are the ramifications of off-label treatment with tenecteplase? (3) And what are the real-world considerations when transitioning from alteplase to tenecteplase for AIS thrombolysis? This commentary provides a practical synthesis of the current evidence and discusses our institutional experience with tenecteplase including treatment considerations, off-label use, patient consent, stroke center accreditation, and cost savings. Necessary "Code Stroke" workflow changes to ensure a safe transition from alteplase to tenecteplase are detailed.
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21
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Huang B, Libman R, Ballout A, DiUbaldi G, Arora R, Katz JM. A bibliometric analysis of tenecteplase research utilizing a commonly used citation index. Clin Neurol Neurosurg 2024; 237:108170. [PMID: 38354425 DOI: 10.1016/j.clineuro.2024.108170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 01/08/2024] [Accepted: 02/06/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND AND PURPOSE Tenecteplase is increasingly being used as a first-line treatment for acute ischemic stroke after several randomized studies demonstrated its safety and efficacy, resulting in a massive increase in the number of published studies on this topic. Our aim was to investigate the most impactful authors and relevant journals that have been instrumental in validating this treatment, in hopes of identifying objective research trends that may assist scientists, health organizations, and funding agencies to collaborate and plan future avenues of research. METHODS Using the search terms "Tenecteplase" and "Tenecteplase" AND "Stroke," 2683 and 1150 references were queried, respectively, using the abstract and citation database, Scopus. Scopus Citation Analysis was used to categorize the countries and authors who produced the most research. Metadata was retrieved and transferred to bibliographic visualization software, VOSviewer, for co-authorship and co-occurrence analyses to identify trends in tenecteplase research. RESULTS Data visualization software identified three tenecteplase research clusters - myocardial infarction, pulmonary embolism, and acute ischemic stroke. Our bibliographic analysis graphically identified that ischemic stroke currently leads both myocardial infarction and pulmonary embolism in annual publications pertaining to tenecteplase therapy, and further pinpointed perfusion imaging and wake-up strokes as the most relevant areas of study. The United States led all countries in tenecteplase publications, including exclusively stroke studies. The European Heart Journal led all journals in overall publications, while Stroke led all journals in stroke-related studies. CONCLUSIONS Through the use of bibliographic analysis and data visualization, we identified major articles and journals that reflected and shaped the current landscape of tenecteplase; recognized authors who engaged in tenecteplase research as it progressed from cardiopulmonary disease to stroke; and postulated future avenues of research.
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Affiliation(s)
- Brendan Huang
- Department of Neurology, Northwell Health, Manhasset, NY, USA.
| | - Richard Libman
- Department of Neurology, Northwell Health, Manhasset, NY, USA
| | - Ahmad Ballout
- Department of Neurology, Northwell Health, Manhasset, NY, USA
| | | | - Rohan Arora
- Department of Neurology, Northwell Health, Manhasset, NY, USA
| | - Jeffrey M Katz
- Department of Neurology, Northwell Health, Manhasset, NY, USA
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Cheng X, Hong L, Churilov L, Lin L, Ling Y, Zhang J, Yang J, Geng Y, Wu D, Liu X, Zhou X, Zhao Y, Zhai Q, Zhao L, Chen Y, Guo Y, Yu X, Gong F, Sui Y, Li G, Yang L, Gu HQ, Wang Y, Parsons M, Dong Q. Tenecteplase thrombolysis for stroke up to 24 hours after onset with perfusion imaging selection: the umbrella phase IIa CHABLIS-T randomised clinical trial. Stroke Vasc Neurol 2024:svn-2023-002820. [PMID: 38286484 DOI: 10.1136/svn-2023-002820] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 12/14/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND The performance of intravenous tenecteplase in patients who had an acute ischaemic stroke with large/medium vessel occlusion or severe stenosis in an extended time window remains unknown. We investigated the promise of efficacy and safety of different doses of tenecteplase manufactured in China, in patients who had an acute ischaemic stroke with large/medium vessel occlusion beyond 4.5-hour time window. METHODS The CHinese Acute tissue-Based imaging selection for Lysis In Stroke-Tenecteplase was an investigator-initiated, umbrella phase IIa, open-label, blinded-endpoint, Simon's two-stage randomised clinical trial in 13 centres across mainland China. Participants who had salvageable brain tissue on automated perfusion imaging and presented within 4.5-24 hours from time of last seen well were randomised to receive 0.25 mg/kg tenecteplase or 0.32 mg/kg tenecteplase, both with a bolus infusion over 5-10 s. The primary outcome was proportion of patients with promise of efficacy and safety defined as reaching major reperfusion without symptomatic intracranial haemorrhage at 24-48 hours after thrombolysis. Assessors were blinded to treatment allocation. All participants who received tenecteplase were included in the analysis. RESULTS A total of 86 patients who had an acute ischaemic stroke identified with anterior large/medium vessel occlusion or severe stenosis were included in this study from November 2019 to December 2021. All of the 86 patients enrolled either received 0.25 mg/kg (n=43) or 0.32 mg/kg (n=43) tenecteplase, and were available for primary outcome analysis. Fourteen out of 43 patients in the 0.25 mg/kg tenecteplase group and 10 out of 43 patients in the 0.32 mg/kg tenecteplase group reached the primary outcome, providing promise of efficacy and safety for both doses based on Simon's two-stage design. DISCUSSION Among patients with anterior large/medium vessel occlusion and significant penumbral mismatch presented within 4.5-24 hours from time of last seen well, tenecteplase 0.25 mg/kg and 0.32 mg/kg both provided sufficient promise of efficacy and safety. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04086147, https://clinicaltrials.gov/ct2/show/NCT04086147).
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Affiliation(s)
- Xin Cheng
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Lan Hong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Leonid Churilov
- Melbourne Medical School, The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Longting Lin
- University of New South Wales South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, Department of Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Yifeng Ling
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Jin Zhang
- Department of Neurology, the First Hospital of Shanxi Medical University, Taiyuan, China
| | - Jianhong Yang
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
| | - Danhong Wu
- Department of Neurology, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Xueyuan Liu
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaoyu Zhou
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuwu Zhao
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qijin Zhai
- Department of Neurology, Xuzhou Medical University Affiliated Hospital of Huaian, Huaian, China
| | - Liandong Zhao
- Department of Neurology, Xuzhou Medical University Affiliated Hospital of Huaian, Huaian, China
| | - Yangmei Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Guo
- Department of Neurology, Pu'er People's Hospital, Pu'er, China
| | - Xiaofei Yu
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Fan Gong
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yi Sui
- Department of Neurology, Shenyang First People's Hospital, Shenyang Medical College Affiliated Brain Hospital, Shenyang, China
| | - Gang Li
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Lumeng Yang
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Hong-Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Yilong Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mark Parsons
- University of New South Wales South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, Department of Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Qiang Dong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
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Li S, Gu HQ, Dai H, Lu G, Wang Y. Reteplase versus alteplase for acute ischaemic stroke within 4.5 hours (RAISE): rationale and design of a multicentre, prospective, randomised, open-label, blinded-endpoint, controlled phase 3 non-inferiority trial. Stroke Vasc Neurol 2024:svn-2023-003035. [PMID: 38286482 DOI: 10.1136/svn-2023-003035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 12/23/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND AND PURPOSE Reteplase is the third generation of alternative thrombolytic agent. We hypothesis that reteplase will be non-inferior to alteplase in achieving excellent functional outcome at 90 days among eligible patients with acute ischaemic stroke. METHODS AND DESIGN Reteplase versus alteplase for acute ischaemic stroke within 4.5 hours (RAISE) trial is a multicentre, prospective, randomised, open-label, blinded endpoint (PROBE), controlled phase 3 non-inferiority trial. A total of 1412 eligible patients will be randomly assigned to receive either reteplase at a dose of 18 mg+ 18 mg or alteplase 0.9 mg/kg at a ratio of 1:1. An independent data monitoring committee will review the trail's progress and safety data. STUDY OUTCOMES The primary efficacy outcome of this study is proportion of individuals attaining an excellent functional outcome, defined as modified Rankin Scale (mRS) 0-1 at 90 days. The secondary efficacy outcomes encompass favourable functional outcome defined as mRS 0-2, major neurological improvement on the National Institutes of Health Stroke Scale, ordinal distribution of mRS and Barthel Index score of at least 95 points at 90 days. The primary safety outcomes are symptomatic intracranial haemorrhage at 36 hours within 90 days. DISCUSSION The RAISE trial will provide crucial insights into the selection of thrombolytic agents for stroke thrombolysis. TRIAL REGISTRATION NUMBER NCT05295173.
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Affiliation(s)
- Shuya Li
- Department of Neurology, and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hong-Qiu Gu
- Department of Neurology, and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongguo Dai
- Department of Emergency, Linfen Central Hospital, Shanxi Province, China
| | - Guozhi Lu
- Department of Neurology, Keshiketeng Banner Traditional Chinese Medicine Mongolian Medical Hospital, The Inner Mongolia autonomous region, China
| | - Yongjun Wang
- Department of Neurology, and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Flint AC, Eaton A, Melles RB, Hartman J, Cullen SP, Chan SL, Rao VA, Nguyen-Huynh MN, Kapadia B, Patel NU, Klingman JG. Comparative safety of tenecteplase vs alteplase for acute ischemic stroke. J Stroke Cerebrovasc Dis 2024; 33:107468. [PMID: 38039801 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/20/2023] [Accepted: 11/03/2023] [Indexed: 12/03/2023] Open
Abstract
INTRODUCTION Tenecteplase has been compared to alteplase in acute stroke randomized trials, with similar outcomes and safety measures, but higher doses of tenecteplase have been associated with higher hemorrhage rates in some studies. Limited data are available on the safety of tenecteplase outside of clinical trials. METHODS We examined the safety measures of intracranial hemorrhage, angioedema, and serious extracranial adverse events in a 21-hospital integrated healthcare system that switched from alteplase (0.9 mg/kg, maximum dose 90 mg) to tenecteplase (0.25 mg/kg, maximum dose 25 mg) for acute ischemic stroke. RESULTS Among 3,689 subjects, no significant differences were seen between tenecteplase and alteplase in the rate of intracranial hemorrhage (ICH), parenchymal hemorrhage, or volume of parenchymal hemorrhage. Symptomatic hemorrhage (sICH) was not different between the two agents: sICH by NINDS criteria was 2.0 % for alteplase vs 2.3 % for tenecteplase (P = 0.57), and sICH by SITS criteria was 0.8 % vs 1.1 % (P = 0.39). Adjusted logistic regression models also showed no differences between tenecteplase and alteplase: the odds ratio for tenecteplase (vs alteplase) modeling sICH by NINDS criteria was 0.9 (95 % CI 0.33 - 2.46, P = 0.83) and the odds ratio for tenecteplase modeling sICH by SITS criteria was 1.12 (95 % CI 0.25 - 5.07, P = 0.89). Rates of angioedema and serious extracranial adverse events were low and did not differ between tenecteplase and alteplase. Elapsed door-to-needle times showed a small improvement after the switch to tenecteplase (51.8 % treated in under 30 min with tenecteplase vs 43.5 % with alteplase, P < 0.001). CONCLUSION In use outside of clinical trials, complication rates are similar between tenecteplase and alteplase. In the context of a stroke telemedicine program, the rates of hemorrhage observed with either agent were lower than expected based on prior trials and registry data. The more easily prepared tenecteplase was associated with a lower door-to-needle time.
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Affiliation(s)
- Alexander C Flint
- Division of Research, Kaiser Permanente Northern California, Department of Neuroscience, Kaiser Permanente Redwood City, 1150 Veterans Blvd, Redwood City, CA 94025, USA.
| | | | | | | | - Sean P Cullen
- Department of Neuroscience, KP Redwood City, CA, USA
| | - Sheila L Chan
- Department of Neuroscience, KP Redwood City, CA, USA
| | - Vivek A Rao
- Department of Neuroscience, KP Redwood City, CA, USA
| | | | - Brij Kapadia
- Department of Radiology, KP San Leandro, CA, USA
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Marè A, Lorenzut S, Janes F, Gentile C, Marinig R, Tereshko Y, Gigli GL, Valente M, Merlino G. Comparison of pharmacokinetic properties of alteplase and tenecteplase. The future of thrombolysis in acute ischemic stroke. Expert Opin Drug Metab Toxicol 2024; 20:25-36. [PMID: 38275111 DOI: 10.1080/17425255.2024.2311168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/24/2024] [Indexed: 01/27/2024]
Abstract
INTRODUCTION The drug most frequently used for thrombolysis in cases of acute ischemic stroke (AIS) is alteplase. However, there is moderate-to-high-quality evidence that tenecteplase has similar or higher efficacy and safety. With improved pharmacokinetic properties over alteplase, tenecteplase could be a significant advantage in treating AIS. AREAS COVERED After conducting an extensive search on Scopus and PubMed, this manuscript reviews and compares the pharmacokinetic properties of alteplase and tenecteplase. Additionally, it provides information on pharmacodynamics, clinical efficacy, safety, tolerability, and drug-drug interactions. EXPERT OPINION The pharmacokinetic profile of alteplase and tenecteplase is derived from studies in patients with acute myocardial infarction. Thanks to its pharmacokinetic properties, tenecteplase is the drug closest to being the ideal fibrinolytic for AIS. Its longer half-life enables a single-bolus administration, which is particularly useful in emergencies. Tenecteplase has proven to have a good efficacy and safety profile in randomized clinical trials. Although we are awaiting the results of the ongoing phase 3 randomized clinical trials, we believe that tenecteplase has the potential to revolutionize the treatment of AIS through thrombolysis.
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Affiliation(s)
- Alessandro Marè
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Simone Lorenzut
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Francesco Janes
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Carolina Gentile
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Roberto Marinig
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Yan Tereshko
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | | | - Mariarosaria Valente
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- DAME, University of Udine, Udine, Italy
| | - Giovanni Merlino
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
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Zhang X, Wan TF, Chen J, Liu L. Tenecteplase versus alteplase for patients with acute ischemic stroke: a meta-analysis of randomized controlled trials. Aging (Albany NY) 2023; 15:14889-14899. [PMID: 38149983 PMCID: PMC10781500 DOI: 10.18632/aging.205315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/06/2023] [Indexed: 12/28/2023]
Abstract
Tenecteplase (TNK), a newer fibrinolytic agent with greater fibrin specificity and longer half-life than alteplase, may has practical advantages over alteplase in acute ischemic stroke (AIS) thrombolysis. We aimed to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare different doses of TNK (0.1, 0.25, 0.4 mg/kg) and alteplase in acute ischemic stroke patients. We systematically searched PubMed, Embase and https://clinicaltrials.gov/ for RCTs comparing TNK with alteplase in this population eligible for thrombolysis. The Cochrane Risk of Bias Tool was used to assess study quality. Random-effects or fixed-effects meta-analysis models were used for evaluating all outcomes. Total 10 RCTs with 5097 patients were included. Compared with alteplase, TNK at doses of 0.25 mg/kg may associated with the greatest odds to achieve 90-day excellent independence (mRS score ≤1), but there were no significant differences between other doses of TNK (0.1 mg/kg and 0.4 mg/kg) and alteplase. Among secondary outcomes, no significant differences were found in functional outcome (mRS score ≤2) and mortality at 90 days between any dose of TNK and alteplase. Compared with alteplase, TNK was effective at doses of 0.1 mg/kg and 0.25 mg/kg without increased risk of symptomatic intracerebral hemorrhage (sICH), but patients treated with TNK 0.4 mg/kg showed increased odds of sICH. In conclusion, compared with alteplase, intravenous thrombolysis with TNK at dose of 0.25 mg/kg has a better efficacy and similar safety profile and is a reasonable option for patients with AIS.
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Affiliation(s)
- Xu Zhang
- Department of Cardiac Surgery, The General Hospital of Northern Theater Command, Shenyang, Liaoning 110000, China
| | - Teng-Fei Wan
- Department of Nursing, Xinqiao Hospital, Chongqing 400037, China
- Department of Critical Care Medicine, The General Hospital of Northern Theater Command, Shenyang, Liaoning 110000, China
| | - Jing Chen
- Department of Neurology, Central Hospital of Baoji, Baoji, Shaanxi 721000, China
| | - Liang Liu
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, Liaoning 110016, China
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Murphy LR, Hill TP, Paul K, Talbott M, Golovko G, Shaltoni H, Jehle D. Tenecteplase Versus Alteplase for Acute Stroke: Mortality and Bleeding Complications. Ann Emerg Med 2023; 82:720-728. [PMID: 37178103 DOI: 10.1016/j.annemergmed.2023.03.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 03/09/2023] [Accepted: 03/20/2023] [Indexed: 05/15/2023]
Abstract
STUDY OBJECTIVE Intravenous thrombolysis with alteplase has been the foundation of initial treatment of acute ischemic stroke for several decades. Tenecteplase is a thrombolytic agent that offers logistical advantages in cost and administration relative to alteplase. There is evidence that tenecteplase has at least similar efficacy and safety outcomes compared with alteplase for stroke. In this study, we compared tenecteplase versus alteplase for acute stroke in a large retrospective US database (TriNetX) regarding the following 3 outcomes: (1) mortality, (2) intracranial hemorrhage, and (3) the need for acute blood transfusions. METHODS In this retrospective study using the US cohort of 54 academic medical centers/health care organizations in the TriNetX database, we identified 3,432 patients treated with tenecteplase and 55,894 patients treated with alteplase for stroke after January 1, 2012. Propensity score matching was performed on basic demographic information and 7 previous clinical diagnostic groups, resulting in a total of 6,864 patients with acute stroke evenly matched between groups. Mortality rates, the frequency of intracranial hemorrhage, and blood transfusions (as a marker of significant blood loss) were recorded for each group over the ensuing 7- and 30-day periods. Secondary subgroup analyses were conducted on a cohort treated from 2021 to 2022 in an attempt to determine whether temporal differences in acute ischemic stroke treatment would alter the results. RESULTS Patients treated with tenecteplase had a significantly lower mortality rate (8.2% versus 9.8%; risk ratio [RR], 0.832) and lower risk of major bleeding as measured by the frequency of blood transfusions (0.3% versus 1.4%; RR, 0.207) than alteplase at 30 days after thrombolysis for stroke. In the larger 10-year data set of patients with stroke treated after January 1, 2012, patients receiving tenecteplase were not found to have a statistically different incidence of intracranial hemorrhage (3.5% versus 3.0%; RR, 1.185) at 30 days after the administration of the thrombolytic agents in patients. However, a subgroup analysis of 2,216 evenly matched patients with stroke treated from 2021 to 2022 demonstrated notably better survival and statistically lower rates of intracranial hemorrhage than the alteplase group. CONCLUSION In our large retrospective multicenter study using real-world evidence from large health care organizations, tenecteplase for the treatment of acute stroke demonstrated a lower mortality rate, decreased intracranial hemorrhage, and less significant blood loss. The favorable mortality and safety profiles observed in this large study, taken together with previous randomized controlled trial data and operational advantages in rapid dosing and cost-effectiveness, all support the preferential use of tenecteplase in patients with ischemic stroke.
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Affiliation(s)
- Luke R Murphy
- Department of Emergency Medicine, University of Texas Medical Branch, Galveston, TX.
| | - T Preston Hill
- Department of Emergency Medicine, University of Texas Medical Branch, Galveston, TX
| | - Krishna Paul
- Department of Emergency Medicine, University of Texas Medical Branch, Galveston, TX
| | - Matthew Talbott
- Department of Emergency Medicine, University of Texas Medical Branch, Galveston, TX
| | - Georgiy Golovko
- Department of Pharmacology and Toxicology, University of Texas Medical Branch, Galveston, TX
| | - Hashem Shaltoni
- Department of Neurology, University of Texas Medical Branch, Galveston, TX
| | - Dietrich Jehle
- Department of Emergency Medicine, University of Texas Medical Branch, Galveston, TX
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Liu C, Liu M, Yang X, Wang J, Li G. Efficacy and safety of bridging therapy versus direct thrombectomy for tandem lesions in acute stroke: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 234:108005. [PMID: 37837908 DOI: 10.1016/j.clineuro.2023.108005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Current studies have concluded that MT (Mechanical Thrombectomy) is safe and effective for tandem lesions (TL). However, The benefit of bridging therapy for TL is controversial. OBJECTIVE To compare efficacy and safety between bridging therapy and direct thrombectomy of tandem lesions. METHOD We conducted a systematic review and meta-analysis of studies comparing bridging therapy versus direct thrombectomy among TL patients with regards to symptomatic intracerebral hemorrhage(sICH), Parenchymal hemorrhage (PH), 3-month mortality, modified Rankin Scale (mRS) score within 3 months, successful reperfusion, and excellent reperfusion. The meta-analysis of proportions was conducted with a common effects model. RESULT Five studies (n = 1198 patients) were identified for the systematic review. For safety outcomes, the bridging group had no significant difference in the rate of symptomatic intracranial hemorrhage (OR = 0.78, 95% CI = 0.49-1.25, P = 0.31) and the rate of PH (OR = 0.67, 95% CI = 0.39-1.13, P = 0.13) but significantly lower rate of 3-month mortality (OR = 0.53, 95% CI = 0.37-0.75, P = 0.0004) compared to the direct thrombectomy group. In terms of efficacy outcomes, the bridging therapy group had a significantly higher rate of 3- month good functional outcome (mRS 0-2) (OR = 1.76, 95% CI = 1.38-2.24, P < 0.00001) and successful recanalization (OR = 1.69, 95% CI = 1.27-2.25, P = 0.0003) but no significant difference in the rate of excellent recanalization(OR = 1.21, 95% CI = 0.91-1.59, P = 0.19) in patients with TL compared to direct thrombectomy group. CONCLUSION Bridging therapy is effective in improving the 3-month functional prognosis and increasing the rate of arterial recanalization without increasing the risk of intracranial hemorrhage in patients with TL compared to direct thrombectomy. A large multicentre clinical RCT is expected, as are advanced intravenous thrombolysis and endovascular thrombectomy techniques.
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Affiliation(s)
- Chenxi Liu
- Department of Neurology, The Frist Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Mingsu Liu
- Department of Neurology, Zhongshan Hospital Affiliated to Fudan University, Shanghai 200032, China
| | - Xun Yang
- Department of Neurology, Hechuan District People's Hospital, Chongqing 401500, China
| | - Jinping Wang
- Department of Neurology, Chongqing University Central Hospital, Chongqing 400050, China
| | - Guangqin Li
- Department of Neurology, The Frist Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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Novotny V, Kvistad CE, Naess H, Logallo N, Fromm A, Khanevski AN, Thomassen L. Tenecteplase, 0.4 mg/kg, in Moderate and Severe Acute Ischemic Stroke: A Pooled Analysis of NOR-TEST and NOR-TEST 2A. J Am Heart Assoc 2023; 12:e030320. [PMID: 37830342 PMCID: PMC10757511 DOI: 10.1161/jaha.123.030320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
Background The optimal dose of tenecteplase in acute ischemic stroke remains to be defined. We present a pooled analysis of the 2 NOR-TESTs (Norwegian Tenecteplase Stroke Trials) exploring the efficacy and safety of tenecteplase, 0.4 mg/kg. Methods and Results We retrospectively reviewed 2 PROBE (Prospective Randomized Open, Blinded End-point) trials, NOR-TEST and NOR-TEST 2A. Patients were randomized to either tenecteplase, 0.4 mg/kg, or alteplase, 0.9 mg/kg. The primary end point was favorable functional outcome at 3 months (modified Rankin Scale score, 0-1) or return to baseline if prestroke modified Rankin Scale score was 2. Secondary end points included favorable functional and clinical outcome and safety data. The pooled analysis includes patients with National Institutes of Health Stroke Scale score ≥6 from both trials and an additional post hoc analysis of patients with National Institutes of Health Stroke Scale score ≤5 from NOR-TEST. The per-protocol analysis contains 483 patients, of whom 235 were assigned to tenecteplase and 248 were assigned to alteplase. In per-protocol analysis, functional outcome was better in the alteplase arm with cutoff modified Rankin Scale score of 2 (odds ratio [OR], 0.52 [95% CI, 0.33-0.80]; P=0.003) and expressed by ordinal shift analysis (OR, 1.64 [95% CI, 1.17-2.28]; P=0.004). Mortality at 3 months was higher in the tenecteplase arm (OR, 2.48 [95% CI, 1.20-5.10]; P=0.01). Mortality and intracranial hemorrhage rates were higher in the severe stroke group randomized to tenecteplase, whereas these rates were similar for alteplase and tenecteplase in moderate and mild stroke. Conclusions Tenecteplase, 0.4 mg/kg, is unsafe in moderate and severe stroke, and the risk of death and intracranial hemorrhage probably increases with stroke severity. A lower tenecteplase dose should be tested in future trials. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01949948, NCT03854500.
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Affiliation(s)
- Vojtech Novotny
- Department of NeurologyHaukeland University HospitalBergenNorway
| | - Christopher Elnan Kvistad
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | - Halvor Naess
- Department of NeurologyHaukeland University HospitalBergenNorway
- Centre for Age‐Related MedicineStavanger University HospitalStavangerNorway
| | - Nicola Logallo
- Department of NeurosurgeryHaukeland University HospitalBergenNorway
| | - Annette Fromm
- Department of NeurologyHaukeland University HospitalBergenNorway
| | | | - Lars Thomassen
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
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Zhang L, Luo H, Li C, Teng H, Powell B, Lu M, Chopp M, Zhang ZG. Treatment of stroke in aged male and female rats with Vepoloxamer and tPA reduces neurovascular damage. Front Neurol 2023; 14:1282736. [PMID: 37869138 PMCID: PMC10587547 DOI: 10.3389/fneur.2023.1282736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/22/2023] [Indexed: 10/24/2023] Open
Abstract
Stroke is a leading cause of death and disability worldwide, mainly affecting the elderly. Unfortunately, current treatments for acute ischemic stroke warrant improvement. To date, tissue plasminogen activator (tPA) is of limited use in stroke patients mainly due to its narrow therapeutic window and potential for hemorrhagic complication. The adjuvant treatment with Vepoloxamer, a purified amphipathic polymer has been shown to enhance the thrombolytic efficacy of tPA treatment in young adult male rats after embolic stroke. However, most stroke patients are aged; therefore, the current study investigated the therapeutic effect of the combined tPA and Vepoloxamer treatment in aged male and female rats subjected to embolic stroke. Methods Male and female Wistar rats at 18 months of age were subjected to embolic middle cerebral artery occlusion and treated either with monotherapy of tPA or Vepoloxamer, a combination of these two agents, or saline at 4 h after stroke onset. Neurological outcomes were evaluated with a battery of behavioral tests including adhesive removal, foot-fault, and modified neurological severity score tests at 1 and 7 days after stroke onset, followed by histopathological analysis of infarct volume. Residual clot size and vascular patency and integrity were analyzed. Results The combination treatment with Vepoloxamer and tPA significantly reduced infarct volume and neurological deficits in male and female rats compared to rats treated with saline and the monotherapies of tPA and Vepoloxamer. While Vepoloxamer monotherapy moderately reduced neurological deficits, monotherapies with tPA and Vepoloxamer failed to reduce infarct volume compared to saline treatment. Furthermore, the combination treatment with tPA and Vepoloxamer accelerated thrombolysis, reduced ischemia and tPA-potentiated microvascular disruption, and concomitantly improved cerebrovascular integrity and perfusion in the male ischemic rats. Conclusion Combination treatment with tPA and Vepoloxamer at 4 h after stroke onset effectively reduces ischemic neurovascular damage by accelerating thrombolysis and reducing ischemia and tPA potentiated side effects in the aged rats. This funding suggests that the combination treatment with tPA and Vepoloxamer represents a promising strategy to potentially apply to the general population of stroke patients.
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Affiliation(s)
- Li Zhang
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
| | - Hao Luo
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
| | - Chao Li
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
| | - Hua Teng
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
| | - Brianna Powell
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
| | - Mei Lu
- Department of Biostatistics and Research Epidemiology, Henry Ford Hospital, Detroit, MI, United States
| | - Michael Chopp
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
- Department of Physics, Oakland University, Rochester, MI, United States
| | - Zheng Gang Zhang
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
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Salamatullah HK, Bashrahil B, Alghamdi AM, Alsharm FS, Alkulli OA, Alzahrani Z, Alkhiri A, Alghamdi S, Makkawi S. Efficacy and safety of tenecteplase in comparison to alteplase in acute ischemic stroke: A systematic review and meta-analysis of randomized controlled trials. Clin Neurol Neurosurg 2023; 233:107961. [PMID: 37713743 DOI: 10.1016/j.clineuro.2023.107961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/01/2023] [Accepted: 09/03/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Alteplase is the standard medical therapy for acute ischemic stroke (AIS) patients who present within 4.5 h of symptom onset. Tenecteplase is a modified alteplase variant with pharmacological and practical advantages over alteplase. Many trials have investigated the efficacy and safety of tenecteplase against alteplase. This systematic review and meta-analysis aimed to compare the efficacy and safety of tenecteplase to alteplase across randomized controlled trials. METHOD Medline, Embase, and Cochrane CENTRAL were used to search the related articles until February 20, 2023. Randomized controlled trials (RCTs) that compared the effectiveness and safety of tenecteplase against alteplase for AIS patients were included. Screening, risk of bias assessment, and data extraction were performed following PRISMA guidelines. Data were pooled using a random-effect model. RESULTS Ten RCTs were included, with a total of 5123 patients. There was no significant difference between the two interventions in modified rankin scale 0-1 (mRS 0-1) (RR= 1.04, 95% CI [0.99-1.10], P = 0.11, I2 =0%) and early neurological improvement (RR= 1.06, 95% CI [0.97-1.15], P = 0.21, I2 =35). There was no difference in the rates of symptomatic intracranial hemorrhage (RR= 1.18, 95% CI [0.84-1.65], P = 0.35, I2 = 0%). Tenecteplase was associated with significantly higher complete recanalization rate compared to alteplase (RR= 1.17, 95% CI [1.00-1.36], P = 0.05, I2 =0%). For large vessel occlusion (LVO) patients assigned to tenecteplase, there was a significant improvement in mRS 0-1 (RR= 1.28, 95% CI [1.07-1.52], P = 0.006, I2 =0%). CONCLUSION Based on our meta-analysis, tenecteplase has similar efficacy and safety to alteplase, with a more promising effect in patients with LVO.
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Affiliation(s)
- Hassan K Salamatullah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Bader Bashrahil
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdulaziz M Alghamdi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Faisal S Alsharm
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Osama A Alkulli
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ziyad Alzahrani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ahmed Alkhiri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Saeed Alghamdi
- Neuroscience Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Seraj Makkawi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia; Department of Medicine, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia.
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Shen Z, Bao N, Tang M, Yang Y, Li J, Liu W, Jiang G. Tenecteplase vs. Alteplase for Intravenous Thrombolytic Therapy of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Neurol Ther 2023; 12:1553-1572. [PMID: 37552459 PMCID: PMC10444744 DOI: 10.1007/s40120-023-00530-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023] Open
Abstract
INTRODUCTION In recent years, as one of the drugs for the treatment of acute ischemic stroke (AIS), the clinical application of tenecteplase is still controversial. Therefore, we aimed to evaluate the safety and efficacy of tenecteplase versus alteplase to guide clinical practice. METHODS A search of PubMed, MEDLINE, EMBASE, Cochrane Library, and Web of Science databases until February 15, 2023 was conducted to identify eligible articles. The quality of the included studies was assessed using the Cochrane Risk of Bias tool. RevMan 5.3 and Stata 17 were used to perform the meta-analysis and detect publication bias, and risk ratios (RRs) with 95% confidence intervals (95% CIs) were reported for each outcome measure. RESULTS A total of 1326 records were retrieved in this meta-analysis. As a result of the limited reports on tenecteplase in patients with AIS and the lack of high-quality randomized controlled trials (RCTs), and considering the impact of publication bias, we did not include any of these studies published before 2015. Ultimately we included 16 RCTs with a total of 7508 patients, including 3940 patients treated with alteplase and 3568 patients treated with tenecteplase. Tenecteplase was associated with better early neurological improvement (RR 0.10; 95% CI 0.00-0.19; P = 0.04), recanalization of blood vessels (RR 0.24; 95% CI 0.07-0.40; P = 0.01), and 90-day excellent neurological recovery (RR 0.12; 95% CI 0.01-0.24; P = 0.04). In addition, there were no significant differences in other efficacy and safety outcomes between the two groups. The funnel plot and Begg's as well as Egger's tests showed no significant publication bias. CONCLUSIONS This meta-analysis showed that tenecteplase was not inferior to alteplase in early thrombolytic therapy in patients with AIS, and was even better than alteplase on some efficacy outcomes with no significant differences in safety. However, as a result of some inherent limitations of this study, more high-quality prospective clinical studies are needed to confirm these results.
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Affiliation(s)
- Ziyi Shen
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Nana Bao
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Ming Tang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Yang Yang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Jia Li
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Wei Liu
- Department of Neurology, Nanbu County Hospital Affiliated to North Sichuan Medical College, Nanchong, Sichuan, China.
| | - Guohui Jiang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China.
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China.
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Patel A, Desai HN, Seffah KD, Naveen N, Krishna V, Khan S. The Efficacy and Safety of Mechanical Thrombectomy in Posterior Circulation Large Vessel Occlusion as Compared to Anterior Circulation Large Vessel Occlusion: A Systematic Review. Cureus 2023; 15:e45861. [PMID: 37881373 PMCID: PMC10597533 DOI: 10.7759/cureus.45861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/24/2023] [Indexed: 10/27/2023] Open
Abstract
Mechanical thrombectomy (MT) has been established as a standard of care for patients with stroke due to anterior circulation large vessel occlusion (AC-LVO). Due to a lack of robust evidence for the effectiveness of mechanical thrombectomy, intravenous thrombolysis (IVT) is still the only approved first-line acute reperfusion strategy for posterior circulation large vessel occlusion (PC-LVO). This systematic review analyzes and reports on the effectiveness and safety of MT in PC-LVO. A literature review was performed to identify all studies of patients with acute ischemic stroke due to PC-LVO who underwent MT with second-generation devices (stent retrievers and/or aspiration devices) that were reported between January 2017 and January 2023. The primary outcome was functional independence at 90 days, defined as a modified Rankin (mRS) score of ≤2. Secondary outcomes were successful recanalization (modified treatment in cerebral infarction score (mTICI) 2b/3), symptomatic intracerebral hemorrhage (sICH), and mortality at 90 days post-procedure. We looked at 13 studies with a total of 30,407 participants in four meta-analyses and 5951 participants in nine observational studies. In most studies, patients in the PC-LVO group were male and younger than the AC-LVO group. Higher baseline National Institutes of Health Stroke Scale (NIHSS) score, lower rates of IVT, longer onset-to-groin puncture time, lower likelihood of sICH, higher 90-day mortality rates, and higher futile recanalization rates were frequently observed in the PC-LVO group with a large discrepancy in the likelihood of functional independence at 90 days with majority studies showing comparable rates. Hence, in patients with acute ischemic stroke caused by the PC-LVO, successful reperfusion can be achieved via MT, though at the cost of higher mortality rates. Such futile recanalization can be avoided with the refinement of procedures through technical improvements, skills training, and recognition of reliable predictors associated with it, which might help increase the efficacy of MT in PC-LVO. Additionally, future large-scale RCTs comparing patient selection and interventional strategies to avoid futile interventions are also needed.
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Affiliation(s)
- Anandkumar Patel
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Heet N Desai
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Kofi D Seffah
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Namballa Naveen
- Cardiology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Emergency Medicine, Steel Authority of India (SAIL) Hospital, Bokaro, IND
| | - Vamsi Krishna
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Nguyen CP, Lahr MMH, van der Zee DJ, van Voorst H, Roos YBWEM, Uyttenboogaart M, Buskens E. Cost-effectiveness of tenecteplase versus alteplase for acute ischemic stroke. Eur Stroke J 2023; 8:638-646. [PMID: 37641549 PMCID: PMC10472948 DOI: 10.1177/23969873231174943] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/24/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Alteplase is widely used as an intravenous thrombolytic drug in acute ischemic stroke (AIS). Recently however, tenecteplase, a modified form of tissue plasminogen activator, has been shown to increase early recanalization rate and has proven to be non-inferior with a similar safety profile compared to alteplase. This study aims to evaluate the cost-effectiveness of 0.25 mg/kg tenecteplase versus 0.9 mg/kg alteplase for intravenous thrombolysis in AIS patients from the Dutch healthcare payer perspective. METHODS A Markov decision-analytic model was constructed to assess total costs, total quality-adjusted life year (QALY), an incremental cost-effectiveness ratio, and incremental net monetary benefit (INMB) of two treatments at willingness-to-pay (WTP) thresholds of €50,000/QALY and €80,000/QALY over a 10-year time horizon. One-way sensitivity analysis, probabilistic sensitivity analysis, and scenario analysis were conducted to test the robustness of results. Clinical data were obtained from large randomized controlled trials and real-world data. RESULTS Treatment with tenecteplase saved €21 per patient while gaining 0.05 QALYs, resulting in INMB of €2381, clearly rendering tenecteplase cost-effective compared to alteplase. Importantly, tenecteplase remained the cost-effective alternative in all scenarios, including AIS patients due to large vessel occlusion (LVO). Probabilistic sensitivity analysis proved tenecteplase to be cost-effective with a 71.0% probability at a WTP threshold of €50,000/QALY. CONCLUSIONS Tenecteplase treatment was cost-effective for all AIS patients (including AIS patients with LVO) compared to alteplase. The finding supports the broader use of tenecteplase in acute stroke care, as health outcomes improve at acceptable costs while having practical advantages, and a similar safety profile.
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Affiliation(s)
- Chi Phuong Nguyen
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Pharmaceutical Management and Economic, Hanoi University of Pharmacy, Vietnam
| | - Maarten MH Lahr
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Radiology, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik Buskens
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Wei H, Fu B, Yang C, Huang M. The efficacy and safety of intravenous thrombolysis with tenecteplase versus alteplase for acute ischemic stroke: a systematic review and meta-analysis. Neurol Sci 2023; 44:3005-3015. [PMID: 37061572 DOI: 10.1007/s10072-023-06801-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 04/03/2023] [Indexed: 04/17/2023]
Abstract
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.
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Affiliation(s)
- Heng Wei
- Department of Neurology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Hubei University of Chinese Medicine, Wuhan, 430000, China.
| | - Bin Fu
- Department of Neurology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Hubei University of Chinese Medicine, Wuhan, 430000, China
| | - Chao Yang
- Department of Neurology, People's Hospital of Dongxihu District of Wuhan Union Hospital, Wuhan, 430040, China
| | - Ming Huang
- Department of Neurology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Hubei University of Chinese Medicine, Wuhan, 430000, China.
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Lo BM, Carpenter CR, Ducey S, Gottlieb M, Kaji A, Diercks DB, Diercks DB, Wolf SJ, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Trent S, Valente JH, Wall SP, Westafer LM, Yu Y, Cantrill SV, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Acute Ischemic Stroke. Ann Emerg Med 2023; 82:e17-e64. [PMID: 37479410 DOI: 10.1016/j.annemergmed.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
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Mair G, White P, Bath PM, Muir K, Martin C, Dye D, Chappell F, von Kummer R, Macleod M, Sprigg N, Wardlaw JM. Accuracy of artificial intelligence software for CT angiography in stroke. Ann Clin Transl Neurol 2023; 10:1072-1082. [PMID: 37208850 PMCID: PMC10351662 DOI: 10.1002/acn3.51790] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/01/2023] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE Software developed using artificial intelligence may automatically identify arterial occlusion and provide collateral vessel scoring on CT angiography (CTA) performed acutely for ischemic stroke. We aimed to assess the diagnostic accuracy of e-CTA by Brainomix™ Ltd by large-scale independent testing using expert reading as the reference standard. METHODS We identified a large clinically representative sample of baseline CTA from 6 studies that recruited patients with acute stroke symptoms involving any arterial territory. We compared e-CTA results with masked expert interpretation of the same scans for the presence and location of laterality-matched arterial occlusion and/or abnormal collateral score combined into a single measure of arterial abnormality. We tested the diagnostic accuracy of e-CTA for identifying any arterial abnormality (and in a sensitivity analysis compliant with the manufacturer's guidance that software only be used to assess the anterior circulation). RESULTS We include CTA from 668 patients (50% female; median: age 71 years, NIHSS 9, 2.3 h from stroke onset). Experts identified arterial occlusion in 365 patients (55%); most (343, 94%) involved the anterior circulation. Software successfully processed 545/668 (82%) CTAs. The sensitivity, specificity and diagnostic accuracy of e-CTA for detecting arterial abnormality were each 72% (95% CI = 66-77%). Diagnostic accuracy was non-significantly improved in a sensitivity analysis excluding occlusions from outside the anterior circulation (76%, 95% CI = 72-80%). INTERPRETATION Compared to experts, the diagnostic accuracy of e-CTA for identifying acute arterial abnormality was 72-76%. Users of e-CTA should be competent in CTA interpretation to ensure all potential thrombectomy candidates are identified.
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Affiliation(s)
- Grant Mair
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - Philip White
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne Hospitals NHS TrustNewcastle upon TyneUK
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical NeuroscienceUniversity of NottinghamNottinghamUK
| | - Keith Muir
- Institute of Neuroscience & Psychology, University of GlasgowGlasgowUK
| | - Chloe Martin
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - David Dye
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | | | - Rüdiger von Kummer
- Department of NeuroradiologyUniversity Hospital, Technische Universität DresdenDresdenGermany
| | - Malcolm Macleod
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - Nikola Sprigg
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne Hospitals NHS TrustNewcastle upon TyneUK
| | - Joanna M. Wardlaw
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
- UK Dementia Research Institute Centre at the University of EdinburghEdinburghUK
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Warach SJ, Ranta A, Kim J, Song SS, Wallace A, Beharry J, Gibson D, Cadilhac DA, Bladin CF, Kleinig TJ, Harvey J, Palanikumar L, Doss VT, Marescalco R, Fink JN, Tyson A, Schlick KH, Noh L, Wilson D, Figueroa S, Pech MA, Paletz LB, Lewis MK, Castro M, Sahlein DH, Lafranchise EF, Sandall J, Asif KS, Geraghty SR, Cullis PA, Malisch T, Neill TA, LaMonte MP, Campbell BCV, Wu TY. Symptomatic Intracranial Hemorrhage With Tenecteplase vs Alteplase in Patients With Acute Ischemic Stroke: The Comparative Effectiveness of Routine Tenecteplase vs Alteplase in Acute Ischemic Stroke (CERTAIN) Collaboration. JAMA Neurol 2023; 80:732-738. [PMID: 37252708 PMCID: PMC10230371 DOI: 10.1001/jamaneurol.2023.1449] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/31/2023] [Indexed: 05/31/2023]
Abstract
Importance Symptomatic intracranial hemorrhage (sICH) is a serious complication of stroke thrombolytic therapy. Many stroke centers have adopted 0.25-mg/kg tenecteplase instead of alteplase for stroke thrombolysis based on evidence from randomized comparisons to alteplase as well as for its practical advantages. There have been no significant differences in symptomatic intracranial hemorrhage (sICH) reported from randomized clinical trials or published case series for the 0.25-mg/Kg dose. Objective To assess the risk of sICH following ischemic stroke in patients treated with tenecteplase compared to those treated with alteplase. Design, Setting, and Participants This was a retrospective observational study using data from the large multicenter international Comparative Effectiveness of Routine Tenecteplase vs Alteplase in Acute Ischemic Stroke (CERTAIN) collaboration comprising deidentified data on patients with ischemic stroke treated with intravenous thrombolysis. Data from more than 100 hospitals in New Zealand, Australia, and the US that used alteplase or tenecteplase for patients treated between July 1, 2018, and June 30, 2021, were included for analysis. Participating centers included a mix of nonthrombectomy- and thrombectomy-capacity comprehensive stroke centers. Standardized data were abstracted and harmonized from local or regional clinical registries. Consecutive patients with acute ischemic stroke who were considered eligible and received thrombolysis at the participating stroke registries during the study period were included. All 9238 patients who received thrombolysis were included in this retrospective analysis. Main Outcomes and Measures sICH was defined as clinical worsening of at least 4 points on the National Institutes of Health Stroke Scale (NIHSS), attributed to parenchymal hematoma, subarachnoid, or intraventricular hemorrhage. Differences between tenecteplase and alteplase in the risk of sICH were assessed using logistic regression, adjusted for age, sex, NIHSS score, and thrombectomy. Results Of the 9238 patients included in the analysis, the median (IQR) age was 71 (59-80) years, and 4449 patients (48%) were female. Tenecteplase was administered to 1925 patients. The tenecteplase group was older (median [IQR], 73 [61-81] years vs 70 [58-80] years; P < .001), more likely to be male (1034 of 7313 [54%] vs 3755 of 1925 [51%]; P < .01), had higher NIHSS scores (median [IQR], 9 [5-17] vs 7 [4-14]; P < .001), and more frequently underwent endovascular thrombectomy (38% vs 20%; P < .001). The proportion of patients with sICH was 1.8% for tenecteplase and 3.6% for alteplase (P < .001), with an adjusted odds ratio (aOR) of 0.42 (95% CI, 0.30-0.58; P < .01). Similar results were observed in both thrombectomy and nonthrombectomy subgroups. Conclusions and Relevance In this large study, ischemic stroke treatment with 0.25-mg/kg tenecteplase was associated with lower odds of sICH than treatment with alteplase. The results provide evidence supporting the safety of tenecteplase for stroke thrombolysis in real-world clinical practice.
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Affiliation(s)
- Steven J. Warach
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin
- Ascension Texas, Austin
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - Joosup Kim
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Shlee S. Song
- Department of Neurology, Cedars Sinai Medical Center, Los Angeles, California
- Department of Neurology, Torrance Memorial Medical Centre, Torrance, California
- Department of Neurology, Cedars Sinai Marina Del Rey Hospital, Marina del Rey, California
| | | | - James Beharry
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | | | - Dominique A. Cadilhac
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Christopher F. Bladin
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Timothy J. Kleinig
- Department of Neurology. Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jackson Harvey
- Department of Neurology. Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Logesh Palanikumar
- Department of Neurology. Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Vinodh T. Doss
- Department of Neurology, Novant Health - New Hanover Regional Medical Center, Wilmington, North Carolina
| | - Ruth Marescalco
- Department of Neurology, Novant Health - New Hanover Regional Medical Center, Wilmington, North Carolina
| | - John N. Fink
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Alicia Tyson
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - Konrad H. Schlick
- Department of Neurology, Cedars Sinai Medical Center, Los Angeles, California
| | - Lydia Noh
- Department of Neurology, Cedars Sinai Medical Center, Los Angeles, California
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Sonia Figueroa
- Department of Neurology, Cedars Sinai Medical Center, Los Angeles, California
| | - Marco A. Pech
- Department of Neurology, Torrance Memorial Medical Centre, Torrance, California
| | - Laurie B. Paletz
- Department of Neurology, Cedars Sinai Medical Center, Los Angeles, California
| | - Maya K. Lewis
- Department of Neurology, Cedars Sinai Marina Del Rey Hospital, Marina del Rey, California
| | - Marissa Castro
- Department of Neurology, Cedars Sinai Medical Center, Los Angeles, California
- Department of Neurology, Cedars Sinai Marina Del Rey Hospital, Marina del Rey, California
| | - Daniel H. Sahlein
- Goodman Campbell Brain and Spine, Indianapolis, Indiana
- Ascension St Vincent’s, Indianapolis, Indiana
| | | | | | | | | | | | | | | | | | - Bruce C. V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
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Forry J, Chappell A. Tenecteplase: A Review of Its Pharmacology and Uses. AACN Adv Crit Care 2023; 34:77-83. [PMID: 37289625 DOI: 10.4037/aacnacc2023558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Jenna Forry
- Jenna Forry is Clinical Pharmacist, Tampa General Hospital, 1 Tampa General Circle, Tampa, FL 33606
| | - Alyssa Chappell
- Alyssa Chappell is Pharmacotherapy Specialist Coordinator for Emergency Medicine, Tampa General Hospital, Tampa, Florida
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Liang H, Wang X, Quan X, Chen S, Qin B, Liang S, Huang Q, Zhang J, Liang Z. Different doses of tenecteplase vs. alteplase for acute ischemic stroke within 4.5 hours of symptom onset: a network meta-analysis of randomized controlled trials. Front Neurol 2023; 14:1176540. [PMID: 37333014 PMCID: PMC10274135 DOI: 10.3389/fneur.2023.1176540] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/18/2023] [Indexed: 06/20/2023] Open
Abstract
Background The optimal dose of tenecteplase vs. alteplase for acute ischemic stroke (AIS) has yet to be established. Therefore, we included the latest randomized controlled trials (RCT) to assess the efficacy and safety of different doses of tenecteplase vs. alteplase for AIS within 4.5 hours of symptom onset. Methods Literature was searched in PubMed, Cochrane Library, Embase, Web of Science, and clinical trial registries until February 12, 2023. Odds ratios (OR) with 95% credible intervals (CrI) were estimated using Bayesian network meta-analysis (NMA). Treatments were ranked based on efficacy and safety using the surface under the cumulative ranking curve (SUCRA). Results Eleven RCTs with 5,475 patients were included. Tenecteplase 0.25 mg/kg and alteplase 0.9 mg/kg had significantly higher rates of excellent functional outcome (tenecteplase: OR, 1.85; 95% CrI, 1.44-2.37; alteplase: OR, 1.60; 95% CrI, 1.29-1.97) and good functional outcome (tenecteplase: OR, 1.54; 95% CrI, 1.19-1.98; alteplase: OR, 1.40; 95% CrI, 1.14-1.74) than placebo, despite an increased risk of symptomatic intracranial hemorrhage. Furthermore, the NMA (OR, 1.16; 95% CrI, 1.01-1.33) and the pairwise meta-analysis (OR, 1.16; 95% CI, 1.02-1.33; P = 0.03) indicated that tenecteplase 0.25 mg/kg was superior to alteplase 0.9 mg/kg in excellent functional outcome. Alteplase 0.9 mg/kg (OR, 2.54; 95% CrI, 1.45-8.08) significantly increased the risk of any intracranial hemorrhage compared with placebo. SUCRA results demonstrated that tenecteplase 0.25 mg/kg ranked first and tenecteplase 0.4 mg/kg ranked last in efficacy outcomes. Conclusions The NMA indicated that tenecteplase 0.25 mg/kg and alteplase 0.9 mg/kg are safe and significantly improve clinical outcomes in patients with AIS within 4.5 h of symptom onset. Furthermore, tenecteplase 0.25 mg/kg provides more benefit and has the potential to replace alteplase 0.9 mg/kg in AIS treatment. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/index.php, identifier: CRD42022343948.
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Affiliation(s)
- Huo Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xue Wang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xuemei Quan
- Department of Neurology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Shijian Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Bin Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shuolin Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Qiuhui Huang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jian Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Subhash, Yada PK. Expanding Footprints of Biosimilar Tenecteplase. Ann Indian Acad Neurol 2023; 26:219-220. [PMID: 37538426 PMCID: PMC10394453 DOI: 10.4103/aian.aian_256_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 03/25/2023] [Indexed: 08/05/2023] Open
Affiliation(s)
- Subhash
- Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
| | - Praveen K. Yada
- Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
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Rose D, Cavalier A, Kam W, Cantrell S, Lusk J, Schrag M, Yaghi S, Stretz C, de Havenon A, Saldanha IJ, Wu TY, Ranta A, Barber PA, Marriott E, Feng W, Kosinski AS, Laskowitz D, Poli S, Grory BM. Complications of Intravenous Tenecteplase Versus Alteplase for the Treatment of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Stroke 2023; 54:1192-1204. [PMID: 36951049 PMCID: PMC10133185 DOI: 10.1161/strokeaha.122.042335] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/20/2023] [Indexed: 03/24/2023]
Abstract
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.
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Affiliation(s)
- Deborah Rose
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Annie Cavalier
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Wayneho Kam
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Sarah Cantrell
- Duke University Medical Center Library & Archives, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Jay Lusk
- Duke University School of Medicine, Durham, NC, USA
| | - Matthew Schrag
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Shadi Yaghi
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI, USA
| | - Christoph Stretz
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI, USA
| | - Adam de Havenon
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Ian J. Saldanha
- Center for Evidence Synthesis in Health, Departments of Health Services, Policy, and Practice and of Epidemiology, Brown School of Public Health, Providence, RI, USA
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - P. Alan Barber
- Department of Medicine, University of Auckland, New Zealand
| | - Elizabeth Marriott
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Wayne Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Andrzej S. Kosinski
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Daniel Laskowitz
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Sven Poli
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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Ho-Tin-Noé B, Desilles JP, Mazighi M. Thrombus composition and thrombolysis resistance in stroke. Res Pract Thromb Haemost 2023; 7:100178. [PMID: 37538503 PMCID: PMC10394565 DOI: 10.1016/j.rpth.2023.100178] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/14/2023] [Accepted: 05/05/2023] [Indexed: 08/05/2023] Open
Abstract
A State of the Art lecture titled "Thrombus Composition and Thrombolysis Resistance in Stroke" was presented at the ISTH Congress in 2022. Intravenous thrombolysis (IVT) remains the only pharmacologic option to re-establish cerebral perfusion at the acute phase of ischemic stroke. IVT is based on the administration of recombinant tissue plasminogen activator with the objective of dissolving fibrin, the major fibrillar protein component of thrombi. Almost 30 years on from its introduction, although the clinical benefits of IVT have been clearly demonstrated, IVT still suffers from a relatively low efficacy, with a rate of successful early recanalization below 50% overall. Analyses of thrombectomy-recovered acute ischemic stroke (AIS) thrombi have shown that apart from occlusion site, thrombus length, and collateral status, AIS thrombus structure and composition are also important modulators of IVT efficacy. In this article, after a brief presentation of IVT principle and current knowledge on IVT resistance, we review recent findings on how compaction and structural alterations of fibrin together with nonfibrin thrombus components such as neutrophil extracellular traps and von Willebrand factor interfere with IVT in AIS. We further discuss how these new insights could soon result in the development of original adjuvant therapies for improved IVT in AIS. Finally, we summarize relevant new data presented during the 2022 ISTH Congress.
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Affiliation(s)
- Benoit Ho-Tin-Noé
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
| | - Jean-Philippe Desilles
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France
| | - Mikael Mazighi
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France
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Abstract
PURPOSE OF REVIEW This 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 FINDINGS A 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. SUMMARY Converging 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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Affiliation(s)
- Radhika Nair
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Miller SE, Warach SJ. Evolving Thrombolytics: from Alteplase to Tenecteplase. Neurotherapeutics 2023; 20:664-678. [PMID: 37273127 PMCID: PMC10275840 DOI: 10.1007/s13311-023-01391-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 06/06/2023] Open
Abstract
Alteplase has been the primary thrombolytic used in the treatment of acute ischemic stroke since thrombolysis was first established as an effective treatment of acute ischemic stroke in 1995. Tenecteplase, a genetically modified tissue plasminogen activator, has gained attention as an attractive alternative to alteplase given its practical workflow advantages and possible superior efficacy in large vessel recanalization. As more data is analyzed both from randomized trials and non-randomized patient registries, there is mounting support that tenecteplase appears to be at least equally, if not more, safe and potentially more effective than alteplase in the treatment of acute ischemic stroke. Randomized trials investigating tenecteplase in the delayed treatment window and with thrombectomy are ongoing, and their results are eagerly awaited. This paper provides an overview of completed and ongoing randomized trials and nonrandomized studies analyzing tenecteplase in the treatment of acute ischemic stroke. Results reviewed support the safe use of tenecteplase in clinical practice.
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Affiliation(s)
- Samantha E Miller
- Department of Neurology, Dell Medical School, University of Texas at Austin, 1601 Trinity St., Bldg. B, Stop Z0700, Austin, TX, 78712, USA.
| | - Steven J Warach
- Department of Neurology, Dell Medical School, University of Texas at Austin, 1601 Trinity St., Bldg. B, Stop Z0700, Austin, TX, 78712, USA
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Gao L, Parsons M, Churilov L, Zhao H, Campbell BCV, Yan B, Mitchell P, Coote S, Langenberg F, Smith K, Anderson D, Stephenson M, Davis SM, Donnan G, Easton D, Bivard A. Cost-effectiveness of tenecteplase versus alteplase for stroke thrombolysis evaluation trial in the ambulance. Eur Stroke J 2023; 8:448-455. [DOI: 10.1177/23969873231165086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Background: Tenecteplase administered to patients with ischaemic stroke in a mobile stroke unit (MSU) has been shown to reduce the perfusion lesion volumes and result in ultra-early recovery. We now seek to assess the cost-effectiveness of tenecteplase in the MSU. Methods: A within-trial (TASTE-A) economic analysis and a model-based long-term cost-effectiveness analysis were performed. This post hoc within-trial economic analysis utilised the patient-level data (intention to treat, ITT) prospectively collected over the trial to calculate the difference in both healthcare costs and quality-adjusted life years (QALYs, estimated from modified Rankin scale score). A Markov microsimulation model was developed to simulate the long-term costs and benefits. Results: In total, there were 104 patients with ischaemic stroke randomised to tenecteplase ( n = 55) or alteplase ( n = 49) treatment groups, respectively in the TASTE-A trial. The ITT-based analysis showed that treatment with tenecteplase was associated with non-signficantly lower costs (A$28,903 vs A$40,150 ( p = 0.056)) and greater benefits (0.171 vs 0.158 ( p = 0.457)) than that for the alteplase group over the first 90 days post the index stroke. The long-term model showed that tenecteplase led to greater savings in costs (−A$18,610) and more health benefits (0.47 QALY or 0.31 LY gains). Tenecteplase-treated patients had reduced costs for rehospitalisation (−A$1464), nursing home care (−A$16,767) and nonmedical care (−A$620) per patient. Conclusions: Treatment of ischaemic stroke patients with tenecteplase appeared to be cost-effective and improve QALYs in the MSU setting based on Phase II data. The reduced total cost from tenecteplase was driven by savings from acute hospitalisation and reduce need for nursing home care.
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Olindo S, Albucher JF, Bejot Y, Berge J, Cordonnier C, Guillon B, Sablot D, Tardy J, Alamowitch S, Sibon I. Tenecteplase in acute ischemic stroke: Review of the literature and expert consensus from the French Neurovascular Society. Rev Neurol (Paris) 2023; 179:150-160. [PMID: 36369068 DOI: 10.1016/j.neurol.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/04/2022] [Accepted: 08/22/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intravenous alteplase is the only thrombolytic treatment approved for patients with acute ischemic stroke (AIS). Although no randomized controlled trial (RCT) has shown the superiority of tenecteplase over alteplase in AIS, tenecteplase is increasingly used off-label in Stroke Units. The purpose of the present work was to provide an up-to-date set of expert consensus statements on the use of tenecteplase in AIS. METHODS Members of the working group were selected by the French Neurovascular Society. RCTs comparing tenecteplase and alteplase in the treatment of AIS were reviewed. Recent meta-analysis and real-life experience data on tenecteplase published until 30th October 2021 were also analyzed. After a description of the available data, we tried to answer the subsequent questions about the use of tenecteplase in AIS: What dosage of tenecteplase should be preferred? How effective is tenecteplase for cerebral artery recanalization? What is the clinical effectiveness of tenecteplase? What is the therapeutic safety of tenecteplase? What are the benefits associated with tenecteplase ease of use? Then expert consensus statements for tenecteplase use were submitted. In October 2021 the working group was asked to review and revise the manuscript. In November 2021, the current version of the manuscript was approved. EXPERT CONSENSUS A set of three expert consensus statements for the use of tenecteplase within 4.5hours of symptom onset in AIS patients were issued: (1) It is reasonable to use tenecteplase 0.25mg/kg when mechanical thrombectomy (MT) is planned. (2) Tenecteplase 0.25mg/kg can be used as an alternative to alteplase 0.9mg/kg in patients with medium- or small-vessel occlusion not retrievable with MT. (3) Tenecteplase 0.25mg/kg could be considered as an alternative to alteplase 0.9mg/kg in patients without vessel occlusion. CONCLUSIONS These expert consensus statements could provide a framework to guide the clinical decision-making process for the use of tenecteplase according to admission characteristics of AIS patients. However, existing data are limited, requiring inclusions in ongoing RCTs or real-life registries.
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Affiliation(s)
- S Olindo
- Service de Neurovasculaire, Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - J-F Albucher
- Unité Neuro-Vasculaire, Hôpital Pierre-Paul-Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Y Bejot
- Service Hospitalo-Universitaire de Neurologie, CHU de Dijon Bourgogne, Dijon, France
| | - J Berge
- Service de Neuro-Radiologie, Hôpital Pellegrin, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | - C Cordonnier
- Université Lille, Inserm, CHU Lille, U1172, LiINCog, Lille Neuroscience and Cognition, Lille, France
| | - B Guillon
- Unité Neurovasculaire, Hôpital G&R Laënnec, CHU de Nantes, Nantes, France
| | - D Sablot
- Service de Neurologie, Hôpital de Perpignan, Perpignan, France
| | - J Tardy
- Unité Neuro-Vasculaire, Clinique des Cèdres, Cornebarrieu, France
| | - S Alamowitch
- Urgences Cérébro-Vasculaires, Hôpital Salpêtrière-Saint Antoine, AP-HP, Sorbonne Université, Stare Team, iCRIN, Institut du cerveau, Inserm UMRS 938, Paris, France
| | - I Sibon
- Service de Neurovasculaire, Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
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Wang Y, Li S, Pan Y, Li H, Parsons MW, Campbell BCV, Schwamm LH, Fisher M, Che F, Dai H, Li D, Li R, Wang J, Wang Y, Zhao X, Li Z, Zheng H, Xiong Y, Meng X. Tenecteplase versus alteplase in acute ischaemic cerebrovascular events (TRACE-2): a phase 3, multicentre, open-label, randomised controlled, non-inferiority trial. Lancet 2023; 401:645-654. [PMID: 36774935 DOI: 10.1016/s0140-6736(22)02600-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/09/2022] [Accepted: 12/02/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND There is increasing interest in replacing alteplase with tenecteplase as the preferred thrombolytic treatment for patients with acute ischaemic stroke. We aimed to establish the non-inferiority of tenecteplase to alteplase for these patients. METHODS In this multicentre, prospective, open-label, blinded-endpoint, randomised controlled, non-inferiority trial, adults with an acute ischaemic stroke who were eligible for standard intravenous thrombolysis but ineligible for endovascular thrombectomy were enrolled from 53 centres in China and randomly assigned (1:1) to receive intravenous tenecteplase (0·25 mg/kg, maximum dose of 25 mg) or intravenous alteplase (0·9 mg/kg, maximum dose of 90 mg). Participants had to be able to receive treatment within 4·5 h of stroke, have a modified Rankin Scale (mRS) score of no more than 1 before enrolment, and have a National Institutes of Health Stroke Scale score of 5-25. Patients and treating clinicians were not masked to group assignment; clinicians evaluating outcomes were masked to treatment type. The primary efficacy outcome was the proportion of participants who had a mRS score of 0-1 at 90 days, assessed in the modified intention-to-treat population (all randomly assigned participants who received the allocated thrombolytic), with a non-inferiority margin of 0·937 for the risk ratio (RR). The primary safety outcome was symptomatic intracranial haemorrhage within 36 h, assessed in all participants who received study drug and had a safety assessment available. The trial is registered with ClinicalTrials.gov, NCT04797013, and has been completed. FINDINGS Between June 12, 2021, and May 29, 2022, 1430 participants were enrolled and randomly assigned to tenecteplase (n=716) or alteplase (n=714). Six patients assigned to tenecteplase and seven to alteplase did not receive study product, and five participants in the tenecteplase group and 11 in the alteplase group were lost to follow-up at 90 days. The primary outcome in the modified intention-to-treat population occurred in 439 (62%) of 705 in the tenecteplase group versus 405 (58%) of 696 in the alteplase group (RR 1·07, 95% CI 0·98-1·16). The lower limit of the RR's 95% CI was greater than the non-inferiority margin. Symptomatic intracranial haemorrhage within 36 h was observed in 15 (2%) of 711 in the tenecteplase group and 13 (2%) of 706 in the alteplase group (RR 1·18, 95% CI 0·56-2·50). Mortality within 90 days occurred in 46 (7%) individuals in the tenecteplase group versus 35 (5%) in the alteplase group (RR 1·31, 95% CI 0·86-2·01). INTERPRETATION Tenecteplase was non-inferior to alteplase in people with ischaemic stroke who were eligible for standard intravenous thrombolytic but ineligible for or refused endovascular thrombectomy. FUNDING National Science and Technology Major Project, Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences, National Natural Science Foundation of China, and China Shijiazhuang Pharmaceutical Company Recomgen Pharmaceutical (Guangzhou).
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Affiliation(s)
- Yongjun Wang
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Shuya Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Mark W Parsons
- Department of Neurology, Liverpool Hospital, University of New South Wales, Sydney, NSW, Australia; South Western Sydney Clinical School, Sydney, NSW, Australia; The Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Melbourne, VIC, Australia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Lee H Schwamm
- Department of Neurology and Comprehensive Stroke Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Fengyuan Che
- Department of Neurology, LinYi People's Hospital, Linyi, China
| | - Hongguo Dai
- Department of Neurology, Linfen Central Hospital, Linfen, China
| | - Deyang Li
- Department of Neurology, Tengzhou Central People's Hospital, Tengzhou, China
| | - Runhui Li
- Department of Neurology, Central Hospital Affiliated to Shenyang Medical College, Shenyang, China
| | - Junhai Wang
- Department of Neurology, Sinopharm Tongmei General Hospital, Datong, China
| | - Yilong Wang
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Huaguang Zheng
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yunyun Xiong
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
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Menon BK, Singh N, Sylaja PN. Tenecteplase use in patients with acute ischaemic stroke. Lancet 2023; 401:618-619. [PMID: 36774934 DOI: 10.1016/s0140-6736(22)02633-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 12/16/2022] [Indexed: 02/11/2023]
Affiliation(s)
- Bijoy K Menon
- Department of Clinical Neurosciences, and Department of Radiology, Cumming School of Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB T2N2T9, Canada; Hotchkiss Brain Institute, Calgary, AB, Canada.
| | - Nishita Singh
- Department of Neurology, University of Manitoba, Winnipeg, MB, Canada
| | - P N Sylaja
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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Alamowitch S, Turc G, Palaiodimou L, Bivard A, Cameron A, De Marchis GM, Fromm A, Kõrv J, Roaldsen MB, Katsanos AH, Tsivgoulis G. European Stroke Organisation (ESO) expedited recommendation on tenecteplase for acute ischaemic stroke. Eur Stroke J 2023; 8:8-54. [PMID: 37021186 PMCID: PMC10069183 DOI: 10.1177/23969873221150022] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/21/2022] [Indexed: 02/05/2023] Open
Abstract
Within the last year, four randomised-controlled clinical trials (RCTs) have been published comparing intravenous thrombolysis (IVT) with tenecteplase and alteplase in acute ischaemic stroke (AIS) patients with a non-inferiority design for three of them. An expedited recommendation process was initiated by the European Stroke Organisation (ESO) and conducted according to ESO standard operating procedure based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. We identified three relevant Population, Intervention, Comparator, Outcome (PICO) questions, performed systematic reviews of the literature and meta-analyses, assessed the quality of the available evidence, and wrote evidence-based recommendations. Expert consensus statements were provided if insufficient evidence was available to provide recommendations based on the GRADE approach. For patients with AIS of <4.5 h duration who are eligible for IVT, tenecteplase 0.25 mg/kg can be used as a safe and effective alternative to alteplase 0.9 mg/kg (moderate evidence, strong recommendation). For patients with AIS of <4.5 h duration who are eligible for IVT, we recommend against using tenecteplase at a dose of 0.40 mg/kg (low evidence, strong recommendation). For patients with AIS of <4.5 h duration with prehospital management with a mobile stroke unit who are eligible for IVT, we suggest tenecteplase 0.25 mg/kg over alteplase 0.90 mg/kg (low evidence, weak recommendation). For patients with large vessel occlusion (LVO) AIS of <4.5 h duration who are eligible for IVT, we recommend tenecteplase 0.25 mg/kg over alteplase 0.9 mg/kg (moderate evidence, strong recommendation). For patients with AIS on awakening from sleep or AIS of unknown onset who are selected with non-contrast CT, we recommend against IVT with tenecteplase 0.25 mg/kg (low evidence, strong recommendation). Expert consensus statements are also provided. Tenecteplase 0.25 mg/kg may be favoured over alteplase 0.9 mg/kg for patients with AIS of <4.5 h duration in view of comparable safety and efficacy data and easier administration. For patients with LVO AIS of <4.5 h duration who are IVT-eligible, IVT with tenecteplase 0.25 mg/kg is preferable over skipping IVT before MT, even in the setting of a direct admission to a thrombectomy-capable centre. IVT with tenecteplase 0.25 mg/kg may be a reasonable alternative to alteplase 0.9 mg/kg for patients with AIS on awakening from sleep or AIS of unknown onset and who are IVT-eligible after selection with advanced imaging.
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Affiliation(s)
- Sonia Alamowitch
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, STARE team, iCRIN, Institut du Cerveau, Sorbonne Université, Paris, France
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université Paris Cité, Paris, France
- INSERM U1266, Paris, France
- FHU NeuroVasc, Paris, France
| | - Lina Palaiodimou
- Second Department of Neurology, School of Medicine, National & Kapodistrian University of Athens, ‘Attikon’ University Hospital, Athens, Greece
| | - Andrew Bivard
- Melbourne Brain Centre, University of Melbourne, Melbourne, Australia
| | - Alan Cameron
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - Gian Marco De Marchis
- Department of Neurology & Stroke Center, University Hospital Basel, Switzerland
- Department of Clinical Research, University of Basel, Switzerland
| | - Annette Fromm
- Department of Neurology, Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - Melinda B Roaldsen
- Department of Clinical Research, University Hospital of North Norway, Tromsø, Norway
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, ON, Canada
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, National & Kapodistrian University of Athens, ‘Attikon’ University Hospital, Athens, Greece
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