Tenecteplase versus alteplase for management of acute ischaemic stroke (NOR-TEST): a phase 3, randomised, open-label, blinded endpoint trial

Tenecteplase Plus Butyphthalide for Stroke Within 4.5-6 Hours of Onset (EXIT-BT): a Phase 2 Study

To date, the benefit of intravenous thrombolysis is confined to within 4.5 h of onset for acute ischemic stroke (AIS) without advanced neuroimaging selection. The current trial aimed to investigate the safety and efficacy of intravenous tenecteplase (TNK) plus Dl-3-n-Butylphthalide (NBP) in AIS within 4.5 to 6 h of onset. In this randomized, multicenter trial, eligible AIS patients were randomly assigned to receive intravenous TNK (0.25 mg/kg) plus NBP or NBP within 4.5 to 6 h of onset. The primary endpoint was symptomatic intracranial hemorrhage (sICH). Secondary endpoints included excellent functional outcome defined as a modified Rankin Scale score of 0 to 1 at 90 days. 100 patients diagnosed by non-contrast CT (NCCT) were enrolled, including 50 in TNK group and 50 in control group. sICH occurred in 2.0% (1/50) in TNK group and 0.0% (0/49) in control group with no difference (unadjusted P = 0.998). The proportion of excellent functional outcome was 77.6% (38/49) in TNK group and 69.4% (34/49) in control group with non-significance (absolute difference 8.2%, P = 0.36). A significant decrease in NIHSS score at 24 h (P = 0.004) and more early neurological improvement (20.4% vs 4.1%; P = 0.026) was observed in TNK vs control group, but there was no difference in other secondary outcomes. This phase 2 study suggests that intravenous TNK with adjuvant NBP seems safe, feasible and may improve early neurological function in AIS patients within 4.5 to 6 h of symptom onset selected using NCCT.Clinical Trials Registration: This trial was registered with ClinicalTrials.gov (NCT05189509).

Evaluation of Door-to-Needle Times Between Alteplase and Tenecteplase for Acute Ischemic Stroke at Two Academic Medical Centers

BACKGROUND

Off-label tenecteplase use for acute ischemic stroke (AIS) has increased due to ease of administration and comparable efficacy and safety to alteplase.

OBJECTIVE

This study aimed to evaluate time to thrombolysis before and after transition from alteplase to tenecteplase for treatment of AIS at 2 institutions.

METHODS

This retrospective cohort study included adult patients receiving thrombolysis for AIS before and after transition from alteplase to tenecteplase at 2 academic medical centers from January 1, 2020 to January 31, 2024. The primary endpoint was door-to-needle (DTN) time, defined as minutes from hospital arrival to thrombolysis administration. Notable secondary endpoints included time from last known well (LKW) to thrombolysis, time from brain imaging to thrombolysis, hospital length of stay (LOS), and incidence of symptomatic intracranial hemorrhage (sICH).

RESULTS

A total of 328 patients (168 tenecteplase and 160 alteplase) were included. Patients were 51.5% female with a median (interquartile range [IQR]) age of 70 [58-80] years and initial National Institutes of Health Stroke Scale (NIHSS) score of 8 [5-14]. There was no statistically significant difference in DTN time (60 vs 56 minutes), time from LKW to thrombolysis (134 vs 147.5 minutes), or time from brain imaging to thrombolysis (32 vs 31 minutes) between tenecteplase and alteplase. Hospital LOS (5.7 vs 4.9 days) and the rates of sICH (3% vs 3.8%) were similar between groups.

CONCLUSION AND RELEVANCE

Tenecteplase and alteplase had comparable DTN times for treatment of AIS and similar safety endpoints. Further studies are warranted to identify opportunities to streamline DTN times with tenecteplase.

Comparison of the Novel Thrombolytic Constitutively Active ADAMTS13 With Clinical Thrombolytics in a Murine Stroke Model

BACKGROUND

r-tPA (recombinant tissue-type plasminogen activator) and its variant, TNK (tenecteplase), are the currently approved thrombolytic drugs for the treatment of acute ischemic stroke, but they are ineffective in a proportion of patients due to r-tPA resistance of platelet-rich thrombi. A novel thrombolytic, caADAMTS13 (constitutively active a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) has been shown to improve experimental stroke outcomes where platelet-rich thrombi are present but have not been directly compared with r-tPA or TNK.

METHODS

We conducted a direct comparison of caADAMTS13 versus r-tPA versus TNK versus vehicle control in the ferric chloride-mediated distal middle cerebral artery occlusion model in mice, which features platelet and VWF (von Willebrand Factor)-rich thrombi that reproduce r-tPA-resistant occlusion. Treatments were administered intravenously 1 hour after ferric chloride application by bolus injection or bolus followed by infusion, as translationally applicable. Laser speckle contrast imaging measured early reperfusion over the hour following treatment, and magnetic resonance imaging measured cerebral blood flow and lesion volume at 24 hours.

RESULTS

Reperfusion 1 hour after treatment was greatest in caADAMTS13-treated animals. Later cerebral blood flow, 24 hours post-treatment, within the stroke-affected hypoperfused area was higher in caADAMTS13 and r-tPA but not TNK-treated mice. Functionally, this led to the absence of an initial behavioral deficit in caADAMTS13-treated mice, alongside a smaller lesion volume at 24 hours and reduced extent of bleeding.

CONCLUSIONS

These findings demonstrate an overall suggestion that caADAMTS13 has improved thrombolytic efficacy, compared with current stroke treatments, against platelet-rich thrombi, for which there is currently an unmet clinical need.

Comparing Early National Institutes of Health Stroke Scale Versus 90-Day Modified Rankin Scale Outcomes in Acute Ischemic Stroke Trials: A Systematic Review and Analysis

BACKGROUND

Early National Institutes of Health Stroke Scale (NIHSS) assessment may provide practical benefits over 90-day modified Rankin Scale (mRS), but it is unclear how it compares in adjudicating randomized clinical trial (RCT) results in acute ischemic stroke.

METHODS AND RESULTS

We searched Ovid Medline (inception to April 1, 2023) and included RCTs of acute therapies for acute ischemic stroke with data for both 90-day mRS and NIHSS within 7 days. Primary outcome was agreement between trial results (classified as positive, negative, or neutral) based on 24-hour NIHSS and 90-day mRS scores. We additionally assessed agreement for 2-hour, 48-hour, 72- to 96-hour, and 5- to 7-day NIHSS scores. We aimed to validate our findings using individual patient data from the ESCAPE (Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke) and ESCAPE-NA1 (Safety and Efficacy of Nerinetide [NA-1] in Subjects Undergoing Endovascular Thrombectomy for Stroke) RCTs. We included 116 trials (44 387 patients), contributing 165 NIHSS assessments. The 24-hour NIHSS scores resulted in the same classification as 90-day mRS scores in 61/73 (83.6%) trials (Cohen's kappa, 0.64 [95% CI: 0.45-0.83] and Gwet's agreement coefficient 1, 0.79 [95% CI: 0.67-0.90]). Agreement was not statistically different by timing of NIHSS assessments (range 75%-100%, P=0.33). Individual patient data showed higher agreement for assessments between 48 hours and 7 days, varying by NIHSS dichotomization cutoffs (NIHSS score, 0-2; 2 hours, 56.6%; 24 hours, 66.6%; 48 hours, 71.8%; 5-7 days: 76.5%, P<0.01; NIHSS score, 0-7; 2 hours, 72.8%; 24 hours, 80.5%; 48 hours, 83.1%; 5-7 days: 84.7%, P<0.01).

CONCLUSIONS

The 24-hour NIHSS scores aligned with 90-day mRS scores in 84% of RCT results, indicating intermediate-to-good agreement. However, individual patient data showed that early NIHSS risks misclassifying around 1/4 patients. These data contribute to a better understanding of the nuances of early NIHSS score as an outcome in acute ischemic stroke RCTs.

Thrombolysis for acute ischaemic stroke: development and update

Thrombolytic therapy is a cornerstone in managing acute ischaemic stroke, marking significant advancements in treatment. Various generations of thrombolytics play crucial roles in different strategies, including intravenous thrombolysis, bridging therapy and thrombolysis beyond the conventional time window. The continuous development of thrombolytics has brought notable improvements. Compared to first-generation urokinase, second-generation alteplase and third-generation tenecteplase offer significant pharmacological advantages, such as enhanced fibrin specificity and longer half-lives. Tenecteplase demonstrates non-inferiority to alteplase regarding efficacy and safety, with the added benefit of a more convenient administration method. Ongoing trials continue to reveal additional evidence. Furthermore, other thrombolytic agents, including reteplase and non-immunogenic recombinant staphylokinase, are gaining increasing interest in the medical community. This review examines the structural characteristics, pharmacological properties, efficacy and safety profiles of these thrombolytic drugs. It also provides a detailed analysis of the performance of thrombolytic therapy in different acute ischaemic stroke patient subgroups, aiming to trace the evolution of these treatments and compare their effectiveness in acute ischaemic stroke. The goal is to offer a scientific basis for clinical practices and future development of thrombolytic therapies.

Risk of intracerebral haemorrhage with tenecteplase versus alteplase in acute ischaemic stroke: a meta-analysis

BACKGROUND

Tenecteplase (TNK) has been widely used in thrombolytic therapy for acute ischaemic stroke (AIS), but TNK-related intracranial haemorrhage(ICH) remains a severe complication. However, few data are available to guide the management of tenecteplase-related intracranial haemorrhage. The objective of this study was to evaluate the risk of intracranial haemorrhage associated with tenecteplase compared with alteplase in patients with acute ischaemic stroke.

METHODS

A thorough literature search of Embase, PubMed, Cochrane Library, and Web of Science was conducted for randomized controlled trials (RCTs) published up to October 2024. Randomized controlled trials (RCTs) investigating the risk of intracranial haemorrhage between tenecteplase and alteplase (ALT) were eligible for inclusion. To reduce study bias, we uniformly adopted the random-effects model for the meta-analysis of all haemorrhagic outcomes.

RESULTS

Eleven RCTs with a total of 7466 patients were analysed in this meta-analysis. No significant differences were observed between TNK-treated patients and ALT-treated patients in overall ICH (13.22% vs 12.72%; RR = 1.02, 95% CI = 0.8-1.24; p = 0.81), symptomatic ICH (3.09% vs. 2.49%; RR = 1.21, 95% CI = 0.92-1.59; p = 0.18), and asymptomatic ICH (8.68% vs. 9.03%; RR = 0.95, 95% CI = 0.78-1.16; p = 0.62). Subgroup analyses based on TNK dosage (0.25 mg/kg vs. 0.4 mg/kg) compared to ALT showed no significant differences in ICH incidences. The proportions of ICH in different locations, including intraventricular hemorrhage, subarachnoid hemorrhage, hemorrhagic infarction, parenchymal hematoma, and remote parenchymal hematoma, were also similar between the TNK and ALT groups (all P > 0.05).

CONCLUSION

Our study provides the best evidence to date that TNK has a similar risk of ICH to ALT in AIS, with a very low incidence of symptomatic ICH, supporting that TNK has a good safety profile in terms of ICH.

Tenecteplase is here: navigating the shift of a stroke thrombolytic in the United States prior to FDA approval: a mini-review on rationale, barriers, and pathways

The transition from alteplase (TPA) to tenecteplase (TNK) in acute ischemic stroke (AIS) management is gaining traction due to TNK's advantages in ease of administration and lower costs. Several studies have demonstrated at least comparable safety and efficacy profiles, culminating in TNK's Food and Drug Administration (FDA) approval in early March 2025. Prior to this, challenges related to regulatory approvals, operational barriers, logistical constraints, and current clinical guidelines hindered the adoption of TNK across U.S. stroke systems. This mini-review seeks to address the pre-FDA approval obstacles to implementing TNK in stroke care and specifies some key aspects that support a transition, drawing insights from the early adoption experience of a U.S. health system. The discussion focuses on stakeholder involvement, formulary approval, and operational considerations, providing practical recommendations for stroke programs. The experience at Geisinger showcases a deliberate execution of a comprehensive change management strategy that resulted in successful and lasting outcomes. It may further serve as a blueprint for implementation of next generation thrombolytics yet to come.

Efficacy and Safety of Various Intravenous Thrombolytics for Acute Ischemic Stroke (AIS) at Various Dosages: A Systematic Review and Network Meta-Analysis

BACKGROUND

Currently, there is limited evidence on the efficacy and safety of various thrombolytic drugs at different dosages for the treatment of acute ischemic stroke (AIS). From current randomized clinical trials, the optimal type and dosage of thrombolytics for patients with AIS are unclear.

METHODS

This systematic review was registered in PROSPERO (CRD42024563757). We searched four databases using a combination of keywords that contained various intravenous thrombolytics, as well as acute ischemic stroke. Only data from participants with AIS treated with various intravenous thrombolytics within the 4.5-h time window were included. Among initially identified studies, 16 met the selection criteria. Network meta-analysis was conducted for efficacy (90 day modified Rankin scale score) and safety (intracranial hemorrhage events, mortality at 90 days) using Stata 17.0 software, with a fixed-effects model. Cochrane risk of bias tool assessed all risk of bias domains, and the CINeMA Evidence Assessment Tool evaluated the level of evidence for each outcome.

RESULTS

A total of 9056 studies were retrieved through the literature search, and 12,792 patients screened from 16 randomized controlled trials were included in the network meta-analysis. The risk of bias in the included studies ranged from moderate to low. The network meta-analysis results indicated that reteplase at 18 + 18 mg ranked highest in efficacy, though its safety was lower compared to 0.25 mg/kg tenecteplase and alteplase. The dose of 0.25 mg/kg tenecteplase emerged as the optimal dose, demonstrating both superior efficacy and a lower risk of bleeding compared to alteplase, making it a potential alternative to alteplase. The dose of 50 mg prourokinase was associated with the highest risk of symptomatic intracranial hemorrhage and was inferior to reteplase in terms of both efficacy and safety. The CINeMA Evidence Assessment Tool identified one outcome with a high level of evidence, several with moderate levels, and the remainder with low levels.

CONCLUSIONS

Reteplase at 18 + 18 mg may be more suitable for patients with lower incidence of adverse events evaluated by physicians. Compared to 0.9 mg/kg alteplase, 0.25 mg/kg tenecteplase is more effective, with the lowest risk of intracranial hemorrhage. However, as tenecteplase's dosages increase (0.32 mg/kg and 0.4 mg/kg), its efficacy in improving neurological deficits decreases, while the risk of intracranial hemorrhage and death (especially at 0.4 mg/kg) increases. Clinicians are supposed to carefully assess the needs of patients with AIS and the risks then choose decent thrombolytics.

[Acute ischemic stroke treatment]

Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the cornerstones of acute ischemic stroke treatment. While IVT has been an integral part of acute therapy since the mid-1990s, EVT has evolved as one of the most effective treatments in medicine over the past decade. Traditionally, systemic thrombolysis has been performed with alteplase (rtPA). More recently, tenecteplase (TNK) has been shown to be non-inferior to rtPA. TNK has some pharmacological advantages over rtPA and may lead to earlier recanalization, particularly in large vessel occlusions. All recanalization therapies are highly time dependent. To ensure rapid treatment, standard operating procedures (SOPs) should be established and followed in clinical practice. The optimal time window for IVT is 4.5 h after symptom onset and can be extended up to 9 h using specialized imaging techniques. For EVT, studies suggest a time window up to 24 h after symptom onset. In some cases, EVT has been successfully performed beyond this time window. To select patients for EVT, advanced imaging identifying salvageable brain tissue might be necessary. Even in large ischemic stroke, EVT can still improve outcome. Compared to EVT, IVT requires fewer technical and human resources, so more stroke patients can potentially be treated. In contrast, EVT requires highly trained personnel with sophisticated equipment and can, therefore, only be performed in specialized centers. Both procedures should be combined within the 4.5 h time window for patients without contraindications.

Should we switch to tenecteplase for all ischemic strokes? Evidence and logistics

Recent clinical trials provide robust evidence of non-inferiority of tenecteplase 0.25 mg/kg over alteplase 0.9 mg/kg in acute ischemic stroke treated within 4.5 h of time last known well. Aggregate data meta-analysis suggests likely superiority of tenecteplase with respect to excellent (modified Rankin Scale 0 or 1) outcomes at 90 days. Less complex single intravenous bolus administration of tenecteplase brings significant logistical benefits compared to alteplase. Real-world implementation data demonstrate reduced door-to-needle and door-to-puncture times, and potentially improved clinical outcomes. Avoiding the need for infusion pumps and monitoring reduces resource requirements and facilitates inter-hospital transfer. Guidelines favor tenecteplase over alteplase due to its logistical advantages. Transitioning services to tenecteplase requires consideration of education and training for all relevant staff (medical, nursing, pharmacy) and should address physician concerns. Use of stroke-specific tenecteplase 25 mg dose vials is strongly preferable to minimize the chance of dosing errors that might arise from use of cardiac-dose tenecteplase. Some off-label uses of alteplase are supported by positive randomized controlled trial data (wake-up and unknown onset stroke, and imaging-supported late window use 4.5-9 h after onset) while equivalent data for tenecteplase are less conclusive. Trial data comparing tenecteplase to control give relevant safety data for both wake-up / unknown onset stroke and for late time windows, and some efficacy data favor tenecteplase in a late time window. Given the weight of evidence for biologically similar efficacy and safety of tenecteplase 0.25 mg/kg, and potential for dosing errors, retention of alteplase for off-label indications should not be recommended.

Comparative efficacy and safety of tissue plasminogen activators (tPA) in acute ischemic stroke: A systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Intravenous alteplase (ALT) is the standard treatment for acute ischemic stroke (AIS). However, recent trials comparing other tissue plasminogen activators (tPAs) like tenecteplase (TNK) and reteplase with ALT have yielded conflicting results. This necessitated a network meta-analysis to compare the efficacy and safety of various tPAs in AIS patients.

METHODS

We searched MEDLINE, Embase, and CENTRAL (until September 15, 2024) for randomized controlled trials (RCTs) comparing TNK or reteplase (any dose) with ALT (0.9 mg/kg) in AIS patients. A frequentist network meta-analysis was performed using risk ratio (RR) and 95 % CI for each comparison, and P-scores ranked treatments. Analyses were done using R Software 4.4.1.

RESULTS

Sixteen RCTs (9259 patients, 62.1 % males) were included. Reteplase 18+18 mg significantly improved excellent functional recovery (mRS 0-1) (RR: 1.13; p < 0.01) and independent ambulation (mRS 0-2) at 3 months (RR: 1.07; p < 0.01) compared to ALT. The 0.25 mg/kg TNK group also showed improved functional recovery (mRS 0-1) (RR: 1.06; p < 0.01). For safety, 0.1 mg/kg TNK was associated with a higher incidence of symptomatic intracranial hemorrhage (s-ICH) (RR: 7.27; p < 0.01). No significant differences in ICH or all-cause mortality were found between ALT and other treatments. Reteplase 18+18 mg ranked highest for functional recovery (P-score=0.9638) and ambulation (P-score=0.9749), while ALT ranked highest for s-ICH (P-score=0.8060). No significant differences were observed between reteplase and TNK.

CONCLUSION

Reteplase 18+18 mg and TNK 0.25 mg/kg demonstrated higher efficacy and comparable safety to ALT. Larger trials are needed to further explore these agents as alternatives to ALT.

Tenecteplase for the Treatment of Pediatric Arterial Ischemic Stroke: A Safety Surveillance Report

OBJECTIVES

Intravenous tenecteplase (TNK) is increasingly used to treat adult patients with acute arterial ischemic stroke, but the risk profile of TNK in childhood stroke is unknown. This study aims to prospectively gather safety data regarding TNK administration in children.

METHODS

Since December 2023, a monthly email survey was sent to participants recruited from the International Pediatric Stroke Study and Pediatric Neurocritical Care Research Group querying recent experience with TNK in childhood stroke. Limited demographic, safety, and outcome data were collected in a secure REDCap database. Detailed clinical data were not collected.

RESULTS

Eleven children were reported to have received TNK between February 2023 and January 2024. Ten were adolescents (13-17 years old), and 1 was between 5 and 12 years old. TNK was given at an outside facility before transfer to the reporting facility in 7 cases. Final diagnosis was stroke in 8 cases and stroke mimic in 3 cases. No major safety concerns or TNK-related intracranial hemorrhages on follow-up imaging were reported.

DISCUSSION

Our initial data suggest that TNK may be safe in childhood arterial ischemic stroke. Strategically designed prospective studies are needed to further define safety, optimal dosage, and efficacy of TNK in acute pediatric stroke.

Patient-reported symptoms and admission pathways in stroke mimics versus confirmed stroke or transient ischaemic attack: a cross-sectional observational study

OBJECTIVES

To determine patient-reported symptoms and clinical factors associated with mimics and differences in health-seeking behaviour versus stroke.

DESIGN

This is a post-hoc analysis of a cross-sectional survey of interviews on patient-reported factors in patients admitted with suspected stroke. Patients were categorised as genuine stroke or mimic. The surveys were conducted from February 2018 to January 2019.

SETTING

Two non-comprehensive stroke centres in Denmark.

PARTICIPANTS

Patients≥18 years (no upper age limit) admitted with symptoms of stroke to one of the non-comprehensive stroke centres or transferred from a comprehensive- or primary stroke centre were eligible for inclusion. 592 patients were included.

OUTCOME MEASURES

Symptoms or clinical factors associated with stroke mimics. Logistic regression analysis was performed to identify factors associated with mimics. Secondarily, the number of strokes versus mimics presenting at a healthcare facility within 3 hours contacted the emergency medical service (EMS) and arrived by ambulance.

RESULTS

Of 592 suspected patients with stroke, 113 (19.1%) were mimics; most frequently peripheral vertigo (24.7%) and migraine (11.5%). Factors associated with a higher likelihood of mimics were female sex (OR 1.79, 95% CI 1.14 to 2.79), high Scandinavian Stroke Scale scores (OR 1.05, 95% CI 1.02 to 1.09, per point increase), and vertigo (OR 1.86, 95% CI 1.18 to 2.95). Factors associated with a lower likelihood of mimics were increasing age (OR 0.96, 95% CI 0.95 to 0.98 per year increase), reported limb weakness (OR 0.52, 95% CI 0.30 to 0.89) and difficulty steering (OR 0.51, 95% CI 0.28 to 0.93).There was no difference between groups in the proportion of patients for whom time from symptom onset to healthcare services contact exceeded 3 hours (52.2% vs 53.7%, p=0.78). Fewer mimics contacted the EMS first, were accepted at a primary stroke centre and arrived by ambulance (p<0.05 for all variables).

CONCLUSION

Patient-reported vertigo and migraine are common stroke mimics. Increasing age and unilateral limb symptoms increase the likelihood of a stroke. Although symptoms are similar, prehospital pathways differ between mimics and genuine patients with stroke.

Emergency Department Workflow Times of Intravenous Thrombolysis with Tenecteplase versus Alteplase in Acute Ischemic Stroke: A Prospective Cohort Study before and during the COVID-19 Pandemic

INTRODUCTION

Tenecteplase (TNK) has demonstrated to be non-inferior to alteplase (ALT) for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS). There are potential workflow benefits associated with TNK use, aiming to reduce patient length of stay in the emergency department. Our aim was to investigate whether the routine use of TNK during the COVID-19 pandemic influenced workflow times compared to historical use of ALT, while maintaining non-inferior clinical outcomes in a non-drip and ship scenario of a comprehensive stroke center.

METHODS

We included patients with AIS admitted from September 2019 to September 2022 and compared those treated with TNK during the COVID-19 pandemic to those treated with ALT in the period immediately before. We compared emergency department length of stay (EDLOS), door-to-needle time (DTN), door-to-groin puncture time (DTG), clinical and safety outcomes with adjusted general linear regression models.

RESULTS

110 patients treated with TNK and 111 with ALT were included in this study. Mean EDLOS was 251 (SD = 164) min for TNK users versus 240 (SD = 148) min for ALT (p = 0.62). Mean DTN was 43 (SD = 25) min for TNK versus 46 (SD = 27) min for ALT users (p = 0.39). Mean DTN under 60 min was achieved in 86 (78.2%) patients and in 85 (76.5%) patients of the TNK and ALT groups, respectively (p = 1.0). DTN under 45 min was achieved in 65.4% and 58.6% (p = 0.65) of the TNK and ALT groups, respectively. DTG time was 114 (SD = 43) min for TNK versus 111 (58 = SD) min in the ALT group (p = 0.88). DTG under 90 min was achieved in 32% of the TNK group and 35% of the ALT group (p = 0.69). There were no differences in any of the clinical or safety outcomes between groups at 90 days.

CONCLUSIONS

The adoption of TNK during COVID-19 pandemic did not result in a change in EDLOS, DTN, or DTG times when compared to ALT in this cohort. Safety and clinical outcomes were similar between groups. Probably a greater benefit could have been seen in a drip and ship thrombolysis setting. Further research is needed to assess the potential advantages of TNK in drip and ship scenarios of IVT.

INTRODUCTION

Tenecteplase (TNK) has demonstrated to be non-inferior to alteplase (ALT) for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS). There are potential workflow benefits associated with TNK use, aiming to reduce patient length of stay in the emergency department. Our aim was to investigate whether the routine use of TNK during the COVID-19 pandemic influenced workflow times compared to historical use of ALT, while maintaining non-inferior clinical outcomes in a non-drip and ship scenario of a comprehensive stroke center.

METHODS

We included patients with AIS admitted from September 2019 to September 2022 and compared those treated with TNK during the COVID-19 pandemic to those treated with ALT in the period immediately before. We compared emergency department length of stay (EDLOS), door-to-needle time (DTN), door-to-groin puncture time (DTG), clinical and safety outcomes with adjusted general linear regression models.

RESULTS

110 patients treated with TNK and 111 with ALT were included in this study. Mean EDLOS was 251 (SD = 164) min for TNK users versus 240 (SD = 148) min for ALT (p = 0.62). Mean DTN was 43 (SD = 25) min for TNK versus 46 (SD = 27) min for ALT users (p = 0.39). Mean DTN under 60 min was achieved in 86 (78.2%) patients and in 85 (76.5%) patients of the TNK and ALT groups, respectively (p = 1.0). DTN under 45 min was achieved in 65.4% and 58.6% (p = 0.65) of the TNK and ALT groups, respectively. DTG time was 114 (SD = 43) min for TNK versus 111 (58 = SD) min in the ALT group (p = 0.88). DTG under 90 min was achieved in 32% of the TNK group and 35% of the ALT group (p = 0.69). There were no differences in any of the clinical or safety outcomes between groups at 90 days.

CONCLUSIONS

The adoption of TNK during COVID-19 pandemic did not result in a change in EDLOS, DTN, or DTG times when compared to ALT in this cohort. Safety and clinical outcomes were similar between groups. Probably a greater benefit could have been seen in a drip and ship thrombolysis setting. Further research is needed to assess the potential advantages of TNK in drip and ship scenarios of IVT.

The impact of chronic kidney disease on prognosis in acute stroke: unraveling the pathophysiology and clinical complexity for optimal management

BACKGROUND

Chronic kidney disease (CKD) significantly increases stroke risk and severity, posing challenges in both acute management and long-term outcomes. CKD contributes to cerebrovascular pathology through systemic inflammation, oxidative stress, endothelial dysfunction, vascular calcification, impaired cerebral autoregulation, and a prothrombotic state, all of which exacerbate stroke risk and outcomes.

METHODS

This review synthesizes evidence from peer-reviewed literature to elucidate the pathophysiological mechanisms linking CKD and stroke. It evaluates the efficacy and safety of acute reperfusion therapies-intravenous thrombolysis and endovascular thrombectomy-in CKD patients with acute ischemic stroke. Considerations, such as renal function, drug dosage adjustments, and the risk of contrast-induced nephropathy, are critically analyzed. Evidence-based recommendations and research priorities are drawn from an analysis of current practices and existing knowledge gaps.

RESULTS

CKD influences stroke outcomes through systemic and local pathophysiological changes, necessitating tailored therapeutic approaches. Reperfusion therapies are effective in CKD patients but require careful monitoring of renal function to mitigate risks, such as contrast-induced nephropathy and thrombolytic complications. The bidirectional relationship between stroke and CKD highlights the need for integrated management strategies to address both conditions. Early detection and optimized management of CKD significantly reduce stroke-related morbidity and mortality.

CONCLUSION

Optimizing stroke care in CKD patients requires a comprehensive understanding of their pathophysiology and clinical management challenges. This article provides evidence-based recommendations, emphasizing individualized treatment decisions and coordinated care. It underscores the importance of integrating renal considerations into stroke treatment protocols and highlights the need for future research to refine therapeutic strategies, address knowledge gaps, and consider tailored interventions to improve outcomes and quality of life for this high-risk population.

Intravenous thrombolysis for patients with acute ischemic stroke while receiving a direct oral anticoagulant: A systematic review and meta-analysis

Recent guidelines for acute ischemic stroke (AIS) indicate administration of intravenous thrombolysis (IVT) in patients receiving direct oral anticoagulants (DOAC) is not firmly established and may be harmful unless certain potential parameters are met. This systematic review and meta-analysis explores safety outcomes and other clinical parameters from the growing number of publications describing patients taking a DOAC who experience an AIS that is treated acutely with IVT alone. Embase, International Pharmaceutical Abstracts, and PubMed were searched up to January 9, 2024 for studies including adult patients taking a DOAC who experienced an AIS treated with IVT and did not undergo endovascular therapy (EVT), regardless of the use of an anticoagulation reversal agent. Primary safety outcomes evaluated included symptomatic intracranial hemorrhage (sICH), any intracranial hemorrhage, and in-hospital mortality. A total of 873 patients from 78 studies, primarily case reports or case series of patients receiving dabigatran with or without idarucizumab reversal (n = 340), were included in the review. The rate of sICH during the index hospitalization was 3.3%. Seven high-quality studies with low risk of bias included outcomes for patients on DOAC and comparator groups of either patients not taking an oral anticoagulant (no OAC) or patients taking a vitamin K antagonist (VKA) with INR primarily <1.7 at the time of AIS. No significant difference was observed in the incidence of sICH among patients receiving DOAC vs. no OAC (odds ratio [OR] 0.8, 95% confidence interval [CI]: 0.48-1.33) or among patients receiving DOAC vs. VKA (OR 1.02, 95% CI 0.59-1.75). Similar findings of no difference were observed for other safety outcomes. Findings from this study suggest that utilization of IVT as sole recanalization therapy for AIS may be safe in patients taking a DOAC; however, further studies are needed to elucidate specific parameters that differentiate timepoints and variables to ensure safe, optimal treatment.

Advances in the Critical Care of Ischemic Brain Infarction

Acute care for ischemic stroke has dramatically evolved over the last years. Cerebral reperfusion is possible up to 24 h after symptoms onset. Advanced brain imaging allows identifying salvageable ischemic brain tissue, and the development of newer endovascular devices permits access to distal vessels. Monitoring for neurologic deterioration, diagnosis of stroke etiology, and secondary prevention treatments are important after initial treatment. This article reviews the recent advancements in the critical care of acute ischemic stroke.

Low-Cost Strategies for the Development of Neurocritical Care in Resource-Limited Settings

This review explores low-cost neurocritical care interventions for resource-limited settings, including economical devices, innovative care models, and disease-specific strategies. Devices like inexpensive ventilators, wearable technology, smartphone-based ultrasound, brain4care, transcranial Doppler, and smartphone pupillometry offer effective diagnostic and monitoring capabilities. Initiatives such as intermediate care units, minimally equipped stroke units, and tele-neurocritical care have demonstrated benefits by reducing hospital stays, preventing complications, and improving clinical and economic outcomes. The review emphasizes locally applicable tailored approaches for diagnosing and managing conditions such as traumatic brain injury, neuroinfections, status epilepticus, autoimmune neurological disorders, and acute stroke as viable and affordable solutions.

Safety and efficacy of intravenous thrombolysis: a systematic review and meta-analysis of 93,057 minor stroke patients

BACKGROUND

The definition of minor ischemic stroke (MIS) is a topic of debate, however, the most accepted definition is a stroke with National Institutes of Health Stroke Scale (NIHSS) ≤ 5. Intravenous thrombolysis (IVT) is a crucial treatment option for acute ischemic stroke (AIS) including: alteplase, recombinant human tissue-type plasminogen activator (r-tPA), and the recently approved tenecteplase. However, there is a debate regarding its safety and efficacy. Therefore, our objective was to determine the safety and efficacy of IVT in treating minor stroke patients (NIHSS ≤ 5).

METHODS

Using the search strategy assigned which was based on three keywords: "mild" or "minor", "stroke", and "intravenous thrombolysis", we searched for eligible articles on PubMed, Web of Science, Embase, and Scopus from inception till 10th January 2024. We conducted this meta-analysis using the random effect model to account for the heterogeneity among the studies. For the dichotomous variables, we calculated the odds ratio (OR) from the event and total of these variables. While for the continuous variables, we calculated the mean difference (MD) of these variables. Pooling of OR for the occurrence of events was also conducted.

RESULTS

A total of 21 articles with 93,057 patients with MIS were included. The mean age of the participants ranged from 62.3 to 79.6. Most of the included patients had comorbidities such as hypertension, diabetes, previous stroke, smoking, atrial fibrillation, and hyperlipidemia. Of these, 10,850 received IVT while 82,207 did not. The use of IVT was statistically significant associated with 90-day modified Rankin score (mRs) 0-1 when compared with control with OR of 1.67 (95%CI: 1.46, 1.91, p < 0.00001) and was statistically significantly associated with improvement of NIHSS on discharge with OR of 2.19 (95%CI: 1.56, 3.08, p < 0.00001). In terms of safety outcomes, IVT has proven a safe profile, as there was no significant difference in intracranial hemorrhage (ICH) and mortality rates between the IVT and control groups with OR of 1.75 (95CI: 0.95, 3.23, p = 0.07) and 0.93 (95%CI: 0.77, 1.11, p = 0.41), respectively.

CONCLUSION

Although some studies have not found any benefits of IVT in MIS patients, a substantial body of literature strongly endorses IVT as an effective and safe treatment for MIS. IVT has been shown to improve the mRs and NIHSS scores at the 90-day mark without an increased risk of ICH or mortality.

Chinese stroke association guidelines on reperfusion therapy for acute ischaemic stroke 2024

BACKGROUND

Stroke remains a major global health challenge, with China experiencing a significant burden due to its high incidence and severe outcomes. Reperfusion therapies, such as intravenous thrombolysis and endovascular thrombectomy, have shown substantial benefits in improving early outcomes for ischaemic stroke. Recent clinical trials have validated the safety and efficacy of a broader range of thrombolytic agents and expanded the eligible patient populations for both intravenous thrombolysis and mechanical thrombectomy. This guideline aims to provide the latest evidence-based insights in the field of reperfusion therapy.

METHODS

The Chinese Stroke Association (CSA) established a writing group to develop updated guidelines on reperfusion therapy for acute ischaemic stroke. A comprehensive search of MEDLINE (via PubMed) was conducted up to 30 September 2024. Experts in the field of stroke engaged in extensive discussions, both online and offline, to evaluate the latest evidence. Each recommendation was graded using the CSA's class of recommendation and level of evidence in the Guideline Development Manual of the CSA.

RESULTS

This guideline, reviewed and approved by the CSA Guidelines Writing Group, outlines the criteria for patient selection for thrombolysis and thrombectomy and summarises the latest evidence on various thrombolytic drug options to support decision-making in reperfusion therapy. Additionally, the guideline includes green channel flow charts for intravenous thrombolysis and mechanical thrombectomy, designed to assist clinicians in optimising their clinical decisions.

CONCLUSION

This guideline updates the latest advancements in the field of reperfusion therapy for acute ischaemic stroke. It is anticipated that future clinical research will further advance areas such as innovative thrombolytic agents, expanded indications for thrombolysis and mechanical thrombectomy.

Thrombolytic therapy for patients with acute ischemic stroke: systematic review and network meta-analysis of randomized trials

Objective

To systematically compare the benefits and risks of all thrombolytic agents (tenecteplase, reteplase, and alteplase) at different doses for thrombolytic therapy in patients with acute ischemic stroke (AIS).

Background

Alteplase is the cornerstone treatment for AIS, but alternative thrombolytic agents are needed. The efficacy and safety of tenecteplase and reteplase, compared to alteplase, remain unclear, as does the optimal dosing for these treatments.

Method

A systematic search was conducted in PubMed, Web of Science, SCOPUS, and the Cochrane Central Register of Controlled Trials (CENTRAL) for relevant English-language studies up to July 5, 2024. Randomized controlled trials (RCTs) comparing standard-dose alteplase with varying doses of tenecteplase or reteplase in AIS patients were included. Primary outcomes were functional outcome at 90 days, symptomatic intracranial hemorrhage, death within 90 days, and serious adverse events. Data on study characteristics, patient demographics, interventions, and outcomes were extracted, and bias risk assessed. A multivariate random-effects model was used for network meta-analysis to derive odds ratios (OR) and 95% confidence intervals (CI).

Result

Twelve RCTs were included (10 with tenecteplase, 2 with reteplase) involving 6,633 patients, all compared against 0.9 mg/kg alteplase. In comparison with alteplase, tenecteplase demonstrated OR of 1.08 for achieving an excellent functional outcome at 90 days (95% CI: 0.97 to 1.22, P = 0.17). Reteplase, on the other hand, showed a significantly higher OR of 1.55 for the same outcome (95% CI: 1.23 to 1.95, P = 0.0002). Reteplase at 18 mg + 18 mg (OR 1.6, 95% CI: 0.91-2.5) showed a higher probability of achieving an excellent functional outcome at 90 days compared to alteplase. When considering a good functional outcome at 90 days, tenecteplase had an OR of 1.03 (95% CI: 0.81 to 1.3, P = 0.82), while reteplase had an OR of 1.15 (95% CI: 0.61 to 2.19, P = 0.66). Tenecteplase at 0.25 mg/kg (OR 1.3, 95% CI: 0.79-2.5) had the highest probability of achieving a good functional outcome at 90 days. For safety outcomes, 0.25 mg/kg tenecteplase had lower incidences of symptomatic intracranial hemorrhage (OR 0.88, 95% CI: 0.35-1.8), death within 90 days (OR 0.91, 95% CI: 0.54-1.4), and serious adverse events (OR 1.0, 95% CI: 0.47-2.3) compared to alteplase, though differences were not statistically significant. Reteplase at 18 mg + 18 mg had higher incidences of death within 90 days (OR 1.2, 95% CI: 0.48-3) and serious adverse events (OR 1.4, 95% CI: 0.4-5.0) compared to alteplase, without significant differences. Subgroup analysis showed better efficacy with 0.25 mg/kg tenecteplase in Asians (OR 1.18, 95% CI 0.96-1.45, P = 0.12) than in Caucasians (OR 1.08, 95% CI 0.9-1.3, P = 0.39).

Conclusion

This study suggests that tenecteplase and reteplase are viable alternatives to alteplase for thrombolysis in AIS. Tenecteplase at 0.25 mg/kg and reteplase at 18 mg + 18 mg may offer better efficacy compared to standard-dose alteplase, although the risk of adverse events with reteplase should be considered. Tenecteplase at 0.25 mg/kg appears to provide the best benefit-risk profile based on current evidence. Further head-to-head trials of tenecteplase and reteplase are needed to determine the optimal thrombolytic agent and dosing.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, PROSPERO CRD42024566146.

Risk of angioedema and thrombolytic therapy among stroke patients: An analysis of data from the FDA Adverse Event Reporting System database

The angioedema risk may vary among stroke patients receiving different thrombolytic agents. This study aimed to investigate the angioedema risk associated with different thrombolytic agents and to identify associated risk factors. We conducted a large-scale retrospective pharmacovigilance study using the FDA Adverse Event Reporting System (FAERS) database. Stroke patients receiving thrombolytic therapy (i.e., alteplase or tenecteplase) were identified, and the associations with angioedema were explored using disproportionality analysis and time-to-onset analysis. Additionally, we used adapted Bradford Hill criteria to confirm these associations. Risk factors for angioedema were explored using stepwise logistic regression. A total of 17,776 stroke patients were included, with 2973 receiving alteplase and 278 receiving tenecteplase. Disproportionality analysis revealed that angioedema might be associated with alteplase (adjusted ROR [aROR] 5.13 [95 ​% CI, 4.55-5.79]) or tenecteplase (aROR 2.72 [95 ​% CI, 1.98-3.67]). The adapted Bradford Hill criteria suggested a probable causal relationship between alteplase and angioedema, whereas there was insufficient evidence of a probable causal relationship with tenecteplase. Multivariate analysis revealed that ACE-inhibitors use (aROR 9.73 [95 ​% CI, 7.29-12.98]), female sex (aROR 1.38 [95 ​% CI, 1.13-1.67]) and hypertension (aROR 2.11 [95 ​% CI, 1.52-2.92]) were significant risk factors for angioedema among alteplase-treated stroke patients. Our study suggested that alteplase is associated with a greater risk of angioedema among stroke patients, but there is insufficient evidence to support an association between tenecteplase and angioedema. Clinicians should be vigilant for this potentially life-threatening complication, particularly in patients with identified risk factors. It is also prudent to consider tenecteplase as an alternative, if available.

Intravenous tenecteplase compared with alteplase for minor ischaemic stroke: a secondary analysis of the AcT randomised clinical trial

BACKGROUND

In ischaemic stroke, minor deficits (National Institutes of Health Stroke Scale (NIHSS) ≤5) at presentation are common but often progress, leaving patients with significant disability. We compared the efficacy and safety of intravenous thrombolysis with tenecteplase versus alteplase in patients who had a minor stroke enrolled in the Alteplase Compared to Tenecteplase in Patients With Acute Ischemic Stroke (AcT) trial.

METHODS

The AcT trial included individuals with ischaemic stroke, aged >18 years, who were eligible for standard-of-care intravenous thrombolysis. Participants were randomly assigned 1:1 to intravenous tenecteplase (0.25 mg/kg) or alteplase (0.9 mg/kg). Patients with minor deficits pre-thrombolysis were included in this post-hoc exploratory analysis. The primary efficacy outcome was the proportion of patients with a modified Rankin Score (mRS) of 0-1 at 90-120 days. Safety outcomes included mortality and symptomatic intracranial haemorrhage (sICH).

RESULTS

Of the 378 patients enrolled in AcT with an NIHSS of ≤5, the median age was 71 years, 39.7% were women; 194 (51.3%) received tenecteplase and 184 (48.7%) alteplase. The primary outcome (mRS score 0-1) occurred in 100 participants (51.8%) in the tenecteplase group and 86 (47.5 %) in the alteplase group (adjusted risk ratio (RR) 1.14 (95% CI 0.92 to 1.40)). There were no significant differences in the rates of sICH (2.9% in tenecteplase vs 3.3% in alteplase group, unadjusted RR 0.79 (0.24 to 2.54)) and death within 90 days (5.5% in tenecteplase vs 11% in alteplase group, adjusted HR 0.99 (95% CI 0.96 to 1.02)).

CONCLUSION

In this post-hoc analysis of patients with minor stroke enrolled in the AcT trial, safety and efficacy outcomes with tenecteplase 0.25 mg/kg were not different from alteplase 0.9 mg/kg.

Transition from alteplase to tenecteplase for treatment of acute ischemic stroke in a rural stroke network of the Midwest: Planning, execution, safety, and outcomes

PURPOSE

This study aims to document the transition from alteplase to tenecteplase within a rural stroke network in the Midwest. It emphasizes the planning and execution of the transition, and evaluates safety and outcomes of tenecteplase compared to alteplase one year after the adoption of the new thrombolytic.

METHODS

This is a retrospective observational study of patients who were treated with thrombolytic therapy for suspected acute ischemic stroke at Southern Illinois Healthcare rural stroke network between July 2017 and July 2024. For each patient, demographics, past medical history, clinical presentation, National Institutes of Health Stroke Scale (NIHSS), and laboratory values were reviewed. Type of thrombolytic was noted. Door-to-needle time (DTN) and complications of thrombolytic therapy including symptomatic ICH (sICH) were reviewed. The primary outcome was the rate of sICH after administration of thrombolytic therapy. Secondary outcomes included target DTN ≤ 60 minutes and modified Rankin Scale (mRS) 0-2 at 30 days.

RESULTS

Out of 279 patients treated with thrombolytics, 215 (77 %) received alteplase, and 64 (23 %) received tenecteplase. The two groups were severity matched, and did not differ in terms of demographics or baseline comorbidities. Median DTN (IQR) was comparable between alteplase and tenecteplase, in minutes ((50 (40-69) vs. 53 (37-65)). In three distinct regression models for each of the predetermined outcomes, accounting for markers of stroke severity, the type of thrombolytic was not associated with development of sICH (OR 1.59, SE 1.445, p = 0.61), target DTN ≤ 60 min (OR 0.996, SE 0.304, p = 0.988), nor mRS 0-2 at 30 days (OR 1.086, SE 0.446, p = 0.842).

CONCLUSIONS

In our population, safety and outcome of thrombolytic therapy for acute ischemic stroke did not differ based on the type of thrombolytic used. Our study highlights the planning and execution of the transition from alteplase to tenecteplase, with challenges faced and lessons learned, and supports the use of tenecteplase in real-world rural practice.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of teleneurology on door-to-needle times for tenecteplase in acute ischemic stroke

INTRODUCTION

Intravenous thrombolysis remains the primary treatment for acute ischemic stroke (AIS); however, administration is time sensitive. Teleneurology services have increased in popularity in recent years due to their ability to aid in triaging patients with neurological conditions. Teleneurology services were implemented at this comprehensive stroke center, in August 2023 to aid in streamlining the administration of tenecteplase in AIS patients. Currently, there are no studies assessing whether the implementation of teleneurology services at a comprehensive stroke center influences tenecteplase door-to-needle time. The purpose of this study is to evaluate the difference in door-to-needle times when tenecteplase is administered with versus without a teleneurology consult.

METHODS

This was an institutional review board approved, retrospective cohort study conducted at a single comprehensive stroke center. Adult patients who presented to the emergency department between January 1st, 2022 and April 1st, 2023 were included if they received tenecteplase for the treatment of AIS. The primary outcome was door-to-needle time, defined as the moment the patient first enters the door of the emergency department to the moment the IV bolus of fibrinolytic is administered. Secondary outcomes included the proportion of patients with door-to-needle time within 45 min, neurological improvement at 24 h and discharge, and rate of hemorrhagic conversion.

RESULTS

A total of 93 patients were included with 43 patients in the pre-teleneurology group and 50 patients in the post-teleneurology group. Baseline characteristics were comparable between both treatment groups. The median door-to-needle time was significantly reduced in the post-teleneurology group (49 minutes [IQR, 40.0-70.0] preintervention vs. 34.5 minutes [IQR, 23.8-43.0] postintervention, p < 0.01). For secondary outcomes, the post-teleneurology group had more patients with a door-to-needle time within 45 minutes (44.2% vs. 80.0%, p < 0.01). There was no significant difference in early neurological improvement (58.1% vs. 54.0%), neurological improvement at discharge (60.5% vs. 62.0%), or hemorrhagic conversion (7.0% vs. 12.0%).

CONCLUSION

Among patients who received tenecteplase for the treatment of AIS, there was a significant reduction in door-to-needle time with the use of teleneurology services. There was no difference in neurological improvement or rate of hemorrhagic conversion.

Evolving of treatment options for cerebral infarction

In this editorial, we comment on a recent article which addressed the therapeutic effect of aspirin plus edaravone in patients with cerebral infarction (CI). Herein, we outline the progress in therapy of CI. Apart from thrombolysis, aspirin is the most effective treatment for CI. Edaravone, a free radical scavenger, reduces endothelial cell damage and delays neuronal cell death. Aspirin plus edaravone mitigates damage to brain tissue by different mechanisms, thereby expediting the reinstation of neurological function. However, the nephrotoxic effect of edaravone, along with gastrointestinal bleeding associated with aspirin, may restrict this combination therapy. Although clinical studies have demonstrated the efficacy of thrombolytic therapy and mechanical thrombectomy, patients receiving these treatments experience modest efficacy and many adverse events. Moreover, interest in exploring natural medicines for CI is increasing, and they appear to have a high potential to protect against CI. The evolution of therapeutic strategies is expected to improve clinical outcomes of patients with CI.

Thrombolysis in wake-up stroke based on MRI mismatch

OBJECTIVES

Wake-up stroke (WUPS) patients can be selected to intravenous thrombolysis (IVT) treatment based on the Magnetic Resonance Imaging (MRI) mismatch concept. However, recent studies suggest the introduction of modified MRI mismatch criteria, allowing IVT in WUPS patients with a partial mismatch.

MATERIAL AND METHODS

WUPS patients treated with IVT in the NOR-TEST trial and consecutively thereafter at Stavanger University Hospital were included in this study. Patient selection for treatment was performed based on the clinical presentation and the MRI DWI/FLAIR mismatch criteria. MRI examinations were reassessed according to the modified DWI-FLAIR mismatch criteria, allowing partial mismatch. Improvement in NIHSS and mRS at 3 months were used to analyze clinical outcome, and the rate of intracranial hemorrhage (ICH) to analyze safety.

RESULTS

78 WUPS patients were treated with IVT. Only 68 of these patients were independent pre-stroke and included in the clinical analysis. When reassessing the MRI examinations, 41 (60 %) were rated as DWI/ FLAIR mismatch, 14 (21 %) as partial mismatch and 13 (19 %) as match. The results show that the patient groups had a mRS score 0-1 at 3 months measured as primary outcome to respectively 27 (65.9 %), 11 (78.6 %) and 8 (61.5 %); (P = 0.629). The mismatch group showed the best clinical improvement (3-points NIHSS reduction, p = 0.005). No ICH was seen in any of the groups.

CONCLUSION

Our study extended the mismatch concept in clinical praxis to treat WUPS patients with partial mismatch, showing the best clinical outcome in the mismatch group.

Tenecteplase thrombolytic therapy for acute ischaemic stroke in China: a real-world, multicentre, retrospective, controlled study

BACKGROUND AND AIMS

Tenecteplase (TNK) offers logistical advantages in stroke thrombolytic therapy with its single bolus administration compared with alteplase. We aim to investigate the real-world evidence regarding its safety and effectiveness in China.

METHODS

We conducted a retrospective study on patients receiving alteplase or TNK for acute ischaemic stroke (AIS) within 4.5 hours of onset between 1 March 2019 and 1 October 2023, from 18 stroke centres in China. Using propensity score matching (PSM), TNK-treated patients were matched 1:1 with alteplase-treated patients. The primary outcome was the rate of symptomatic intracranial haemorrhage (sICH) within 72 hours post-thrombolysis. Secondary outcomes comprised the rate of parenchymal haemorrhage type 2, any intracranial haemorrhage, any systematic bleeding and mortality at 90 days, as well as 24-hour National Institutes of Health Stroke Scale (NIHSS), early neurological improvement at 24 hours, modified Rankin Scale (mRS) shift, percentage of mRS 0-1 and mRS 0-2 at 90 days.

RESULTS

We identified 1113 patients with AIS who received TNK and 2360 patients who received alteplase. Following PSM, 1113 TNK-treated patients with AIS were matched to 1113 patients treated with alteplase. No significant differences were observed in rates of sICH (1.8% vs 1.98%, p=0.864) or other safety outcomes. Moreover, TNK-treated patients demonstrated a lower rate of any intracranial haemorrhage (OR: 0.51, 95% CI: 0.31 to 0.86, p=0.012). A higher proportion of patients achieving early neurological improvement at 24 hours (OR: 1.76, 95% CI: 1.48 to 2.09, p=0.000), better 90-day mRS (OR: 0.67, 95% CI: 0.57 to 0.79, p=0.000) as well as higher percentages of 90-day mRS 0-1 (OR: 1.27, 95% CI: 1.05 to 1.54, p=0.012) and mRS 0-2 (OR: 1.41, 95% CI: 1.14 to 1.75, p=0.001) compared with alteplase.

CONCLUSIONS

Thrombolysis with TNK is not associated with an increased risk of sICH, and may result in better early neurological improvement and 90-day functional outcomes compared with alteplase in patients with AIS.

Tenecteplase thrombolysis for stroke up to 24 hours after onset with perfusion imaging selection: the umbrella phase IIa CHABLIS-T randomised clinical trial

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).

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

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.

Tenecteplase vs Alteplase for Patients With Acute Ischemic Stroke: The ORIGINAL Randomized Clinical Trial

Importance

Tenecteplase is a bioengineered variant of alteplase with greater fibrin specificity and a longer half-life, allowing single-bolus administration. Evidence on the treatment effect of tenecteplase 0.25 mg/kg in Chinese patients with acute ischemic stroke (AIS) is limited.

Objective

To establish the noninferiority of tenecteplase to alteplase in patients with AIS within 4.5 hours of symptom onset.

Design, Setting, and Participants

The ORIGINAL study was a multicenter, active-controlled, parallel-group, randomized, open-label, blinded end point, noninferiority trial conducted between July 14, 2021, and July 14, 2023. Participants were recruited from 55 neurology clinics and stroke centers in China and were eligible if they had AIS with a National Institutes of Health Stroke Scale score of 1 to 25 with measurable neurologic deficit and were symptomatic for at least 30 minutes without significant improvement.

Interventions

Patients were randomized (1:1) within 4.5 hours of symptom onset to receive intravenous tenecteplase (0.25 mg/kg) or intravenous alteplase (0.9 mg/kg).

Main Outcomes and Measures

The primary outcome was the proportion of patients with a modified Rankin Scale (mRS) score of 0 or 1 (no symptoms or no significant disability) at day 90, tested for noninferiority (risk ratio [RR] margin, 0.937). Safety end points included symptomatic intracerebral hemorrhage (per European Cooperative Acute Stroke Study III definition) and 90-day all-cause mortality.

Results

Among the 1489 patients randomized, 1465 patients were included in the full analysis set (732 in the tenecteplase group; 733 in the alteplase group) and 446 (30.4%) were female. The primary outcome occurred in 72.7% (532/732) of patients receiving tenecteplase and 70.3% (515/733) receiving alteplase (RR, 1.03 [95% CI, 0.97-1.09]; noninferiority threshold met). Symptomatic intracerebral hemorrhage occurred in 9 patients (1.2%) in each group (RR, 1.01 [95% CI, 0.37-2.70]). The 90-day mortality rate was 4.6% (34/732) in the tenecteplase group and 5.8% (43/736) in the alteplase group (RR, 0.80 [95% CI, 0.51-1.23]).

Conclusions and Relevance

In patients with AIS eligible for intravenous thrombolysis within 4.5 hours after stroke onset, tenecteplase was noninferior to alteplase with respect to excellent functional outcome (mRS score of 0 or 1) at 90 days and had a similar safety profile. Findings from this study support tenecteplase as a suitable alternative to alteplase in this setting.

Trial Registration

ClinicalTrials.gov Identifier: NCT04915729.

Anti-stroke biologics: from recombinant proteins to stem cells and organoids

The use of biologics in various diseases has dramatically increased in recent years. Stroke, a cerebrovascular disease, is the second most common cause of death, and the leading cause of disability with high morbidity worldwide. For biologics applied in the treatment of acute ischaemic stroke, alteplase is the only thrombolytic agent. Meanwhile, current clinical trials show that two recombinant proteins, tenecteplase and non-immunogenic staphylokinase, are most promising as new thrombolytic agents for acute ischaemic stroke therapy. In addition, stem cell-based therapy, which uses stem cells or organoids for stroke treatment, has shown promising results in preclinical and early clinical studies. These strategies for acute ischaemic stroke mainly rely on the unique properties of undifferentiated cells to facilitate tissue repair and regeneration. However, there is a still considerable journey ahead before these approaches become routine clinical use. This includes optimising cell delivery methods, determining the ideal cell type and dosage, and addressing long-term safety concerns. This review introduces the current or promising recombinant proteins for thrombolysis therapy in ischaemic stroke and highlights the promise and challenges of stem cells and cerebral organoids in stroke therapy.

Mortality Outcomes with Tenecteplase Versus Alteplase in the Treatment of Massive Pulmonary Embolism

BACKGROUND

Pulmonary embolism (PE) leads to many emergency department visits annually. Thrombolytic agents, such as alteplase, are currently recommended for massive PE, but genetically modified tenecteplase (TNK) presents advantages. Limited comparative studies exist between TNK and alteplase in PE treatment.

OBJECTIVE

The aim of this study was to assess the safety and mortality of TNK compared with alteplase in patients with PE using real-world evidence obtained from a large multicenter registry. Primary outcomes included mortality, intracranial hemorrhage, and blood transfusions.

METHODS

This retrospective cohort study used the TriNetX Global Health Research Network. Patients aged 18 years or older with a PE diagnosis (International Classification of Diseases, 10th Revision, Clinical Modification code I26) were included. The following two cohorts were defined: TNK-treated (29 organizations, 266 cases) and alteplase-treated (22,864 cases). Propensity matching controlled for demographic characteristics, anticoagulant use, pre-existing conditions, and vital sign abnormalities associated with PE severity. Patients received TNK or alteplase within 7 days of diagnosis and outcomes were measured at 30 days post thrombolysis.

RESULTS

Two hundred eighty-three patients in each cohort were comparable in demographic characteristics and pre-existing conditions. Mortality rates at 30 days post thrombolysis were similar between TNK and alteplase cohorts (19.4% vs 19.8%; risk ratio 0.982; 95% CI 0.704-1.371). Rates of intracerebral hemorrhages and transfusion were too infrequent to analyze.

CONCLUSIONS

This study found TNK to exhibit a similar mortality rate to alteplase in the treatment of PE with hemodynamic instability. The results necessitate prospective evaluation. Given the cost-effectiveness and ease of administration of TNK, these findings contribute to the ongoing discussion about its adoption as a primary thrombolytic agent for stroke and PE.

Optimizing Acute Ischemic Stroke Outcomes: The Role of Tenecteplase Before Mechanical Thrombectomy

PURPOSE

Acute ischemic stroke (AIS) is a life-threatening condition demanding prompt reperfusion to salvage brain tissue. Thrombolytic drugs, like tenecteplase (TNK), offer clot dissolution, but time constraints and contraindications limit their use. Mechanical thrombectomy (MT) revolutionized AIS treatment, especially for large vessel occlusions (LVO). Recent evidence suggests that administering TNK before MT improves recanalization and outcomes, challenging the dominance of alteplase.

METHODS

Relevant articles focusing on TNK before MT were retrieved from PubMed, Scopus, and Web of Science, looking for randomized controlled trials (RCT), clinical trials, and meta-analyses in humans until 2024.

FINDINGS

TNK, a genetically engineered thrombolytic, exhibits superior fibrin specificity and a longer half-life than alteplase. Clinical trials comparing TNK and alteplase before MT showcase enhanced recanalization, functional outcomes, and safety with TNK. Advanced neuroimaging aids patient selection, though its cost-effectiveness warrants consideration. Dosing studies favor a 0.25 mg/kg dose for efficacy and reduced complications. Clinical guidelines from various associations acknowledge TNK's potential as an alteplase alternative for AIS treatment, particularly for LVOs eligible for thrombectomy.

IMPLICATIONS

In conclusion, TNK emerges as a promising option for bridging therapy in AIS, displaying efficacy and safety benefits, especially when administered before MT. Its fibrin specificity, longer half-life, and potential for improved outcomes position TNK as a viable alternative to alteplase, potentially transforming the landscape of AIS treatment strategies. While limitations like small sample sizes and variations in protocols exist, future research should focus on large-scale RCT, subgroup analyses, and cost-effectiveness evaluations to further elucidate TNK's role in optimizing AIS management.

The association between serum S100β levels and prognosis in acute stroke patients after intravenous thrombolysis: a multicenter prospective cohort study

BACKGROUND

S100β is a biomarker of astroglial damage, the level of which is significantly increased following brain injury. However, the characteristics of S100β and its association with prognosis in patients with acute ischemic stroke following intravenous thrombolysis (IVT) remain unclear.

METHODS

Patients in this multicenter prospective cohort study were prospectively and consecutively recruited from 16 centers. Serum S100β levels were measured 24 h after IVT. National Institutes of Health Stroke Scale (NIHSS) and hemorrhagic transformation (HT) were measured simultaneously. NIHSS at 7 days after stroke, final infarct volume, and modified Rankin Scale (mRS) scores at 90 days were also collected. An mRS score ≥ 2 at 90 days was defined as an unfavorable outcome.

RESULTS

A total of 1072 patients were included in the analysis. The highest S100β levels (> 0.20 ng/mL) correlated independently with HT and higher NIHSS at 24 h, higher NIHSS at 7 days, larger final infarct volume, and unfavorable outcome at 3 months. The patients were divided into two groups based on dominant and non-dominant stroke hemispheres. The highest S100β level was similarly associated with the infarct volume in patients with stroke in either hemisphere (dominant: β 36.853, 95% confidence interval (CI) 22.659-51.048, P < 0.001; non-dominant: β 23.645, 95% CI 10.774-36.516, P = 0.007). However, serum S100β levels at 24 h were more strongly associated with NIHSS scores at 24 h and 3-month unfavorable outcome in patients with dominant hemisphere stroke (NIHSS: β 3.470, 95% CI 2.392-4.548, P < 0.001; 3-month outcome: odds ratio (OR) 5.436, 95% CI 2.936-10.064, P < 0.001) than in those with non-dominant hemisphere stroke (NIHSS: β 0.326, 95% CI  - 0.735-1.387, P = 0.547; 3-month outcome: OR 0.882, 95% CI 0.538-1.445, P = 0.619). The association of S100β levels and HT was not significant in either stroke lateralization group.

CONCLUSIONS

Serum S100β levels 24 h after IVT were independently associated with HT, infarct volume, and prognosis in patients with IVT, which suggests the application value of serum S100β in judging the degree of disease and predicting prognosis.

The Changing Landscape of Intravenous Thrombolysis for Acute Ischaemic Stroke

Intravenous thrombolysis remains the most accessible and effective reperfusion therapy available to patients with acute ischaemic stroke. Treatment with intravenous thrombolysis improves the odds of favourable functional outcome with the unacceptably low risk of haemorrhagic complications. Even in the current era of endovascular thrombectomy, intravenous thrombolysis remains the backbone of acute stroke treatment due to its accessibility and relative ease of administration. Since intravenous alteplase was first approved for acute ischaemic stroke in the mid 1990s, there have been significant advances in expanding the indication and time window for treatment, in addition to transitioning towards tenecteplase use for stroke thrombolysis. In this review, we will provide a narrative on the use of thrombolysis in acute ischaemic stroke including an up-to-date discussion on recent advances in thrombolytic therapy.

Novel metabolic biomarkers for the diagnosis of acute ischemic stroke

Aim: To identify novel metabolic biomarkers for patients with acute ischemic stroke (AIS).Methods: The metabolites in the sera of 63 patients with AIS aged 45∼77 years and 60 healthy individuals were analyzed by liquid chromatography (LC)-mass spectrometry (MS)/MS. The efficiency of significantly altered metabolites as biomarkers of AIS was evaluated by ROC curve analysis.Results: Different metabolic profiles were revealed in AIS patients' sera compared with healthy persons. Twelve significantly altered metabolites had an area under the curve (AUC) value >0.80, demonstrating their potential as a biomarker of AIS. Among them, six metabolites are firstly reported to distinguish between AIS patients and healthy individuals.Conclusion: These 12 metabolites can be further researched as potential diagnostic biomarkers of AIS.

Ethnic Differences in the Safety and Efficacy of Tenecteplase Versus Alteplase for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Tenecteplase is a thrombolytic agent with pharmacological advantages over alteplase and has been shown to be noninferior to alteplase for acute ischemic stroke in randomized trials. However, evidence pertaining to the safety and efficacy of tenecteplase in patients from different ethnic groups is lacking. The aim of this systematic review and metaanalysis was to investigate ethnicity-specific differences in the safety and efficacy of tenecteplase versus alteplase in patients with acute ischemic stroke.

METHODS

Following an International Prospective Register of Systematic Reviews (PROSPERO)- registered protocol (CRD42023475038), three authors conducted a systematic review of the PubMed/MEDLINE, Embase, Cochrane Library, and CINAHL databases for articles comparing the use of tenecteplase with any thrombolytic agent in patients with acute ischemic stroke up to November 20, 2023. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Two independent authors extracted data onto a standardized data collection sheet. A pairwise meta-analysis was conducted in risk ratios (RR).

RESULTS

From 34 studies (59,601 participants), the rate of complete recanalization was significantly higher (P<0.01) in Asian (RR: 1.91, 95% confidence interval [CI]: 1.30 to 2.80) versus Caucasian patients (RR: 0.99, 95% CI: 0.87 to 1.14). However, Asian patients (RR: 1.18, 95% CI: 0.87 to 1.62) had significantly higher (P=0.01) rates of mortality compared with Caucasian patients (RR: 1.10, 95% CI: 1.00 to 1.22). Caucasian patients were also more likely to attain a modified Rankin Scale (mRS) score of 0 to 2 at follow-up (RR: 1.14, 95% CI, 1.10 to 1.19) compared with Asian (RR: 1.00, 95% CI, 0.95 to 1.05) patients. There was no significant difference in the rate of symptomatic intracranial hemorrhage (P=0.20) and any intracranial hemorrhage (P=0.83) between Asian and Caucasian patients.

CONCLUSION

Tenecteplase was associated with significantly higher rates of complete recanalization in Asian patients compared with Caucasian patients. However, tenecteplase was associated with higher rates of mortality and lower rates of mRS 0 to 2 in Asian patients compared with Caucasian patients. It may be beneficial to study the variations in response to tenecteplase among patients of different ethnic groups in large prospective cohort studies.

Influence of Socioeconomic Status on Patients' Choice of Thrombolytic Agent and its Outcome in Acute Ischemic Stroke

BACKGROUND AND OBJECTIVE

Alteplase, a recombinant tissue-type plasminogen activator (rtPA) is the only FDA-approved thrombolytic drug in acute ischemic stroke (AIS). Tenecteplase is a modified rtPA, which is cheaper. We aimed to study influence of socioeconomic status (SES) in patients' preference of thrombolytic agent and its outcome.

METHODS

This prospective observational study conducted in PGIMER, a tertiary care center in India, recruited AIS patients thrombolyzed between July 2017 and September 2018. We studied variables including SES, thrombolytic agent chosen, and outcomes like National Institutes of Health Stroke Scale (NIHSS) scores at 24-h and at discharge; and modified Rankin Scale (mRS) after 3 months.

RESULTS

Thirty-nine patients received tenecteplase and 39 patients received alteplase. Seven patients belonged to upper class, all of whom (100%) chose alteplase. Thirty patients belonged to upper middle class, of whom 25 (83.3%) and five (16.7%) patients chose alteplase and tenecteplase, respectively. Twenty-five patients belonged to lower middle class in which seven (28%) and 15 (72%) chose alteplase and Tenecteplase, respectively. Twenty patients were in upper lower class, of whom 4 (20%) and 16 (80%) chose alteplase and Tenecteplase, respectively. The difference in distribution of SES in tenecteplase and alteplase groups was significant (P = 0.000). Median 3 month-mRS scores were 3 and 3.5 in alteplase and tenecteplase groups, respectively (P = 0.608). There were no significant differences in NIHSS score improvement at 24 h postthrombolysis (P = 0.537) or at discharge (P = 0.429) among different SES categories. No correlation between SES and 3 month-mRS score was found (Spearman's ρ = 0.101, P = 0.398).

CONCLUSIONS

Majority of patients in upper and lower SES chose alteplase and Tenecteplase, respectively. However, there were no significant differences in outcomes among various SES categories.

Tenecteplase versus alteplase for acute ischaemic stroke: a meta-analysis of phase III randomised trials

BACKGROUND

Tenecteplase (TNK) was found non-inferior to alteplase in recent clinical trials. We aimed to elucidate the efficacy and safety of TNK versus alteplase for acute ischaemic stroke (AIS).

METHODS

Systematic literature search and a meta-analysis of phase III clinical trials in ischaemic stroke patients with TNK use were conducted. The primary outcome was excellent functional outcome which was defined as modified Rankin Scale score of 0-1 at 90 days and safety outcomes included symptomatic intracerebral haemorrhage and death at 90 days. We used random-effects model to estimate the pooled risk difference and 95% CI in R package 'Meta'. The included trials were adapted to the non-inferiority analysis with a margin of -4%.

RESULTS

Three trials enrolling 4094 patients were identified by systematic search. All trials included AIS patients within 4.5 hours time window. Meta-analysis indicated that 1089 (53.0%) of 2056 patients in the TNK arm and 1016 (50.5%) of 2012 in the alteplase arm had excellent functional outcome at 90 days (0.03 (95% CI -0.00 to 0.06); I2=0%), meeting the prespecified non-inferiority threshold. And TNK thrombolysis was not correlated with increased risk of symptomatic intracerebral haemorrhage (0.00 (95% CI -0.01 to 0.01); I2=0%) or death (0.01 (95% CI -0.01 to 0.02); I2=0%) at 90 days. The sensitivity analysis with the 0.25 mg/kg trials exclusively showed similar results to the main analysis.

CONCLUSIONS

TNK was non-inferior to alteplase for achieving excellent functional outcome at 90 days without increasing the safety concern in treating patients with AIS. These findings suggest that TNK can be an alternative to alteplase.

PROSPERO REGISTRATION NUMBER

CRD42022354342.

Association between lower neutrophil-to-albumin ratio and early neurological improvement in patients with acute cerebral infarction after intravenous thrombolysis

Elevated neutrophil counts and decreased albumin levels have been linked to an unfavorable prognosis in acute cerebral infarction (ACI). The objective of this study is to explore the correlation between the neutrophil-to-albumin ratio (NAR) and the early neurological improvement (ENI) of ACI patients following intravenous thrombolysis (IVT). ACI patients who underwent IVT between June 2019 and June 2023 were enrolled. The severity of ACI was assessed using the National Institutes of Health Stroke Scale (NIHSS). ENI was defined as a reduction in NIHSS score of ≥ 4 or complete resolution of neurological deficit within 24 h after IVT. Propensity score match (PSM) and logistic regression analysis were used to explore the correlation between these variables and the early neurological outcomes of patients. A total of 545 ACI patients were included, with 253 (46.4 %) experiencing ENI. Among the 193 pairs of patients after PSM, there was a significant association between NAR and ENI (OR, 0.89; 95 % CI, 0.85-0.94; p < 0.001). The restricted cubic splines analysis revealed a significant nonlinear correlation between NAR and ENI (p for nonlinear = 0.0004; p for overall = 0.0002). The optimal cutoff for predicting ENI was determined as a NAR level of 10.20, with sensitivity and specificity values of 73.6 % and 60.9 %. NAR levels are associated with ENI in ACI patients after IVT. The decreased levels of NAR indicate an increased likelihood of post-thrombolysis ENI in ACI patients.

Sex Differences in the Dual Antiplatelet Therapy Versus Alteplase for Patients with Minor Nondisabling Acute Ischemic Stroke: A Secondary Analysis of the ARAMIS Study

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.

Comparative efficacy and safety among different doses of tenecteplase for acute ischemic stroke: A systematic review and network meta-analysis

OBJECTIVES

Tenecteplase (TNK) is a promising alternative to alteplase (ALT) as the thrombolytic agent for acute ischemic stroke (AIS). However, its clinical outcomes in certain populations remain unclear. This study aimed to compare the efficacy and safety among different doses of TNK in AIS patients.

METHODS

We searched PubMed, Scopus, Cochrane Central Register of Controlled Trials, and Embase for studies comparing at least one dose of TNK to another dose of TNK or ALT 0.90 mg/kg. We conducted Bayesian network meta-analyses to estimate the relative risks (RRs) and 95% credible intervals (CrIs) for all outcomes using ALT 0.90 mg/kg as the reference. The treatments were ranked according to their surface under the cumulative ranking (SUCRA) values.

RESULTS

We included 11 trials from 16 publications comprising 5423 participants. There were no significant differences between any doses of TNK and ALT for reperfusion, 3-month modified Rankin Score (mRS) 0-1 (rank 1st: TNK 0.25 mg/kg; SUCRA = 0.68), mRS 0-2 (rank 1st: TNK 0.25 mg/kg; SUCRA = 0.86), mortality (rank 1st: TNK 0.25 mg/kg; SUCRA = 0.82), intracranial hemorrhage (ICH) (rank 1st: TNK 0.25 mg/kg; SUCRA = 0.88), symptomatic ICH (sICH) (rank 1st: TNK 0.10 mg/kg; SUCRA = 0.70), and parenchymal hematoma (rank 1st: TNK 0.10 mg/kg; SUCRA = 0.68). TNK 0.40 mg/kg had a significantly higher sICH rate compared to TNK 0.25 mg/kg (RR = 2.39, 95% CrI = 1.00-7.92). Among elderly patients, TNK 0.25 mg/kg had a significantly lower rate of sICH than ALT 0.9 mg/kg (RR = 3.0 × 10-13, 95% CrI = 3.4 × 10-40-0.07).

CONCLUSIONS

TNK has efficacy and safety outcomes comparable to those of ALT. TNK 0.25 mg/kg may be the optimal dose of TNK for patients with AIS.

Door to needle time trends after transition to tenecteplase: A Multicenter Texas stroke registry

BACKGROUND

Tenecteplase (TNK) is considered a promising option for the treatment of acute ischemic stroke (AIS) with the potential to decrease door-to-needle times (DTN). This study investigates DTN metrics and trends after transition to tenecteplase.

METHODS

The Lone Star Stroke (LSS) Research Consortium TNK registry incorporated data from three Texas hospitals that transitioned to TNK. Subject data mapped to Get-With-the-Guidelines stroke variables from October 1, 2019 to March 31, 2023 were limited to patients who received either alteplase (ALT) or TNK within the 90 min DTN times. The dataset was stratified into ALT and TNK cohorts with univariate tables for each measured variable and further analyzed using descriptive statistics. Logistic regression models were constructed for both ALT and TNK to investigate trends in DTN times.

RESULTS

In the overall cohort, the TNK cohort (n = 151) and ALT cohort (n = 161) exhibited comparable population demographics, differing only in a higher prevalence of White individuals in the TNK cohort. Both cohorts demonstrated similar clinical parameters, including mean NIHSS, blood glucose levels, and systolic blood pressure at admission. In the univariate analysis, no difference was observed in median DTN time within the 90 min time window compared to the ALT cohort [40 min (30-53) vs 45 min (35-55); P = .057]. In multivariable models, DTN times by thrombolytic did not significantly differ when adjusting for NIHSS, age (P = .133), or race and ethnicity (P = .092). Regression models for the overall cohort indicate no significant DTN temporal trends for TNK (P = .84) after transition; nonetheless, when stratified by hospital, a single subgroup demonstrated a significant DTN upward trend (P = 0.002).

CONCLUSION

In the overall cohort, TNK and ALT exhibited comparable temporal trends and at least stable DTN times. This indicates that the shift to TNK did not have an adverse impact on the DTN stroke metrics. This seamless transition is likely attributed to the similarity of inclusion and exclusion criteria, as well as the administration processes for both medications. When stratified by hospital, the three subgroups demonstrated variable DTN time trends which highlight the potential for either fatigue or unpreparedness when switching to TNK. Because our study included a multi-ethnic cohort from multiple large Texas cities, the stable DTN times after transition to TNK is likely applicable to other healthcare systems.

Number needed to treat with intravenous tenecteplase to reduce the need for mechanical thrombectomy in large vessel occlusion acute ischemic stroke patients: A retrospective look at real-world experience data

OBJECTIVE

We sought to describe short term outcomes in patients with large vessel occlusion acute ischemic stroke (LVOAIS) who were treated with intravenous tenecteplase (TNK) as compared to alteplase (tPA), focusing on reduction in the need for mechanical thrombectomy (MT).

BACKGROUND

In LVOAIS, TNK has shown improved reperfusion and outcomes with a similar safety profile to tPA. Ultra-early reperfusion has been described with TNK which would prevent the need for MT. We analyze the magnitude of this effect in a "real-world" setting.

DESIGN/METHODS

In this retrospective study, demographic, clinical, and imaging information from patients with LVOAIS treated with intravenous thrombolysis was collected. Data was compared between the group treated with TNK and tPA.

RESULTS

One hundred eighty-six patients met the criteria for the study. Of these,144patients received tPA and 42 received TNK. Nine had clinical improvement prior to groin puncture and did not require angiography. When combining the number of patients who had recanalization on angiography before MT and those who had clinical improvement prior to angiography, there were a total of 23 patients. This was noted in 9.7 % of patients who received tPA and 21.4 % of those who received TNK (p = 0.043). For patients treated with TNK we observed a rapid clinical improvement, improved NIHSS, improved functional outcomes and decreased length of stay compared to patients treated with tPA. For patients with spontaneous recanalization either angiographically or with clinical improvement from intravenous thrombolysis, MT may not be required.

CONCLUSIONS

Intravenous TNK in patients with LVOAIS decreases the need for MT, and is associated with improved outcomes and reduced length of stay.

Functional Outcome and Hemorrhage Rates After Bridging Therapy With Tenecteplase or Alteplase in Patients With Large Ischemic Core

BACKGROUND AND OBJECTIVES

IV tenecteplase is an alternative to alteplase before mechanical thrombectomy (MT) in patients with large-vessel occlusion (LVO) ischemic stroke. Little data are available on its use in patients with large ischemic core. We aimed to compare the efficacy and safety of both thrombolytics in this population.

METHODS

We conducted a retrospective analysis of patients with anterior circulation LVO strokes and diffusion-weighed imaging Alberta Stroke Program Early CT Score (DWI-ASPECTS) ≤5 treated with tenecteplase or alteplase before MT from the TETRIS (tenecteplase) and ETIS (alteplase) French multicenter registries. Primary outcome was reduced disability at 3 months (ordinal analysis of the modified Rankin scale [mRS]). Safety outcomes were 3-month mortality, parenchymal hematoma (PH), and symptomatic intracranial hemorrhage (sICH). We used propensity score overlap weighting to reduce baseline differences between treatment groups.

RESULTS

We analyzed 647 patients (tenecteplase: n = 194; alteplase: n = 453; inclusion period 2015-2022). Median (interquartile range) age was 71 (57-81) years, with NIH Stroke Scale score 19 (16-22), DWI-ASPECTS 4 (3-5), and last seen well-to-IV thrombolysis and puncture times 165 minutes (130-226) and 260 minutes (203-349), respectively. After MT, the successful reperfusion rate was 83.1%. After propensity score overlap weighting, all baseline variables were well balanced between both treatment groups. Compared with patients treated with alteplase, patients treated with tenecteplase had better 3-month mRS (common odds ratio [OR] for reduced disability: 1.37, 1.01-1.87, p = 0.046) and lower 3-month mortality (OR 0.52, 0.33-0.81, p < 0.01). There were no significant differences between thrombolytics for PH (OR 0.84, 0.55-1.30, p = 0.44) and sICH incidence (OR 0.70, 0.42-1.18, p = 0.18).

DISCUSSION

Our data are encouraging regarding the efficacy and reassuring regarding the safety of tenecteplase compared with that of alteplase in bridging therapy for patients with LVO strokes and a large ischemic core in routine clinical care. These results support its consideration as an alternative to alteplase in bridging therapy for patients with large ischemic cores.

TRIALS REGISTRATION INFORMATION

NCT03776877 (ETIS registry) and NCT05534360 (TETRIS registry).

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that patients with anterior circulation LVO stroke and DWI-ASPECTS ≤5 treated with tenecteplase vs alteplase before MT experienced better functional outcomes and lower mortality at 3 months.

Fibrinolytic Agents in Thromboembolic Diseases: Historical Perspectives and Approved Indications

Fibrinolytic agents catalyze the conversion of the inactive proenzyme plasminogen into the active protease plasmin, degrading fibrin within the thrombus and recanalizing occluded vessels. The history of these medications dates to the discovery of the first fibrinolytic compound, streptokinase, from bacterial cultures in 1933. Over time, researchers identified two other plasminogen activators in human samples, namely urokinase and tissue plasminogen activator (tPA). Subsequently, tPA was cloned using recombinant DNA methods to produce alteplase. Several additional derivatives of tPA, such as tenecteplase and reteplase, were developed to extend the plasma half-life of tPA. Over the past decades, fibrinolytic medications have been widely used to manage patients with venous and arterial thromboembolic events. Currently, alteplase is approved by the U.S. Food and Drug Administration (FDA) for use in patients with pulmonary embolism with hemodynamic compromise, ST-segment elevation myocardial infarction (STEMI), acute ischemic stroke, and central venous access device occlusion. Reteplase and tenecteplase have also received FDA approval for treating patients with STEMI. This review provides an overview of the historical background related to fibrinolytic agents and briefly summarizes their approved indications across various thromboembolic diseases.