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

Tenecteplase versus alteplase for intravenous thrombolysis of acute ischemic stroke patients with large-vessel occlusion: a systematic review and meta-analysis

Background

Tenecteplase (TNK) was found non-inferior to alteplase (ALT) for acute ischemic stroke (AIS). We sought to further elucidate the efficacy and safety of intravenous TNK versus ALT for AIS patients with large-vessel occlusion (LVO).

Methods

We systematically searched PubMed, Embase, Web of Science, and https://clinicaltrials.gov/ till 20 January 2024 for randomized controlled clinical trials (RCTs) comparing TNK with ALT in AIS patients with LVO. The quality of the included studies was estimated using the Cochrane Risk of Bias Tool. Pooled analysis and publication bias were conducted using RevMan 5.3 and Stata 15. Risk ratios (RRs) with 95% confidence intervals (95% CIs) were reported for each outcome measure. The primary outcome was excellent neurological recovery, which was defined as a modified Rankin Scale (mRS) score of 0-1 at 90 days, and safety outcomes included any parenchymal hematoma, sympomatic intracerebral hemorrhage, and 3-month death.

Results

Five RCTs enrolling 1,028 patients were included. There were no significant differences in terms of 90-day excellent neurological recovery (RR 1.18; 95% CI 1.00-1.40; p = 0.05), good neurological recovery (RR 1.18; 95% CI 0.90-1.54; p = 0.23), early neurological improvement (RR 1.00; 95% CI 0.57-1.77; p = 1.00), or successful reperfusion (RR 1.15; 95% CI 0.93-1.44; p = 0.20). In addition, no significant differences were observed in safety outcomes, including any parenchymal hematoma (RR 1.01; 95% CI 0.70-1.45; p = 0.98), symptomatic intracerebral hemorrhage (RR 1.14; 95% CI 0.62-2.10; p = 0.68), or 3-month mortality (RR 1.22; 95% CI 0.52-2.84; p = 0.65).

Conclusion

TNK is an alternative to ALT for thrombolysis in AIS patients with confirmed LVO, offering lower cost and easier administration without increasing safety concerns.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024540215.

Tenecteplase Thrombolysis for Stroke up to 24 Hours After Onset With Perfusion Imaging Selection: The CHABLIS-T II Randomized Clinical Trial

BACKGROUND

Whether it is effective and safe to extend the time window of intravenous thrombolysis up to 24 hours after the last known well is unknown. We aimed to determine the efficacy and safety of tenecteplase in Chinese patients with acute ischemic stroke due to large/medium vessel occlusion within an extended time window.

METHODS

Patients with ischemic stroke presenting 4.5 to 24 hours from the last known well, with a favorable penumbral profile and an associated large/medium vessel occlusion, were randomized 1:1 to either 0.25 mg/kg tenecteplase or the best medical treatment. A favorable penumbral profile was defined as a hypoperfusion lesion volume to infarct core volume ratio >1.2, with an absolute volume difference >10 mL, and an ischemic core volume <70 mL. The primary outcome was the achievement of major reperfusion without symptomatic intracranial hemorrhage within 24 to 48 hours post-randomization. Major reperfusion was defined as the restoration of blood flow of >50% of the involved ischemic territory. Secondary outcomes included recanalization, infarct growth, major neurological improvements, change in the National Institutes of Health Stroke Scale score, hemorrhagic transformation within 24 to 48 hours, systemic bleeding at discharge, and modified Rankin Scale (score 0-1, score 0-2, score 5-6, and modified Rankin Scale distribution) at 90 days. The comparison of the primary outcome between groups was conducted using modified Poisson regression with a log-link function and robust error variance, adjusted for time from the last known well to randomization, the site of vessel occlusion, and planned endovascular treatment.

RESULTS

Among 224 enrolled patients, 111 were assigned to receive tenecteplase and 113 to receive the best medical treatment (including 23% [n=26] of participants who received intravenous tissue-type plasminogen activator). The mean (SD) age of the tenecteplase group and the best medical treatment group was 64.2 (10.4) and 63.6 (11.0) years old, with 72.1% (n=80) and 70.8% (n=80) male enrolled, respectively. A proportion of 54.9% (n=123) of patients were transferred to the catheter room for preplanned endovascular treatment. The primary outcome occurred in 33.3% (n=37) of the tenecteplase group versus 10.8% (n=12) in the best medical treatment group (adjusted relative risk, 3.0 [95% CI, 1.6-5.7]; P=0.001). Tenecteplase significantly increased the recanalization rate compared with the best medical treatment (35.8% [n=39] versus 14.3% [n=16], adjusted relative risk, 2.5 [95% CI, 1.4-4.4]; P=0.002). There were no significant differences in clinical efficacy outcomes or rates of hemorrhagic transformation between the groups.

CONCLUSIONS

Administered at a dose of 0.25 mg/kg intravenously, tenecteplase increased reperfusion without symptomatic intracranial hemorrhage in patients with ischemic stroke selected by imaging in late-time window treatment but did not change clinical outcomes at 90 days.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04516993.

CHinese Acute Tissue-Based Imaging Selection for Lysis In Stroke Tenecteplase II (CHABLIS-T II): rationale and design

BACKGROUND AND PURPOSE

Tenecteplase (TNK) has demonstrated non-inferiority to alteplase in patients who had an acute ischaemic stroke presenting within 4.5 hours from symptom onset. The trial is aimed to explore the efficacy and safety of TNK in Chinese patients who had an acute ischaemic stroke with large/medium vessel occlusion in an extended time window.

METHODS AND DESIGN

Chinese Acute Tissue-Based Imaging Selection for Lysis In Stroke Tenecteplase II (CHABLIS-T II) is a multicentre, prospective, block-randomised, open-label, blinded-endpoint, phase IIb study. Eligible patients are 1:1 randomised into two groups: 0.25 mg/kg TNK versus best medical management (excluding TNK). The safety and efficacy of 0.25 mg/kg TNK are assessed through reperfusion status and presence of symptomatic intracranial haemorrhage (sICH).

STUDY OUTCOMES

The primary outcome is major reperfusion without sICH at 24-48 hours after randomisation. Major reperfusion is defined as restoration of blood flow to greater than 50% of the involved ischaemic territory assessed by catheter angiography or repeated perfusion imaging. Secondary outcomes include post-thrombolytic recanalisation, neurological improvements, change in the National Institutes of Health Stroke Scale score, haemorrhagic transformation at 24-48 hours, systematic bleeding at discharge, modified Rankin Scale (mRS) 0-1, mRS 0-2, mRS 5-6, mRS distribution and Barthel index at 90 days.

DISCUSSION

CHABLIS-T II will provide important evidence of intravenous thrombolysis with TNK for patients who had an acute stroke in an extended time window.

Comprehensive Review of Tenecteplase for Thrombolysis in Acute Ischemic Stroke

Although intravenous thrombolysis with alteplase remains the primary treatment for acute ischemic stroke, tenecteplase has shown potential advantages over alteplase. Animal studies have demonstrated the favorable pharmacokinetics and pharmacodynamics of tenecteplase. Moreover, it is easier to administer. Clinical trials have demonstrated that tenecteplase is not inferior to alteplase and may even be superior in cases of acute ischemic stroke with large vessel occlusion. Current evidence supports the time and cost benefits of tenecteplase, suggesting that it could potentially replace alteplase as the main option for thrombolytic therapy, especially in patients with large vessel occlusion.