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Xiong Y, Wang L, Pan Y, Wang M, Schwamm LH, Duan C, Campbell BCV, Li S, Hao M, Wu N, Cao Z, Wu S, Li Z, Wang Y. Tenecteplase versus alteplase for acute ischaemic stroke in the elderly patients: a post hoc analysis of the TRACE-2 trial. Stroke Vasc Neurol 2024:svn-2023-003048. [PMID: 38858097 DOI: 10.1136/svn-2023-003048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 05/20/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND The benefit-risk profile of tenecteplase in the elderly patients with acute ischaemic stroke (AIS) is uncertain. We sought to investigate the efficacy and safety of 0.25 mg/kg tenecteplase compared with alteplase for AIS patients aged ≥80 years. METHODS We performed a post hoc analysis of the Tenecteplase Reperfusion Therapy in Acute Ischaemic Cerebrovascular Events-2 Trial, a randomised, phase 3, non-inferiority clinical trial. Disabling AIS patients aged ≥80 years who initiated intravenous thrombolytics within 4.5 hours of symptom onset were enrolled from June 2021 to May 2022 across 53 centres in China and were randomly allocated to receive 0.25 mg/kg tenecteplase or 0.9 mg/kg alteplase. The primary efficacy outcome was the proportion of participants with a modified Rankin Scale (mRS) score of 0-1 at 90 days. Symptomatic intracranial haemorrhage (sICH) within 36 hours was the safety outcome. RESULTS Of 137 participants, mRS 0-1 at 90 days occurred in 37 (49.3%) of 75 in the tenecteplase group vs 20 (33.9%) of 59 in the alteplase group (risk ratio (RR) 1.47, 95% CI 0.96 to 2.23). sICH within 36 hours was observed in 3 (4.0%) of 76 in the tenecteplase group and two (3.3%) of 61 in the alteplase group (RR 1.30, 95% CI 0.20 to 8.41). CONCLUSIONS The risk-benefit profile of tenecteplase thrombolysis was preserved in the elderly patients, which lends further support to intravenous 0.25 mg/kg tenecteplase as an alternative to alteplase in these patients.
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Affiliation(s)
- Yunyun Xiong
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liyuan Wang
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Mengxing Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lee H Schwamm
- Yale New Haven Health System, Yale School of Medicine, New Haven, Connecticut, USA
| | - Chunmiao Duan
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Neurology, Beijing Daxing Hospital, Capital Medical University, Beijing, China
| | - Bruce C V Campbell
- Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Shuya Li
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Manjun Hao
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Na Wu
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhixin Cao
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuangzhe Wu
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
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Wang L, Hao M, Wu N, Wu S, Fisher M, Xiong Y. Comprehensive Review of Tenecteplase for Thrombolysis in Acute Ischemic Stroke. J Am Heart Assoc 2024; 13:e031692. [PMID: 38686848 PMCID: PMC11179942 DOI: 10.1161/jaha.123.031692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 02/20/2024] [Indexed: 05/02/2024]
Abstract
Although intravenous thrombolysis with alteplase remains the primary treatment for acute ischemic stroke, tenecteplase has shown potential advantages over alteplase. Animal studies have demonstrated the favorable pharmacokinetics and pharmacodynamics of tenecteplase. Moreover, it is easier to administer. Clinical trials have demonstrated that tenecteplase is not inferior to alteplase and may even be superior in cases of acute ischemic stroke with large vessel occlusion. Current evidence supports the time and cost benefits of tenecteplase, suggesting that it could potentially replace alteplase as the main option for thrombolytic therapy, especially in patients with large vessel occlusion.
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Affiliation(s)
- Liyuan Wang
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University Beijing China
| | - Manjun Hao
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University Beijing China
| | - Na Wu
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University Beijing China
| | - Shuangzhe Wu
- Chinese Institute for Brain Research Beijing China
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center Harvard Medical School Boston MA USA
| | - Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University Beijing China
- Chinese Institute for Brain Research Beijing China
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Marè A, Lorenzut S, Janes F, Gentile C, Marinig R, Tereshko Y, Gigli GL, Valente M, Merlino G. Comparison of pharmacokinetic properties of alteplase and tenecteplase. The future of thrombolysis in acute ischemic stroke. Expert Opin Drug Metab Toxicol 2024; 20:25-36. [PMID: 38275111 DOI: 10.1080/17425255.2024.2311168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/24/2024] [Indexed: 01/27/2024]
Abstract
INTRODUCTION The drug most frequently used for thrombolysis in cases of acute ischemic stroke (AIS) is alteplase. However, there is moderate-to-high-quality evidence that tenecteplase has similar or higher efficacy and safety. With improved pharmacokinetic properties over alteplase, tenecteplase could be a significant advantage in treating AIS. AREAS COVERED After conducting an extensive search on Scopus and PubMed, this manuscript reviews and compares the pharmacokinetic properties of alteplase and tenecteplase. Additionally, it provides information on pharmacodynamics, clinical efficacy, safety, tolerability, and drug-drug interactions. EXPERT OPINION The pharmacokinetic profile of alteplase and tenecteplase is derived from studies in patients with acute myocardial infarction. Thanks to its pharmacokinetic properties, tenecteplase is the drug closest to being the ideal fibrinolytic for AIS. Its longer half-life enables a single-bolus administration, which is particularly useful in emergencies. Tenecteplase has proven to have a good efficacy and safety profile in randomized clinical trials. Although we are awaiting the results of the ongoing phase 3 randomized clinical trials, we believe that tenecteplase has the potential to revolutionize the treatment of AIS through thrombolysis.
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Affiliation(s)
- Alessandro Marè
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Simone Lorenzut
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Francesco Janes
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Carolina Gentile
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Roberto Marinig
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Yan Tereshko
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | | | - Mariarosaria Valente
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- DAME, University of Udine, Udine, Italy
| | - Giovanni Merlino
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
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Novotny V, Kvistad CE, Naess H, Logallo N, Fromm A, Khanevski AN, Thomassen L. Tenecteplase, 0.4 mg/kg, in Moderate and Severe Acute Ischemic Stroke: A Pooled Analysis of NOR-TEST and NOR-TEST 2A. J Am Heart Assoc 2023; 12:e030320. [PMID: 37830342 PMCID: PMC10757511 DOI: 10.1161/jaha.123.030320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
Background The optimal dose of tenecteplase in acute ischemic stroke remains to be defined. We present a pooled analysis of the 2 NOR-TESTs (Norwegian Tenecteplase Stroke Trials) exploring the efficacy and safety of tenecteplase, 0.4 mg/kg. Methods and Results We retrospectively reviewed 2 PROBE (Prospective Randomized Open, Blinded End-point) trials, NOR-TEST and NOR-TEST 2A. Patients were randomized to either tenecteplase, 0.4 mg/kg, or alteplase, 0.9 mg/kg. The primary end point was favorable functional outcome at 3 months (modified Rankin Scale score, 0-1) or return to baseline if prestroke modified Rankin Scale score was 2. Secondary end points included favorable functional and clinical outcome and safety data. The pooled analysis includes patients with National Institutes of Health Stroke Scale score ≥6 from both trials and an additional post hoc analysis of patients with National Institutes of Health Stroke Scale score ≤5 from NOR-TEST. The per-protocol analysis contains 483 patients, of whom 235 were assigned to tenecteplase and 248 were assigned to alteplase. In per-protocol analysis, functional outcome was better in the alteplase arm with cutoff modified Rankin Scale score of 2 (odds ratio [OR], 0.52 [95% CI, 0.33-0.80]; P=0.003) and expressed by ordinal shift analysis (OR, 1.64 [95% CI, 1.17-2.28]; P=0.004). Mortality at 3 months was higher in the tenecteplase arm (OR, 2.48 [95% CI, 1.20-5.10]; P=0.01). Mortality and intracranial hemorrhage rates were higher in the severe stroke group randomized to tenecteplase, whereas these rates were similar for alteplase and tenecteplase in moderate and mild stroke. Conclusions Tenecteplase, 0.4 mg/kg, is unsafe in moderate and severe stroke, and the risk of death and intracranial hemorrhage probably increases with stroke severity. A lower tenecteplase dose should be tested in future trials. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01949948, NCT03854500.
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Affiliation(s)
- Vojtech Novotny
- Department of NeurologyHaukeland University HospitalBergenNorway
| | - Christopher Elnan Kvistad
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | - Halvor Naess
- Department of NeurologyHaukeland University HospitalBergenNorway
- Centre for Age‐Related MedicineStavanger University HospitalStavangerNorway
| | - Nicola Logallo
- Department of NeurosurgeryHaukeland University HospitalBergenNorway
| | - Annette Fromm
- Department of NeurologyHaukeland University HospitalBergenNorway
| | | | - Lars Thomassen
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
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Wei H, Fu B, Yang C, Huang M. The efficacy and safety of intravenous thrombolysis with tenecteplase versus alteplase for acute ischemic stroke: a systematic review and meta-analysis. Neurol Sci 2023; 44:3005-3015. [PMID: 37061572 DOI: 10.1007/s10072-023-06801-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 04/03/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVES We aimed to evaluate the available evidence on the efficacy and safety outcomes of intravenous tenecteplase (TNK) compared with intravenous alteplase(ALT) for patients with acute ischemic stroke (AIS) in randomized controlled trials (RCTs). METHODS The MEDLINE/PubMed, Embase, Springer, Web of Science, Cochrane Collaboration database, China National Knowledge Infrastructure (CNKI) database, and Wanfang database were comprehensively searched for RCTs regarding the effects of TNK versus ALT among AIS patients in these English and Chinese electronic databases from inception dates to August 1, 2022. This meta-analysis followed PRISMA guidelines. Two reviewers independently retrieved RCTs and extracted relevant information. The methodological quality of the included trials was estimated using the Cochrane risk of bias tool. The pooled analyses were performed using RevMan 5.3 software. The primary outcome was functional outcome on the modified Rankin Scale (mRS) (range 0 to 5) and mortality at 90 days. The secondary outcomes included successful recanalization, early neurologic improvement < 48 h, any intracranial hemorrhage (ICH), and symptomatic ICH. The follow-up time of all studies was at least 3 months. RESULTS A total of nine RCTs involving 1958 patients in TNK group and 1731 patients in ALT group were finally included. For the efficacy outcomes, there were no significant differences between the two groups in terms of mRS score 0 ~ 2 (RR 1.00; 95% CI 0.88-1.13; P = 0.96), mRS score 0 ~ 1 (RR 1.03; 95% CI 0.96-1.10; P = 0.36), successful recanalization (RR 1.25; 95% CI 0.88-1.76; P = 0.21), and early neurologic improvement < 48 h (RR 1.08; 95% CI 0.92-1.26; P = 0.37). Similar results were seen for the safety outcomes, which have no statistical differences in terms of any ICH (RR 1.01; 95% CI 0.72-1.41; P = 0.96), symptomatic ICH (RR 1.19; 95% CI 0.81-1.76; P = 0.37), and mortality at 90 days (RR 0.99; 95% CI 0.83-1.19; P = 0.94). CONCLUSION Overall, the efficacy and safety outcomes of intravenous thrombolysis with TNK versus ALT for AIS were not statistically different. However, TNK at a dose of 0.25 mg/kg may be a reasonable alternative to ALT for thrombolysis.
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Affiliation(s)
- Heng Wei
- Department of Neurology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Hubei University of Chinese Medicine, Wuhan, 430000, China.
| | - Bin Fu
- Department of Neurology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Hubei University of Chinese Medicine, Wuhan, 430000, China
| | - Chao Yang
- Department of Neurology, People's Hospital of Dongxihu District of Wuhan Union Hospital, Wuhan, 430040, China
| | - Ming Huang
- Department of Neurology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Hubei University of Chinese Medicine, Wuhan, 430000, China.
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Lo BM, Carpenter CR, Ducey S, Gottlieb M, Kaji A, Diercks DB, Diercks DB, Wolf SJ, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Trent S, Valente JH, Wall SP, Westafer LM, Yu Y, Cantrill SV, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Acute Ischemic Stroke. Ann Emerg Med 2023; 82:e17-e64. [PMID: 37479410 DOI: 10.1016/j.annemergmed.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
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Hajian K, Abdi Dezfouli R, Darvishi A, Radmanesh R, Heshmat R. Tenecteplase in managing acute ischemic stroke: a long-term cost-utility analysis in Iran. Expert Rev Pharmacoecon Outcomes Res 2023; 23:123-133. [PMID: 36420792 DOI: 10.1080/14737167.2023.2152008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND & AIMS The advantage of tenecteplase (TNK) over alteplase (ALT) in managing acute ischemic stroke (AIS) has been reported, but the cost-effectiveness of these two strategies has not received as much attention. The objective of this study was to compare TNK and ALT for the management of AIS patients in Iran in terms of cost-effectiveness. METHODS This study was carried out from the payer's perspective in Iran, with a lifetime horizon. A full economic evaluation model was designed as a decision tree and a Markov model. After defining different Markov states, each health state was assigned a utility value, and quality-adjusted life year (QALY) was estimated using that value. The incremental cost-effectiveness ratio (ICER) was ultimately used for evaluating the comparative cost-effectiveness. Both deterministic and probabilistic sensitivity analyses were carried out. RESULTS Compared to ALT, TNK can save approximately 4333.81 USD, and is able to increase one unit of QALY while saving approximately 17,450.29 USD. So, Base-case results showed that TNK strongly dominates ALT. Moreover, the base case results were strongly confirmed by deterministic and probabilistic sensitivity analysis. CONCLUSIONS Base-case and sensitivity analysis showed that TNK is the dominant strategy compared to ALT for the management of AIS patients.
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Affiliation(s)
- Kosar Hajian
- Department of Pharmacoeconomics and Pharmaceutical Management, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran.,Chronic Diseases Research Center, Endocrinology and Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ramin Abdi Dezfouli
- Department of Pharmacoeconomics and Pharmaceutical Management, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran.,Chronic Diseases Research Center, Endocrinology and Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Darvishi
- Chronic Diseases Research Center, Endocrinology and Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Ramin Radmanesh
- Department of Pharmacoeconomics and Pharmaceutical Management, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Ramin Heshmat
- Chronic Diseases Research Center, Endocrinology and Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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Yogendrakumar V, Churilov L, Mitchell PJ, Kleinig TJ, Yassi N, Thijs V, Wu TY, Shah DG, Ng FC, Dewey HM, Wijeratne T, Yan B, Desmond PM, Parsons MW, Donnan GA, Davis SM, Campbell BCV. Safety and Efficacy of Tenecteplase in Older Patients With Large Vessel Occlusion: A Pooled Analysis of the EXTEND-IA TNK Trials. Neurology 2022; 98:e1292-e1301. [PMID: 35017305 DOI: 10.1212/wnl.0000000000013302] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 12/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Detailed study of tenecteplase (TNK) in patients greater than 80 years of age is limited. The objective of our study was to assess the safety and efficacy of TNK at 0.25 and 0.40 mg/kg doses in patients greater than 80 years with large vessel occlusion. METHODS A pooled analysis of the EXTEND-IA TNK randomized controlled trials (n=502). Patients were adults presenting with ischemic stroke due to occlusion of the intracranial internal carotid, middle cerebral, or basilar artery presenting within 4.5 hours of symptom onset. We compared the treatment effect of TNK 0.25mg/kg, TNK 0.40mg/kg, and alteplase 0.90mg/kg, stratifying for patient age (>80 years). Outcomes evaluated include 90-day modified Rankin scale (mRS), all-cause mortality, and symptomatic ICH. Treatment effect was adjusted for baseline NIHSS, age, and time from symptom onset to puncture via mixed effects proportional odds and logistic regression models. RESULTS In patients >80 years (n=137), TNK 0.25 mg/kg was associated with improved 90-day mRS (median 3 vs. 4, adjusted common OR=2.70, 95% CI: 1.23-5.94) and reduced mortality (aOR=0.34, 95% CI: 0.13-0.91) versus 0.40 mg/kg. TNK 0.25 mg/kg was associated with improved 90-day mRS (median 3 vs. 4, acOR=2.28, 95% CI: 1.03-5.05) versus alteplase. No difference in 90-day mRS or mortality was detected between alteplase and TNK 0.40 mg/kg. Symptomatic ICH was observed in 4 patients treated with TNK 0.40 mg/kg, one patient treated with alteplase and zero patients treated with TNK 0.25 mg/kg. In patients ≤ 80 years, no differences in 90-day mRS, mortality, or symptomatic ICH was observed between TNK 0.25 mg/kg, alteplase, and TNK 0.40 mg/kg. CONCLUSIONS TNK 0.25 mg/kg was associated with improved 90-day mRS and lower mortality in patients greater than 80 years of age. No differences between the doses were observed in younger patients. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that tenecteplase 0.25 mg/kg given before endovascular therapy in patients >80 years old with large vessel occlusion stroke is associated with better functional outcomes at 90 days and reduced mortality when compared to tenecteplase 0.40 mg/kg or alteplase 0.90 mg/kg. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT02388061, NCT03340493 https://www.clinicaltrials.gov/ct2/show/NCT02388061 https://www.clinicaltrials.gov/ct2/show/NCT03340493.
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Affiliation(s)
- Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
| | - Vincent Thijs
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Darshan G Shah
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Felix C Ng
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Helen M Dewey
- Eastern Health and Eastern Health Clinical School, Department of Neurosciences, Monash University, Clayton, Victoria, Australia
| | - Tissa Wijeratne
- Melbourne Medical School, Department of Medicine and Neurology, The University of Melbourne and Western Health, Sunshine Hospital, St Albans Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Department of Neurology, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Geoffrey Alan Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
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Charbonnier G, Bonnet L, Biondi A, Moulin T. Intracranial Bleeding After Reperfusion Therapy in Acute Ischemic Stroke. Front Neurol 2021; 11:629920. [PMID: 33633661 PMCID: PMC7900408 DOI: 10.3389/fneur.2020.629920] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/29/2020] [Indexed: 12/16/2022] Open
Abstract
Intracranial hemorrhage is one of the most feared complications following brain infarct. Ischemic tissues have a natural tendency to bleed. Moreover, the first recanalization trials using intravenous thrombolysis have shown an increase in mild to severe intracranial hemorrhage. Symptomatic intracerebral hemorrhage is strongly associated with poor outcomes and is an important factor in recanalization decisions. Stroke physicians have to weigh the potential benefit of recanalization therapies, first, with different risks of intracranial hemorrhage described in randomized controlled trials, and second with numerous risk markers that have been found to be associated with intracranial hemorrhage in retrospective series. These decisions have become quite complex with different intravenous thrombolytics and mechanical thrombectomy. This review aims to outline some elements of the pathophysiological mechanisms and classifications, describe most of the risk factors identified for each reperfusion therapy, and finally suggest future research directions that could help physicians dealing with these complications.
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Affiliation(s)
- Guillaume Charbonnier
- Neurology Department, Besançon University Hospital, Besançon, France.,Interventional Neuroradiology Department, Besançon University Hospital, Besançon, France.,EA 481 Neurosciences laboratory, Franche-Comté University, Besançon, France
| | - Louise Bonnet
- Neurology Department, Besançon University Hospital, Besançon, France
| | - Alessandra Biondi
- Interventional Neuroradiology Department, Besançon University Hospital, Besançon, France.,CIC-1431 Inserm, Besançon, France
| | - Thierry Moulin
- Neurology Department, Besançon University Hospital, Besançon, France.,EA 481 Neurosciences laboratory, Franche-Comté University, Besançon, France.,CIC-1431 Inserm, Besançon, France
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10
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Abstract
Tenecteplase is a fibrinolytic drug with higher fibrin specificity and longer half-life than the standard stroke thrombolytic, alteplase, permitting the convenience of single bolus administration. Tenecteplase, at 0.5 mg/kg, has regulatory approval to treat ST-segment-elevation myocardial infarction, for which it has equivalent 30-day mortality and fewer systemic hemorrhages. Investigated as a thrombolytic for ischemic stroke over the past 15 years, tenecteplase is currently being studied in several phase 3 trials. Based on a systematic literature search, we provide a qualitative synthesis of published stroke clinical trials of tenecteplase that (1) performed randomized comparisons with alteplase, (2) compared different doses of tenecteplase, or (3) provided unique quantitative meta-analyses. Four phase 2 and one phase 3 study performed randomized comparisons with alteplase. These and other phase 2 studies compared different tenecteplase doses and effects on early outcomes of recanalization, reperfusion, and substantial neurological improvement, as well as symptomatic intracranial hemorrhage and 3-month disability on the modified Rankin Scale. Although no single trial prospectively demonstrated superiority or noninferiority of tenecteplase on clinical outcome, meta-analyses of these trials (1585 patients randomized) point to tenecteplase superiority in recanalization of large vessel occlusions and noninferiority in disability-free 3-month outcome, without increases in symptomatic intracranial hemorrhage or mortality. Doses of 0.25 and 0.4 mg/kg have been tested, but no advantage of the higher dose has been suggested by the results. Current clinical practice guidelines for stroke include intravenous tenecteplase at either dose as a second-tier option, with the 0.25 mg/kg dose recommended for large vessel occlusions, based on a phase 2 trial that demonstrated superior recanalization and improved 3-month outcome relative to alteplase. Ongoing randomized phase 3 trials may better define the comparative risks and benefits of tenecteplase and alteplase for stroke thrombolysis and answer questions of tenecteplase efficacy in the >4.5-hour time window, in wake-up stroke, and in combination with endovascular thrombectomy.
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Affiliation(s)
- Steven J Warach
- Department of Neurology, Dell Medical School, University of Texas at Austin
| | - Adrienne N Dula
- Department of Neurology, Dell Medical School, University of Texas at Austin
| | - Truman J Milling
- Department of Neurology, Dell Medical School, University of Texas at Austin
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