Tenecteplase Versus Alteplase in Medium Vessel Occlusion Ischemic Stroke: A Secondary Analysis of the Alteplase Compared to Tenecteplase Randomized Trial

Fouzi Bala; Nishita Singh; Katrina Ignacio; Ibrahim Alhabli; Ayoola Ademola; Anas Alrohimi; Houman Khosravani; Aleksander Tkach; Luciana Catanese; Dariush Dowlatshahi; Thalia Field; Gary Hunter; Faysal Benali; MacKenzie Horn; Andrew Demchuk; Michael Hill; Tolulope Sajobi; Brian Buck; Richard Swartz; Mohammed Almekhlafi; Bijoy K Menon

doi:10.5853/jos.2023.03713

Tenecteplase Versus Alteplase in Medium Vessel Occlusion Ischemic Stroke: A Secondary Analysis of the Alteplase Compared to Tenecteplase Randomized Trial

J Stroke. 2024 May;26(2):280-289. doi: 10.5853/jos.2023.03713. Epub 2024 May 30.

Authors

Fouzi Bala^{1

2}, Nishita Singh^{2

3}, Katrina Ignacio², Ibrahim Alhabli², Ayoola Ademola^{2

4}, Anas Alrohimi^{5

6}, Houman Khosravani⁷, Aleksander Tkach⁸, Luciana Catanese⁹, Dariush Dowlatshahi¹⁰, Thalia Field¹¹, Gary Hunter¹², Faysal Benali¹³, MacKenzie Horn², Andrew Demchuk^{2

4}, Michael Hill^{2

4}, Tolulope Sajobi^{2

4}, Brian Buck⁵, Richard Swartz⁶, Mohammed Almekhlafi^{2

4}, Bijoy K Menon^{2

4}

Affiliations

¹ Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France.
² Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.
³ Department of Internal Medicine (Neurology Division), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
⁴ Department of Community Health Sciences, University of Calgary, Calgary, Canada.
⁵ Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada.
⁶ Department of Medicine (Neurology), King Saud University, Riyadh, Saudi Arabia.
⁷ Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Canada.
⁸ Kelowna General Hospital, Kelowna, Canada.
⁹ Hamilton Health Sciences Centre and McMaster University, Hamilton, Canada.
¹⁰ Department of Medicine, University of Ottawa, and the Ottawa Heart Research Institute, Ottawa, Canada.
¹¹ Vancouver Stroke Program and the Division of Neurology, University of British Columbia, Vancouver, Canada.
¹² University of Saskatchewan, Saskatoon, Canada.
¹³ Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands.

Abstract

Background and purpose: The safety and efficacy of tenecteplase in patients with ischemic stroke due to medium vessel occlusion (MeVO) are not well studied. We aimed to compare tenecteplase with alteplase in stroke due to MeVO.

Methods: Patients with baseline M2-middle cerebral artery (MCA), M3/M4-MCA, P2/P3/P4-posterior cerebral artery (PCA), A2/A3/A4-anterior cerebral artery (ACA) occlusions from the Alteplase Compared to Tenecteplase (AcT) trial were included. Primary outcome was the proportion of 90-day modified Rankin Scale (mRS) 0-1. Secondary outcomes were 90-day mRS 0-2, ordinal mRS, mortality, quality of life measures (EuroQol 5-Dimension 5-Level, EuroQol visual analog scale), and symptomatic intracerebral hemorrhage (sICH). Initial and final successful reperfusion were reported in patients undergoing endovascular thrombectomy (EVT).

Results: Among 1,558 patients with available baseline computed tomography angiography; 455 (29.2%) had MeVO of which 27.5% (125/455) were proximal M2; 16.3% (74/455) were distal M2; 35.2% (160/455) were M3/M4; 7.5% (34/455) were A2/A3/A4; and 13.6% (62/455) were P2/P3/P4 occlusions. EVT was performed in 87/455 (19.1%) patients. mRS 0-1 at 90 days was achieved in 37.9% in the tenecteplase versus 34.7% in the alteplase group (adjusted risk ratio [aRR] 1.07; 95% confidence interval [CI] 0.91-1.25). Rates of 90-day mRS 0-2, sICH, and mortality were similar in both groups. No statistical difference was noted in initial successful reperfusion rates (13.0% vs. 7.5%) among the 87 patients who underwent endovascular thrombectomy. However, final successful reperfusion was higher in the tenecteplase group (71.7% vs. 60.0%, aRR 1.29, 95% CI 1.04-1.61).

Conclusion: Intravenous tenecteplase had comparable safety, functional outcomes and quality of life compared to intravenous alteplase among patients with MeVO. Among those treated with EVT, tenecteplase was associated with higher successful reperfusion rates than alteplase.

Keywords: Alteplase; Ischemic; Mechanical thrombectomy; Occlusion; Stroke; Thrombolysis.

Grants and funding

CAPMC/ CIHR/Canada