Campbell BCV, et al. - Experts compared the outcomes of alteplase vs tenecteplase therapy before endovascular thrombectomy for ischemic stroke. A higher incidence of reperfusion and better functional outcome was seen with tenecteplase vs alteplase in patients with ischemic stroke treated within 4.5 hours after symptom onset.

Methods

• Authors randomly assigned patients with ischemic stroke who had occlusion of the internal carotid, basilar, or middle cerebral artery and who were eligible to undergo thrombectomy to receive tenecteplase (at a dose of 0.25 mg per kilogram of body weight; maximum dose, 25 mg) or alteplase (at a dose of 0.9 mg per kilogram; maximum dose, 90 mg) within 4.5 hours after symptom onset.
• Reperfusion of greater than 50% of the involved ischemic territory or an absence of retrievable thrombus at the time of the initial angiographic assessment was the primary outcome.
• Researchers tested noninferiority of tenecteplase, followed by superiority.
• The modified Rankin scale score (on a scale from 0 [no neurologic deficit] to 6 [death]) at 90 days were the secondary outcomes.
• Death and symptomatic intracerebral hemorrhage were the safety outcomes.

Results

• Out of 202 patients, 101 received tenecteplase and 101 to received alteplase.
• The primary outcome occurred in 22% of patients who received tenecteplase vs 10% of those who received alteplase (incidence difference, 12 percentage points; 95% confidence interval [CI], 2 to 21; incidence ratio, 2.2; 95% CI, 1.1 to 4.4; P=0.002 for noninferiority; P=0.03 for superiority).
• Compared to alteplase, tenecteplase resulted in a better 90-day functional outcome (median modified Rankin scale score, 2 vs 3; common odds ratio, 1.7; 95% CI, 1.0 to 2.8; P=0.04).
• In each group, symptomatic intracerebral hemorrhage occurred in 1% of the patients.