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Haj Mohamad Ebrahim Ketabforoush A, Hosseinpour A, Habibi MA, Ariaei A, Farajollahi M, Chegini R, Mirzaasgari Z. Optimizing Acute Ischemic Stroke Outcomes: The Role of Tenecteplase Before Mechanical Thrombectomy. Clin Ther 2024:S0149-2918(24)00223-6. [PMID: 39266330 DOI: 10.1016/j.clinthera.2024.08.014] [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: 03/16/2024] [Revised: 08/09/2024] [Accepted: 08/13/2024] [Indexed: 09/14/2024]
Abstract
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.
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Affiliation(s)
| | - Ali Hosseinpour
- Department of Neurology, Clinical Research Development Unit (CRDU) of Shahid Rajaei Hospital, Alborz University of Medical Sciences, Karaj, Iran
| | - Mohamad Amin Habibi
- Clinical Research Development Center, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom, Iran
| | - Armin Ariaei
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Rojin Chegini
- Metabolic liver disease research center, Isfahan University of medical sciences, Isfahan, Iran
| | - Zahra Mirzaasgari
- Department of Neurology, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran.
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Ma Y, Xiang H, Busse JW, Yao M, Guo J, Ge L, Li B, Luo X, Mei F, Liu J, Wang Y, Liu Y, Li W, Zou K, Li L, Sun X. Tenecteplase versus alteplase for acute ischemic stroke: a systematic review and meta-analysis of randomized and non-randomized studies. J Neurol 2024; 271:2309-2323. [PMID: 38436679 DOI: 10.1007/s00415-024-12243-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Alteplase is the current standard of care for acute ischemic stroke. Tenecteplase is a newer fibrinolytic agent with preferable administration and lower costs; however, its comparative effectiveness to alteplase remains uncertain. We set out to perform a systematic review and meta-analysis to establish the benefits and harms of tenecteplase versus alteplase for acute ischemic stroke. METHODS We searched PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov from inception to April 2023 for randomized and non-randomized studies that compared tenecteplase versus alteplase for acute ischemic stroke. Paired reviewers independently assessed risk of bias and extracted data. We performed both conventional meta-analyses and Bayesian network meta-analyses (NMA) with random-effects models and used the GRADE approach to evaluate the certainty of evidence. Our primary efficacy outcome was excellent functional outcome at 3 months, defined as a score of 0-1 on the modified Rankin Scale. Our primary safety outcomes were symptomatic intracranial hemorrhage and all-cause mortality. RESULTS Thirty-six studies were eligible for review, including 12 randomized (n = 5533) and 24 non-randomized studies (n = 44,956). Moderate certainty evidence showed that there was no difference between tenecteplase and alteplase in increasing the proportion of patients achieving excellent functional outcome at 3 months (odds ratio [OR], 1.10; 95% CI 0.98-1.23; risk difference [RD] 2.4%, 95% CI - 0.5 to 5.2), while moderate certainty evidence from NMA suggested that 0.25 mg/kg tenecteplase significantly improved excellent functional outcome at 3 months (OR, 1.16; 95% credible interval 1.02-1.32). Moderate certainty evidence showed that, compared to alteplase, tenecteplase may make little to no difference in the prevalence of symptomatic intracranial hemorrhage (OR, 1.12; 95% CI 0.79-1.59; RD 0.3%, 95% CI - 0.5 to 1.4), and probably reduces all-cause mortality (adjusted odds ratio [aOR], 0.44; 95% CI 0.30-0.64; RD - 4.6%; 95% CI - 5.8 to - 2.9). CONCLUSIONS Moderate certainty evidence suggested that there was little to no difference between tenecteplase and alteplase in increasing the proportion of patients achieving excellent functional outcome at 3 months and the risk of symptomatic intracranial hemorrhage, while compared to alteplase, tenecteplase probably reduce all-cause mortality. Administration of 0.25 mg/kg tenecteplase after acute ischemic stroke is suggestive of increasing the proportion of patients that achieve excellent functional outcome at 3 months.
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Affiliation(s)
- Yu Ma
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Hunong Xiang
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Jason W Busse
- Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Anaesthesia, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Minghong Yao
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Jian Guo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Long Ge
- Evidence Based Social Science Research Centre, School of Public Health, Lanzhou University, Lanzhou, 730000, China
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, 730000, China
| | - Bo Li
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300381, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Xiaochao Luo
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Fan Mei
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Jiali Liu
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Yuning Wang
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Yanmei Liu
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Wentao Li
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300381, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Kang Zou
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Ling Li
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China.
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China.
| | - Xin Sun
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China.
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China.
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Astier A, Abouqal R, Abid L, Aoudia Y, Ahid S. Biosimilarity. Do not confuse biosimilar and biocopy. Example of tenecteplase. ANNALES PHARMACEUTIQUES FRANÇAISES 2023; 81:942-949. [PMID: 37422254 DOI: 10.1016/j.pharma.2023.07.001] [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: 03/29/2023] [Revised: 06/30/2023] [Accepted: 07/01/2023] [Indexed: 07/10/2023]
Abstract
Non-innovator biological products (NIBPs) or 'biocopies' are available in several countries at lower prices than biosimilars. These drugs, sometimes so-called 'biosimilars', may not meet all of the quality criteria expected of clinically equivalent products. NIBPs can exhibit major differences in physicochemical and pharmacological properties compared with their reference biological but may be presented to prescribers based on clinical trial data and claimed clinical equivalence. Tenecteplase (TNK-tpA) is a recombinant derivative of tissue plasminogen activator, used as a third-generation thrombolytic agent for treatment of acute myocardial infarction. A TNK-tPA presented as biosimilar to the originator (Metalyse®, Boehringer Ingelheim; TNKase®, Roche/Genentech) is now available for use in India (Elaxim®, Gennova Pharmaceuticals). Elaxim® is not approved in Europe or the USA but has been proposed in several countries as a replacement for the originator. Based on available literature, we discuss why this biocopy cannot be considered biosimilar to the originator tenecteplase. We describe clear differences in physicochemical and pharmacological properties. For example, the biocopy demonstrates clot lysis activity that is substantially lower than the originator and contains high concentrations of foreign proteins that confer potential for immunological reactions. Clinical data on the biocopy are limited; randomized trials to demonstrate the absence of difference in efficacy and safety between the biocopy and originator have not been conducted. This example demonstrates that confirmation of similarity, by close examination of pharmaceutical quality attributes, and preclinical and clinical data, is mandatory before presenting to prescribers a biological product as clinically equivalent.
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Affiliation(s)
- A Astier
- Académie nationale de pharmacie, faculté de pharmacie, 4, avenue de l'Observatoire, 75004 Paris, France.
| | - R Abouqal
- Laboratoire de biostatistique, de recherche clinique et épidémiologie, faculté de médecine et de pharmacie, université Mohammed V, avenue Mohamed Belarbi El Alaoui, BP 6203 Rabat-Institut, Rabat, Morocco.
| | - L Abid
- Hôpital Hédi Chaker, route Elain 0.5, 3029 Sfax, Tunisia.
| | - Y Aoudia
- Faculté de médecine SI Ahmed El Mahdi, université Saad Dahled Blida 1, Soumaa, Blida, Algeria.
| | - S Ahid
- Équipe de recherche pharmacoépidémiologie et pharmacoéconomie, faculté de médecine et de pharmacie, université Mohammed V, avenue Mohamed Belarbi El Alaoui, BP 6203 Rabat-Institut, Rabat, Morocco.
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Subhash, Yada PK. Expanding Footprints of Biosimilar Tenecteplase. Ann Indian Acad Neurol 2023; 26:219-220. [PMID: 37538426 PMCID: PMC10394453 DOI: 10.4103/aian.aian_256_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 03/25/2023] [Indexed: 08/05/2023] Open
Affiliation(s)
- Subhash
- Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
| | - Praveen K. Yada
- Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
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Rose D, Cavalier A, Kam W, Cantrell S, Lusk J, Schrag M, Yaghi S, Stretz C, de Havenon A, Saldanha IJ, Wu TY, Ranta A, Barber PA, Marriott E, Feng W, Kosinski AS, Laskowitz D, Poli S, Grory BM. Complications of Intravenous Tenecteplase Versus Alteplase for the Treatment of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Stroke 2023; 54:1192-1204. [PMID: 36951049 PMCID: PMC10133185 DOI: 10.1161/strokeaha.122.042335] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/20/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Prior systematic reviews have compared the efficacy of intravenous tenecteplase and alteplase in acute ischemic stroke, assigning their relative complications as a secondary objective. The objective of the present study is to determine whether the risk of treatment complications differs between patients treated with either agent. METHODS We performed a systematic review including interventional studies and prospective and retrospective, observational studies enrolling adult patients treated with intravenous tenecteplase for ischemic stroke (both comparative and noncomparative with alteplase). We searched MEDLINE, Embase, the Cochrane Library, Web of Science, and the www. CLINICALTRIALS gov registry from inception through June 3, 2022. The primary outcome was symptomatic intracranial hemorrhage, and secondary outcomes included any intracranial hemorrhage, angioedema, gastrointestinal hemorrhage, other extracranial hemorrhage, and mortality. We performed random effects meta-analyses where appropriate. Evidence was synthesized as relative risks, comparing risks in patients exposed to tenecteplase versus alteplase and absolute risks in patients treated with tenecteplase. RESULTS Of 2226 records identified, 25 full-text articles (reporting 26 studies of 7913 patients) were included. Sixteen studies included alteplase as a comparator, and 10 were noncomparative. The relative risk of symptomatic intracranial hemorrhage in patients treated with tenecteplase compared with alteplase in the 16 comparative studies was 0.89 ([95% CI, 0.65-1.23]; I2=0%). Among patients treated with low dose (<0.2 mg/kg; 4 studies), medium dose (0.2-0.39 mg/kg; 13 studies), and high dose (≥0.4 mg/kg; 3 studies) tenecteplase, the RRs of symptomatic intracranial hemorrhage were 0.78 ([95% CI, 0.22-2.82]; I2=0%), 0.77 ([95% CI, 0.53-1.14]; I2=0%), and 2.31 ([95% CI, 0.69-7.75]; I2=40%), respectively. The pooled risk of symptomatic intracranial hemorrhage in tenecteplase-treated patients, including comparative and noncomparative studies, was 0.99% ([95% CI, 0%-3.49%]; I2=0%, 7 studies), 1.69% ([95% CI, 1.14%-2.32%]; I2=1%, 23 studies), and 4.19% ([95% CI, 1.92%-7.11%]; I2=52%, 5 studies) within the low-, medium-, and high-dose groups. The risks of any intracranial hemorrhage, mortality, and other studied outcomes were comparable between the 2 agents. CONCLUSIONS Across medium- and low-dose tiers, the risks of complications were generally comparable between those treated with tenecteplase versus alteplase for acute ischemic stroke.
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Affiliation(s)
- Deborah Rose
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Annie Cavalier
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Wayneho Kam
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Sarah Cantrell
- Duke University Medical Center Library & Archives, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Jay Lusk
- Duke University School of Medicine, Durham, NC, USA
| | - Matthew Schrag
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Shadi Yaghi
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI, USA
| | - Christoph Stretz
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI, USA
| | - Adam de Havenon
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Ian J. Saldanha
- Center for Evidence Synthesis in Health, Departments of Health Services, Policy, and Practice and of Epidemiology, Brown School of Public Health, Providence, RI, USA
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - P. Alan Barber
- Department of Medicine, University of Auckland, New Zealand
| | - Elizabeth Marriott
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Wayne Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Andrzej S. Kosinski
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Daniel Laskowitz
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Sven Poli
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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The EZ, Lin NN, Matar M, Teoh HL, Yeo LLL. Different dosing regimens of Tenecteplase in acute ischemic stroke: A network meta-analysis of the clinical evidence. Eur Stroke J 2022; 8:93-105. [PMID: 37021171 PMCID: PMC10069195 DOI: 10.1177/23969873221129924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/13/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction: Acute ischemic stroke remains the major cause of death and disability and conclusive evidence of Tenecteplase in treating stroke is lacking. Objective: To conduct a meta-analysis to determine whether Tenecteplase produces better outcomes than Alteplase and a network meta-analysis comparing the different dosing regimens of Tenecteplase. Methods: Searches were made in MEDLINE, CENTRAL, and ClinicalTrials.gov. The outcome measures are recanalization, early neurological improvement, functional outcomes at 90 days (modified Rankin Scale 0–1 and 0–2), intracranial hemorrhage, symptomatic intracranial hemorrhage, and mortality within 90 days from treatment. Results: Fourteen studies are included in the meta-analyses and 18 studies in the network meta-analyses. In the meta-analysis, Tenecteplase 0.25 mg/kg has significant results in early neurological improvement (OR = 2.35, and 95% CI = 1.16–4.72) and excellent functional outcome (OR = 1.20, and 95% CI = 1.02–1.42). In the network meta-analysis, Tenecteplase 0.25 mg/kg produces significant results in early neurological improvement (OR = 1.52 [95% CI = 1.13–2.05], p-value = 0.01), functional outcomes (mRS 0–1 and 0–2) (OR = 1.19 [95% CI = 1.03–1.37], p-value = 0.02; OR = 1.21 [95% CI = 1.05–1.39], p-value = 0.01; respectively) and mortality (OR = 0.78 [95% CI = 0.64–0.96], p-value = 0.02) whereas Tenecteplase 0.40 mg/kg increases the chances of symptomatic intracranial hemorrhage (OR = 2.35 [95% CI = 1.19–4.64], p-value = 0.01). Conclusion: While not conclusive, our study lends evidence to 0.25 mg/kg Tenecteplase dose for ischemic stroke treatment. Further randomized trials need to be done to validate this finding. Registration: International prospective register of systematic reviews (PROSPERO) – CRD42022339774 URL: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=339774
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Affiliation(s)
- Ei Zune The
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Mazen Matar
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
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Tsivgoulis G, Katsanos AH, Christogiannis C, Faouzi B, Mavridis D, Dixit AK, Palaiodimou L, Khurana D, Petruzzellis M, Psychogios K, Macleod MJ, Ahmed N. IV thrombolysis with tenecteplase for the treatment of acute ischemic stroke. Ann Neurol 2022; 92:349-357. [PMID: 35713213 DOI: 10.1002/ana.26445] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Intravenous thrombolysis (IVT) with tenecteplase has been associated with better clinical outcomes in acute ischemic stroke (AIS) patients with confirmed large vessel occlusions compared to IVT with alteplase. However, the utility of tenecteplase for the treatment of all AIS patients eligible for IVT has not been established. METHODS We compared the safety and efficacy of tenecteplase vs. alteplase in AIS patients by analysing propensity score matched data from 20 centres participating in the SITS-ISTR registry. Patients receiving IVT with tenecteplase were matched with up to three patients receiving alteplase from the same centre. The primary outcome of interest was the distribution of 3-month functional outcomes. Secondary outcomes included the rates of patients with symptomatic intracranial hemorrhage (SICH) in the first 24 hours, excellent (mRS-scores of 0-1) or good (mRS-scores of 0-2) functional outcome, and all-cause mortality at 3 months. RESULTS A total of 331 tenecteplase-treated AIS patients were matched to 797 patients treated with alteplase [median age of 70 years; 43.9% women; median NIHSS-score: 11 (IQR: 6-17)]. Patients treated with tenecteplase had better three-month functional outcomes (common OR=1.54,95%CI:1.18-2.00) with higher odds of good functional outcome (OR=2.00,95%CI:1.45-2.77) and a lower likelihood of all-cause mortality (OR=0.43,95%CI:0.27-0.67) at three months, compared to alteplase-treated patients. No difference was found in the likelihood of the three-month excellent functional outcomes (OR=1.31,95%CI:0.96-1.78) and 24-hour SICH (1.0% vs. 1.3%; OR=0.72,95%CI:.20-2.64). INTERPRETATION IVT with tenecteplase was associated with better three-month clinical outcomes compared to IVT with alteplase in AIS patients, with no increased risk of symptomatic intracranial bleeding. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, ON, Canada
| | | | - Belahsen Faouzi
- Department of Neurology, Hassan II University Teaching Hospital, Fez, Morocco
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Paris Descartes University, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
| | - Anand K Dixit
- Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Newcastle-Upon-Tyne, UK
| | - Lina Palaiodimou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dheeraj Khurana
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Marco Petruzzellis
- Neurology Unit and Stroke Center, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Klearchos Psychogios
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - Mary Joan Macleod
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Chen S, Chen D, Liu Y, Xu Y, Lin H, Cheng Y, Li J, Meng C, Liang M, Yuan C, Huang M. Enhanced clot lysis by a single point mutation in a reteplase variant. Br J Haematol 2021; 196:1076-1085. [PMID: 34783361 DOI: 10.1111/bjh.17942] [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: 06/08/2021] [Revised: 10/02/2021] [Accepted: 10/22/2021] [Indexed: 11/30/2022]
Abstract
Recombinant tissue-type plasminogen activator (rtPA) is the clot lysis drug approved for clinical use, and is characterised by a short half-life and substantial inactivation by plasminogen activator inhibitor-1 (PAI-1). We previously discovered that a tPA mutation (A419Y) at the protease domain led to enhanced fibrinolysis activity. In the present study, we studied the mechanism of such mutation in enhancing the proteolytic activity, and whether such enhancement persists in reteplase, an United States Food and Drug Administration-approved tPA truncated variant. We constructed and expressed a series of reteplase-based mutants, including rPAG (glycosylated rPA), rPAG -Y (with A419Y mutant at rPAG ), rPAG -A4 (tetra-alanine mutation at 37-loop of rPAG ), and rPAG -A4/Y (with both) and evaluated their plasminogen activation and PAI-1 resistance. Surface plasmon resonance analysis showed that the rPAG had fibrin affinity comparable to full-length tPA. Moreover, rPAG -Y had 8·5-fold higher plasminogen activation and stronger tolerance to PAI-1 compared to rPAG . We also found that the mutations containing tetra-alanine (rPAG -A4 and rPAG -A4/Y) had dramatically reduced plasminogen activation and impaired clot lysis. In a pulmonary embolism murine model, rPAG -Y displayed a more efficient thrombolytic effect than rPAG . These results identified a novel mutant reteplase variant of tPA with increased fibrinolytic activity, laying the foundation for the development of a new potent fibrinolytic agent.
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Affiliation(s)
- Shanli Chen
- College of Chemistry, Fuzhou University, Fuzhou, China
| | - Dan Chen
- College of Chemistry, Fuzhou University, Fuzhou, China
| | - Yurong Liu
- College of Chemistry, Fuzhou University, Fuzhou, China
| | - Yanyan Xu
- College of Chemistry, Fuzhou University, Fuzhou, China
| | - Huajian Lin
- College of Chemistry, Fuzhou University, Fuzhou, China
| | - Yuan Cheng
- College of Chemistry, Fuzhou University, Fuzhou, China
| | - Jinyu Li
- College of Chemistry, Fuzhou University, Fuzhou, China
| | - Chun Meng
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, China
| | - Mingli Liang
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, China
| | - Cai Yuan
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, China.,Fujian Key Laboratory of Marine Enzyme Engineering, Fuzhou University, Fuzhou, China
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9
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Tenecteplase for thrombolysis in stroke patients: Systematic review with meta-analysis. Am J Emerg Med 2021; 42:31-37. [DOI: 10.1016/j.ajem.2020.12.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 12/11/2020] [Indexed: 11/19/2022] Open
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10
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Abstract
The introduction of thrombolytic therapy in the 1990s has transformed acute ischemic stroke treatment. Thus far, intravenous recombinant tissue plasminogen activator (rt-PA) also known as alteplase is the only thrombolytic proven to be efficacious and approved by the United States Food and Drug Administration. But the thrombolytic agent tenecteplase (TNK) is emerging as a potential replacement for rt-PA. TNK has greater fibrin specificity, slower clearance, and higher resistance to plasminogen activator inhibitor-1 than rt-PA. Hence, TNK has the potential to provide superior lysis with fewer hemorrhagic complications. Also, easier bolus-only administration makes TNK a very practical rt-PA alternative. In several clinical trials, TNK has shown similar efficacy and safety to rt-PA, and the potential to be at least noninferior to rt-PA in some settings. TNK may be superior to rt-PA for reperfusing large vessel occlusions in patients with salvageable penumbra, although this has not yet translated to improved clinical outcomes. Further phase 3 studies are in progress comparing rt-PA with TNK for acute ischemic stroke during the first 4.5 hours. Studies are also in progress to evaluate the use of TNK for extended applications, such as wake-up stroke.
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Affiliation(s)
| | | | - Weijun Jin
- SUNY Downstate Medical Center, Brooklyn, New York
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11
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Chang Z, Zou H, Xie Z, Deng B, Que R, Huang Z, Weng G, Wu Z, Pan Y, Wang Y, Li M, Xie H, Zhu S, Xiong L, Ct Mok V, Jin K, Yenari MA, Wei X, Wang Q. Cystatin C is a potential predictor of unfavorable outcomes for cerebral ischemia with intravenous tissue plasminogen activator treatment: A multicenter prospective nested case-control study. Eur J Neurol 2020; 28:1265-1274. [PMID: 33277774 DOI: 10.1111/ene.14663] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/12/2020] [Accepted: 11/30/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to explore whether cystatin C (CysC) could be used as a potential predictor of clinical outcomes in acute ischemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (IV-tPA). METHODS We performed an observational study including a retrospective analysis of data from 125 AIS patients with intravenous thrombolysis. General linear models were applied to compare CysC levels between groups with different outcomes; logistic regression analysis and receiver-operating characteristic curves were adopted to identify the association between CysC and the therapeutic effects. RESULTS Compared with the "good and sustained benefit" (GSB) outcome group (defined as ≥4-point reduction in National Institutes of Health Stroke Scale or a score of 0-1 at 24 h and 7 days) and the "good functional outcome" (GFO) group (modified Rankin Scale score 0-2 at 90 days), serum CysC baseline levels were increased in the non-GSB and non-GFO groups. Logistic regression analysis found that CysC was an independent negative prognostic factor for GSB (odds ratio [OR] 0.010; p = 0.005) and GFO (OR 0.011; p = 0.021) after adjustment for potential influencing factors. Receiver-operating characteristic curves showed the CysC-involved combined models provided credible efficacy for predicting post-90-day favorable clinical outcome (area under the curve 0.86; p < 0.001). CONCLUSIONS Elevated serum CysC is independently associated with unfavorable clinical outcomes after IV-tPA therapy in AIS. Our findings provide new insights into discovering potential mediators for neuropathological process or treatment in stroke.
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Affiliation(s)
- Zihan Chang
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Haiqiang Zou
- Department of Neurology, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Zhenchao Xie
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Bin Deng
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Rongfang Que
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Zifeng Huang
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Guomei Weng
- Department of Neurology, 1st People Hospital of Zhaoqing, Zhaoqing, China
| | - Zhihuan Wu
- Department of Neurology, 1st People Hospital of Zhaoqing, Zhaoqing, China
| | - Ying Pan
- Department of Neurology, the 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yanping Wang
- Department of Neurology, the 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Mengyan Li
- Department of Neurology, Guangzhou First People's Hospital, Guangzhou, China
| | - Huifang Xie
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Shuzhen Zhu
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Li Xiong
- Department of Medicine and Therapeutics, Faculty of Medicine, Gerald Choa Neuroscience Centre, Prince of Wales hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vincent Ct Mok
- Department of Medicine and Therapeutics, Faculty of Medicine, Gerald Choa Neuroscience Centre, Prince of Wales hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kunlin Jin
- Department of Neurology, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Midori A Yenari
- Department of Neurology, San Francisco & the San Francisco Veterans Affairs Medical Center, University of California, San Francisco, CA, USA
| | - Xiaobo Wei
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Qing Wang
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
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12
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Shen T, Zhou J, Zhao Y. Efficacy and safety of different doses of tenecteplase for the treatment of acute ischemic stroke: A protocol for a systematic review and network meta-analysis. Medicine (Baltimore) 2020; 99:e23379. [PMID: 33285721 PMCID: PMC7717732 DOI: 10.1097/md.0000000000023379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/28/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) has become the major reason of causing death around the world. As a newer generation fibrinolytic agent, the potential of tenecteplase in treating AIS has been determined in clinical studies and meta-analysis. However, various doses have been prescribed for tenecteplase in clinical practice, and the optimal dose is not yet clear. METHODS We will perform a systematic search to capture all potential randomized controlled trials (RCTs) of persons with confirmed AIS who were instructed to administer tenecteplase that report at least one outcome in PubMed, Embase, and the Cochrane Library. Two reviewers will independently check the titles, abstracts, and full-texts, extracting data, assessing the risk of bias and evaluating the certainty of evidence. We will use a random-effect model based on the Bayesian framework to completely direct and network meta-analyses. We will also test the robustness of all pooled results through conducting subgroup analyses according to the following criteria: DISCUSSION:: Our systematic review and network meta-analysis will generate several valuable findings and have several strengths including:We therefore believe that findings from this network meta-analysis will benefit future study design and improve evidence-based treatment of AIS. ETHICS AND DISSEMINATION We will disseminate the results from the present study through submitting it to conferences or peer-reviewed journal. PROTOCOL REGISTRY The protocol of our systematic review and network meta-analysis was registered in International Plateform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) platform with an approval number of INPLASY2020100086 (https://inplasy.com/inplasy-2020-10-0086/). Moreover, this protocol was funded through a protocol registry.
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Affiliation(s)
- Ting Shen
- Department of Neurology, Zhuji Hospital Affiliated to Shaoxing University of Arts and Science, Zhuji, Shaoxing
| | - Jinjian Zhou
- Department of Neurology, Zhuji Hospital Affiliated to Shaoxing University of Arts and Science, Zhuji, Shaoxing
| | - Yan Zhao
- Department of Neurology, People's Hospital of Banan District of Chongqing, Chongqing, China
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13
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Abstract
Stroke is a major cause of death and disability globally. Diagnosis depends on clinical features and brain imaging to differentiate between ischaemic stroke and intracerebral haemorrhage. Non-contrast CT can exclude haemorrhage, but the addition of CT perfusion imaging and angiography allows a positive diagnosis of ischaemic stroke versus mimics and can identify a large vessel occlusion target for endovascular thrombectomy. Management of ischaemic stroke has greatly advanced, with rapid reperfusion by use of intravenous thrombolysis and endovascular thrombectomy shown to reduce disability. These therapies can now be applied in selected patients who present late to medical care if there is imaging evidence of salvageable brain tissue. Both haemostatic agents and surgical interventions are investigational for intracerebral haemorrhage. Prevention of recurrent stroke requires an understanding of the mechanism of stroke to target interventions, such as carotid endarterectomy, anticoagulation for atrial fibrillation, and patent foramen ovale closure. However, interventions such as lowering blood pressure, smoking cessation, and lifestyle optimisation are common to all stroke subtypes.
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Affiliation(s)
- Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital and The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
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14
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Srivastava MP, Bhatia R, Vishnu VY, Goyal M. Essential Workflow and Performance Measures for Optimizing Acute Ischemic Stroke Treatment in India. Stroke 2020; 51:1969-1977. [DOI: 10.1161/strokeaha.119.026733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- M.V. Padma Srivastava
- Head of Department (Neurology), All India Institute of Medical Sciences (AIIMS), New Delhi (M.V.P.S.)
| | | | | | - Mayank Goyal
- Department of Radiology, Seaman Family MR Research Centre, Foothills Medical Centre, Calgary, Canada (M.G.)
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15
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Misra UK, Kalita J, Kumar M, Pradeep M. Authors' Reply to Rana et al. "Efficacy and Safety of Intravenous Tenecteplase Bolus in Acute Ischemic Stroke: Results of Two Open-Label, Multicenter Trials". Am J Cardiovasc Drugs 2019; 19:223-224. [PMID: 30793260 DOI: 10.1007/s40256-019-00334-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Usha K Misra
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Mritunjai Kumar
- Department of Neurology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, 492099, India
| | - Methil Pradeep
- K.G. Hospital and Post Graduate Institute, Coimbatore, Tamil Nadu, 641018, India.
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16
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Rana PB, Jacob NT, Toms T, Bhure S. Comment on: "Efficacy and Safety of Intravenous Tenecteplase Bolus in Acute Ischemic Stroke: Results of Two Open-Label, Multicenter Trials". Am J Cardiovasc Drugs 2019; 19:219-221. [PMID: 30793261 DOI: 10.1007/s40256-019-00333-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Prashant B Rana
- Boehringer Ingelheim India Pvt. Ltd, 400051, Mumbai, Maharashtra, India.
| | - Nilan T Jacob
- Boehringer Ingelheim India Pvt. Ltd, 400051, Mumbai, Maharashtra, India
| | - Tomson Toms
- Boehringer Ingelheim India Pvt. Ltd, 400051, Mumbai, Maharashtra, India
| | - Shraddha Bhure
- Boehringer Ingelheim India Pvt. Ltd, 400051, Mumbai, Maharashtra, India
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17
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Abstract
Vascular neurology is witnessing unprecedented innovations in the management of acute ischemic stroke, especially in reperfusion strategies. The emergence of mechanical thrombectomy with new generation devices has revolutionized the treatment of acute ischemic stroke with large vessel occlusion. The reperfusion strategies are evolving with the extension of the window period for thrombolysis and endovascular therapy through the concept of “tissue clock” in addition to the established “time clock.” The newer generation of thrombolytic drugs like tenecteplase are promising exciting times ahead in acute stroke care. In this “viewpoint,'” the evolution of reperfusion therapy in acute ischemic stroke will be discussed followed by recent innovations in reperfusion strategies.
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Affiliation(s)
- Venugopalan Y Vishnu
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - M V Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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