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Parsons MW, Yogendrakumar V, Churilov L, Garcia-Esperon C, Campbell BCV, Russell ML, Sharma G, Chen C, Lin L, Chew BL, Ng FC, Deepak A, Choi PMC, Kleinig TJ, Cordato DJ, Wu TY, Fink JN, Ma H, Phan TG, Markus HS, Molina CA, Tsai CH, Lee JT, Jeng JS, Strbian D, Meretoja A, Arenillas JF, Buck BH, Devlin MJ, Brown H, Butcher KS, O'Brien B, Sabet A, Wijeratne T, Bivard A, Grimley RS, Agarwal S, Munshi SK, Donnan GA, Davis SM, Miteff F, Spratt NJ, Levi CR. Tenecteplase versus alteplase for thrombolysis in patients selected by use of perfusion imaging within 4·5 h of onset of ischaemic stroke (TASTE): a multicentre, randomised, controlled, phase 3 non-inferiority trial. Lancet Neurol 2024; 23:775-786. [PMID: 38880118 DOI: 10.1016/s1474-4422(24)00206-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/05/2024] [Accepted: 05/07/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Intravenous tenecteplase increases reperfusion in patients with salvageable brain tissue on perfusion imaging and might have advantages over alteplase as a thrombolytic for ischaemic stroke. We aimed to assess the non-inferiority of tenecteplase versus alteplase on clinical outcomes in patients selected by use of perfusion imaging. METHODS This international, multicentre, open-label, parallel-group, randomised, clinical non-inferiority trial enrolled patients from 35 hospitals in eight countries. Participants were aged 18 years or older, within 4·5 h of ischaemic stroke onset or last known well, were not being considered for endovascular thrombectomy, and met target mismatch criteria on brain perfusion imaging. Patients were randomly assigned (1:1) by use of a centralised web server with randomly permuted blocks to intravenous tenecteplase (0·25 mg/kg) or alteplase (0·90 mg/kg). The primary outcome was the proportion of patients without disability (modified Rankin Scale 0-1) at 3 months, assessed via masked review in both the intention-to-treat and per-protocol populations. We aimed to recruit 832 participants to yield 90% power (one-sided alpha=0·025) to detect a risk difference of 0·08, with an absolute non-inferiority margin of -0·03. The trial was registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613000243718, and the European Union Clinical Trials Register, EudraCT Number 2015-002657-36, and it is completed. FINDINGS Recruitment ceased early following the announcement of other trial results showing non-inferiority of tenecteplase versus alteplase. Between March 21, 2014, and Oct 20, 2023, 680 patients were enrolled and randomly assigned to tenecteplase (n=339) and alteplase (n=341), all of whom were included in the intention-to-treat analysis (multiple imputation was used to account for missing primary outcome data for five patients). Protocol violations occurred in 74 participants, thus the per-protocol population comprised 601 people (295 in the tenecteplase group and 306 in the alteplase group). Participants had a median age of 74 years (IQR 63-82), baseline National Institutes of Health Stroke Scale score of 7 (4-11), and 260 (38%) were female. In the intention-to-treat analysis, the primary outcome occurred in 191 (57%) of 335 participants allocated to tenecteplase and 188 (55%) of 340 participants allocated to alteplase (standardised risk difference [SRD]=0·03 [95% CI -0·033 to 0·10], one-tailed pnon-inferiority=0·031). In the per-protocol analysis, the primary outcome occurred in 173 (59%) of 295 participants allocated to tenecteplase and 171 (56%) of 306 participants allocated to alteplase (SRD 0·05 [-0·02 to 0·12], one-tailed pnon-inferiority=0·01). Nine (3%) of 337 patients in the tenecteplase group and six (2%) of 340 in the alteplase group had symptomatic intracranial haemorrhage (unadjusted risk difference=0·01 [95% CI -0·01 to 0·03]) and 23 (7%) of 335 and 15 (4%) of 340 died within 90 days of starting treatment (SRD 0·02 [95% CI -0·02 to 0·05]). INTERPRETATION The findings in our study provide further evidence to strengthen the assertion of the non-inferiority of tenecteplase to alteplase, specifically when perfusion imaging has been used to identify reperfusion-eligible stroke patients. Although non-inferiority was achieved in the per-protocol population, it was not reached in the intention-to-treat analysis, possibly due to sample size limtations. Nonetheless, large-scale implementation of perfusion CT to assist in patient selection for intravenous thrombolysis in the early time window was shown to be feasible. FUNDING Australian National Health Medical Research Council; Boehringer Ingelheim.
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Affiliation(s)
- Mark W Parsons
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia; Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia.
| | - Vignan Yogendrakumar
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Leonid Churilov
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Carlos Garcia-Esperon
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Bruce C V Campbell
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Michelle L Russell
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia
| | - Gagan Sharma
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia; Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Chushuang Chen
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Longting Lin
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Beng Lim Chew
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia
| | - Felix C Ng
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Austin Health, Melbourne, VIC, Australia
| | | | - Philip M C Choi
- Department of Neuroscience, Box Hill Hospital, Eastern Health, Melbourne, VIC, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dennis J Cordato
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - John N Fink
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Henry Ma
- Schools of Clinical Science at Monash Health, Department of Medicine and Neurology, Monash University, Melbourne, VIC, Australia
| | - Thanh G Phan
- Schools of Clinical Science at Monash Health, Department of Medicine and Neurology, Monash University, Melbourne, VIC, Australia
| | - Hugh S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Carlos A Molina
- Vall d'Hebron Stroke Center, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Chon-Haw Tsai
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Juan F Arenillas
- Department of Neurology, Hospital Clínico Universitario, Valladolid Health Research Institute, University of Valladolid, Valladolid, Spain
| | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Michael J Devlin
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Helen Brown
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Ken S Butcher
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Arman Sabet
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Tissa Wijeratne
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, Western Health, Sunshine Hospital, St Albans, VIC, Australia
| | - Andrew Bivard
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Rohan S Grimley
- Sunshine Coast University Hospital, School of Medicine and Dentistry, Griffith University, Birtinya, QLD, Australia
| | - Smriti Agarwal
- Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge, UK
| | - Sunil K Munshi
- Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Geoffrey A Donnan
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Stephen M Davis
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Ferdinand Miteff
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Neil J Spratt
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Christopher R Levi
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
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Chausson N, Olindo S, Laborne FX, Aghasaryan M, Renou P, Soumah D, Debruxelles S, Altarcha T, Poli M, L'Hermitte Y, Sagnier S, Toudou-Daouda M, Aminou-Tassiou NR, Bentamra L, Benmoussa N, Alecu C, Imbernon C, Smadja L, Ouanounou G, Rouanet F, Sibon I, Smadja D. Second-dose intravenous thrombolysis with tenecteplase in alteplase-resistant medium-vessel-occlusion strokes: A retrospective and comparative study. Eur Stroke J 2024:23969873241254936. [PMID: 38829011 DOI: 10.1177/23969873241254936] [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: 06/05/2024] Open
Abstract
INTRODUCTION In intracranial medium-vessel occlusions (MeVOs), intravenous thrombolysis (IVT) shows inconsistent effectiveness and endovascular interventions remains unproven. We evaluated a new therapeutic strategy based on a second IVT using tenecteplase for MeVOs without early recanalization post-alteplase. PATIENTS AND METHODS This retrospective, comparative study included consecutively low bleeding risk MeVO patients treated with alteplase 0.9 mg/kg at two stroke centers. One center used a conventional single-IVT approach; the other applied a dual-IVT strategy, incorporating a 1-h post-alteplase MRI and additional tenecteplase, 0.25 mg/kg, if occlusion persisted. Primary outcomes were 24-h successful recanalization for efficacy and symptomatic intracranial hemorrhage (sICH) for safety. Secondary outcomes included 3-month excellent outcomes (modified Rankin Scale score of 0-1). Comparisons were conducted in the overall cohort and a propensity score-matched subgroup. RESULTS Among 146 patients in the dual-IVT group, 103 failed to achieve recanalization at 1 h and of these 96 met all eligible criteria and received additional tenecteplase. Successful recanalization at 24 h was higher in the 146 dual-IVT cohort patients than in the 148 single-IVT cohort patients (84% vs 61%, p < 0.0001), with similar sICH rate (3 vs 2, p = 0.68). Dual-IVT strategy was an independent predictor of 24-h successful recanalization (OR, 2.7 [95% CI, 1.52-4.88]; p < 0.001). Dual-IVT cohort patients achieved higher rates of excellent outcome (69% vs 44%, p < 0.0001). Propensity score matching analyses supported all these associations. CONCLUSION In this retrospective study, a dual-IVT strategy in selected MeVO patients was associated with higher odds of 24-h recanalization, with no safety concerns. However, potential center-level confounding and biases seriously limit these findings' interpretation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05809921.
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Affiliation(s)
- Nicolas Chausson
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
- INSERM U1266, Paris, France
| | | | | | - Manvel Aghasaryan
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Pauline Renou
- Unité Neuro-vasculaire, CHU de Bordeaux, Bordeaux, France
| | - Djibril Soumah
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | | | - Tony Altarcha
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Mathilde Poli
- Unité Neuro-vasculaire, CHU de Bordeaux, Bordeaux, France
| | - Yann L'Hermitte
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | | | | | | | - Leila Bentamra
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Narimane Benmoussa
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Cosmin Alecu
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Carole Imbernon
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Léonard Smadja
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Gary Ouanounou
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | | | - Igor Sibon
- Unité Neuro-vasculaire, CHU de Bordeaux, Bordeaux, France
| | - Didier Smadja
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
- INSERM U1266, Paris, France
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Zarzour A, Batot C, Boisseau W, Cho TH, Guillon B, Richard S, Marnat G, Arquizan C, Lapergue B, Weisenburger Lile D. Tenecteplase versus Alteplase before thrombectomy: A comprehensive evaluation of clinical and angiographic impact: Insights from the ETIS registry. J Neuroradiol 2024; 51:101189. [PMID: 38462131 DOI: 10.1016/j.neurad.2024.02.007] [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: 01/13/2024] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Data on prior use of Tenecteplase versus Alteplase in acute stroke management by mechanical thrombectomy are controversial. Our primary objective was to make a comprehensive comparative assessment of clinical and angiographic efficacy and safety outcomes in a large prospective observational study. METHODS We included stroke patients who were eligible for intravenous thrombolysis and endovascular thrombectomy between 2019 and 2021, from an ongoing registry in twenty comprehensive stroke centers in France. We divided patients into two groups based on the thrombolytic agent used (Alteplase vs Tenecteplase). We then compared their treatment times, and their angiographic (TICI scale), clinical (mRS at three months and sICH) and safety outcomes after controlling for potential confounders using propensity score methods. RESULTS We evaluated 1131 patients having undergone thrombectomy for the final analysis, 250 received Tenecteplase and 881 Alteplase. Both groups were of the same median age (75 vs 74 respectively), and had the same baseline NIHSS score (16) and ASPECTS (8). There was no significant difference for First Pass Effect (OR 0.93, 95 % CI 0.76-1.14, p = 0.75), time required for reperfusion (OR 0.03, 95 % CI 0.09-0.16, p = 0.49), or for final reperfusion status. Clinically, functional independence at 90 days was similar in both groups (OR 0.82, 95 % CI 0.61-1.10, p = 0.18) with the same risk of sICH (OR 1.36, 95 % CI 0.77-2.41, p = 0.28). However, Tenecteplase patients had shorter imaging-to-groin puncture times (99 vs 142 min, p < 0.05). CONCLUSIONS Tenecteplase showed no better clinical or angiographic impact on thrombectomy compared to Alteplase. Nevertheless, it appeared associated with a shorter thrombolysis-to-groin puncture time.
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Affiliation(s)
- Amine Zarzour
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France.
| | - Cedric Batot
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - William Boisseau
- Stroke Unit Neurology, Hôpital Fondation A. de Rothschild, Université Paris-Cité, Université, Paris-Cité and Université Sorbonne Paris Nord (J.P.D.), INSERM, LVTS, F-75018 Paris, France
| | - Tae-Hee Cho
- From the Department of Stroke Medicine, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1044, INSA-Lyon, Hospices Civils de Lyon, Lyon, France
| | - Benoit Guillon
- Department of Neurology, Stroke Center, University Hospital of Nantes, Nantes, France
| | - Sébastien Richard
- Neurology, Stroke Unit, Université, CIC-P 1433, INSERM U1116, CHRU-Nancy, F-54000 Nancy, France
| | - Gaultier Marnat
- Department of Interventional Neuroradiology, University Hospital of Bordeaux, France
| | - Caroline Arquizan
- Department of Neurology, Stroke center, Hôpital Gui de Chauliac, Montpellier Neuroradiology, France
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
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Xu Y, Hu Y, Wu G, Niu L, Fang C, Li Y, Jiang L, Yuan C, Huang M. Specific inhibition on PAI-1 reduces the dose of Alteplase for ischemic stroke treatment. Int J Biol Macromol 2024; 257:128618. [PMID: 38070813 DOI: 10.1016/j.ijbiomac.2023.128618] [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: 09/08/2023] [Revised: 11/30/2023] [Accepted: 12/02/2023] [Indexed: 12/21/2023]
Abstract
Administration of recombinant tPA (rtPA, or trade name Alteplase®) is an FDA-approved therapy for acute ischemic stroke (AIS), but poses the risk of hemorrhagic complications. Recombinant tPA can be rapidly inactivated by the endogenous inhibitor, plasminogen activator inhibitor 1 (PAI-1). In this work, we study a novel treatment approach that combines a PAI-1 inhibitor, PAItrap4, with a reduced dose of rtPA to address the hemorrhagic concern of rtPA. PAItrap4 is a highly specific and very potent protein-based inhibitor of PAI-1, comprising of a variant of uPA serine protease domain, human serum albumin, and a cyclic RGD peptide. PAItrap4 efficiently targets and inhibits PAI-1 on activated platelets, and also possesses a long half-life in vivo. Our results demonstrate that PAItrap4 effectively counteracts the inhibitory effects of PAI-1 on rtPA, preserving rtPA activity based on amidolytic and clot lysis assays. In an in vivo murine stroke model, PAItrap4, together with low-dose rtPA, enhances the blood perfusion in the stroke-affected areas, reduces infarct size, and promotes neurological recovery in mice. Importantly, such treatment does not increase the amount of cerebral hemorrhage, thus reducing the risk of cerebral hemorrhage. In addition, PAItrap4 does not compromise the normal blood coagulation function in mice, demonstrating its safety as a therapeutic agent. These findings highlight this combination therapy as a promising alternative for the treatment of ischemic stroke, offering improved safety and efficacy.
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Affiliation(s)
- Yanyan Xu
- College of Chemical Engineering, Fuzhou University, Fujian 350108, China; National Joint Research Center on Biomedical Photodynamic Technology, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Yinping Hu
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China; National Joint Research Center on Biomedical Photodynamic Technology, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Guangqian Wu
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China; National Joint Research Center on Biomedical Photodynamic Technology, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Lili Niu
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China; National Joint Research Center on Biomedical Photodynamic Technology, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Chao Fang
- Department of Pharmacology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Yongkun Li
- Department of Neurology, Fujian Provincial Hospital, Shengli Clinical College of Fujian Medical University, No. 134 Dong Street, Fuzhou, Fujian 350001, China
| | - Longguang Jiang
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China; National Joint Research Center on Biomedical Photodynamic Technology, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Cai Yuan
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian, 350108, China; National Joint Research Center on Biomedical Photodynamic Technology, Fuzhou University, Fuzhou, Fujian 350108, China.
| | - Mingdong Huang
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China; National Joint Research Center on Biomedical Photodynamic Technology, Fuzhou University, Fuzhou, Fujian 350108, China.
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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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Ostos F, Rodríguez-López A, Martin Jiménez P, Sánchez CS, Martínez-Salio A, Ballenilla F, Lizasoaín I, Calleja-Castaño P. Use of Tenecteplase in Acute Ischemic Stroke in the Time of SARS-CoV-2. Neurohospitalist 2023; 13:266-271. [PMID: 37441211 PMCID: PMC10334066 DOI: 10.1177/19418744231167491] [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: 07/15/2023] Open
Abstract
Tenecteplase (TNK) is a fibrinolytic drug that is administrated in a single bolus, recommended in eligible patients with acute ischemic stroke prior to mechanical thrombectomy. This study explores its usefulness in adverse situations, such as the SARS-CoV-2 pandemic. We conducted a retrospective study involving consecutive patients with suspected acute ischemic stroke treated either with intravenous fibrinolysis with alteplase during 2019 or with TNK (.25 mg/kg) between March 2020 and February 2021. A comparative analysis was made to compare patient treatment times and prognosis. A total of 117 patients treated with alteplase and 92 with TNK were included. No significant differences were observed in age, main vascular risk factors or previous treatments. The median National Institutes of Health Stroke Scale was 8 in the alteplase group and 10 in those treated with TNK (P = .13). Combined treatment with mechanical thrombectomy was performed in 47% in the alteplase group and 46.7% in the TNK group; Thrombolysis In Cerebral Infarction scale 2b-3 recanalization was achieved in 83% and 90.7%, respectively (P = .30). There was a decrease in onset-to-needle median time (165 min vs 140 min, P < .01) and no significant variations in door-needle median time. There was no significant difference in the incidence of symptomatic hemorrhagic transformation in mortality or functional independence at 3 months. The easier administration of TNK has improved the accessibility of fibrinolytic therapy, even in adverse circumstances, such as the COVID-19 pandemic. Its use appears to be safe and effective, even in patients who are not candidates for mechanical thrombectomy.
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Affiliation(s)
- Fernando Ostos
- Stroke Center, Department of Neurology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain
| | | | - Paloma Martin Jiménez
- Stroke Center, Department of Neurology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Carmen Sánchez Sánchez
- Stroke Center, Department of Neurology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Antonio Martínez-Salio
- Stroke Center, Department of Neurology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Federico Ballenilla
- Department of Radiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ignacio Lizasoaín
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain
- Unidad de Investigación Neurovascular, Department of Pharmacology, Faculty of Medicine, Universidad Complutense, Madrid, Spain
| | - Patricia Calleja-Castaño
- Stroke Center, Department of Neurology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain
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Sinclair JE, Plante M, Harrison MF, Sanghavi DK. ST-elevation myocardial infarction after thrombolytic therapy with Tenecteplase for acute ischaemic stroke. BMJ Case Rep 2023; 16:e252253. [PMID: 37316282 PMCID: PMC10277056 DOI: 10.1136/bcr-2022-252253] [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] [Indexed: 06/16/2023] Open
Abstract
Myocardial infarction (MI) secondary to thrombolytic therapy in the setting of acute ischaemic stroke (AIS) is a rare but severe complication. This phenomenon has been well documented in the past with recombinant tissue-type plasminogen activator, also known as Alteplase. However, there are no documented reports of MI secondary to Tenecteplase (TNKase), an alternative thrombolytic agent rapidly gaining favour in managing AIS. We report a male patient in his 50s who received TNKase for an AIS and subsequently developed an inferolateral ST elevation MI.
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Affiliation(s)
- Jorge Enrique Sinclair
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Marie Plante
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael F Harrison
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Devang K Sanghavi
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
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Yogendrakumar V, Churilov L, Mitchell PJ, Kleinig TJ, Yassi N, Thijs V, Wu T, Shah D, Bailey P, Dewey HM, Choi PMC, Ma A, Wijeratne T, Garcia-Esperon C, Cloud G, Chandra RV, Cordato DJ, Yan B, Sharma G, Desmond PM, Parsons MW, Donnan GA, Davis SM, Campbell BCV. Safety and Efficacy of Tenecteplase and Alteplase in Patients With Tandem Lesion Stroke: A Post Hoc Analysis of the EXTEND-IA TNK Trials. Neurology 2023; 100:e1900-e1911. [PMID: 36878701 PMCID: PMC10159769 DOI: 10.1212/wnl.0000000000207138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 01/18/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The safety and efficacy of tenecteplase (TNK) in patients with tandem lesion (TL) stroke is unknown. We performed a comparative analysis of TNK and alteplase in patients with TLs. METHODS We first compared the treatment effect of TNK and alteplase in patients with TLs using individual patient data from the EXTEND-IA TNK trials. We evaluated intracranial reperfusion at initial angiographic assessment and 90-day modified Rankin scale (mRS) with ordinal logistic and Firth regression models. Because 2 key outcomes, mortality and symptomatic intracranial hemorrhage (sICH), were few in number among those who received alteplase in the EXTEND-IA TNK trials, we generated pooled estimates for these outcomes by supplementing trial data with estimates of incidence obtained through a meta-analysis of studies identified in a systematic review. We then calculated unadjusted risk differences to compare the pooled estimates for those receiving alteplase with the incidence observed in the trial among those receiving TNK. RESULTS Seventy-one of 483 patients (15%) in the EXTEND-IA TNK trials possessed a TL. In patients with TLs, intracranial reperfusion was observed in 11/56 (20%) of TNK-treated patients vs 1/15 (7%) alteplase-treated patients (adjusted odds ratio 2.19; 95% CI 0.28-17.29). No significant difference in 90-day mRS was observed (adjusted common odds ratio 1.48; 95% CI 0.44-5.00). A pooled study-level proportion of alteplase-associated mortality and sICH was 0.14 (95% CI 0.08-0.21) and 0.09 (95% CI 0.04-0.16), respectively. Compared with a mortality rate of 0.09 (95% CI 0.03-0.20) and an sICH rate of 0.07 (95% CI 0.02-0.17) in TNK-treated patients, no significant difference was observed. DISCUSSION Functional outcomes, mortality, and sICH did not significantly differ between patients with TLs treated with TNK and those treated with alteplase. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that TNK is associated with similar rates of intracranial reperfusion, functional outcome, mortality, and sICH compared with alteplase in patients with acute stroke due to TLs. However, the CIs do not rule out clinically important differences. TRIAL REGISTRATION INFORMATION: clinicaltrials.gov/ct2/show/NCT02388061; clinicaltrials.gov/ct2/show/NCT03340493.
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Affiliation(s)
- Vignan Yogendrakumar
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia.
| | - Leonid Churilov
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Peter J Mitchell
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Timothy J Kleinig
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Nawaf Yassi
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Vincent Thijs
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Teddy Wu
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Darshan Shah
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Peter Bailey
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Helen M Dewey
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Philip M C Choi
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Alice Ma
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Tissa Wijeratne
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Carlos Garcia-Esperon
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Geoffrey Cloud
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Ronil V Chandra
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Dennis J Cordato
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Bernard Yan
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Gagan Sharma
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Patricia M Desmond
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Mark W Parsons
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Geoffrey A Donnan
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Stephen M Davis
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Bruce C V Campbell
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
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9
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Olindo S, Albucher JF, Bejot Y, Berge J, Cordonnier C, Guillon B, Sablot D, Tardy J, Alamowitch S, Sibon I. Tenecteplase in acute ischemic stroke: Review of the literature and expert consensus from the French Neurovascular Society. Rev Neurol (Paris) 2023; 179:150-160. [PMID: 36369068 DOI: 10.1016/j.neurol.2022.08.005] [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: 02/22/2022] [Revised: 08/04/2022] [Accepted: 08/22/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intravenous alteplase is the only thrombolytic treatment approved for patients with acute ischemic stroke (AIS). Although no randomized controlled trial (RCT) has shown the superiority of tenecteplase over alteplase in AIS, tenecteplase is increasingly used off-label in Stroke Units. The purpose of the present work was to provide an up-to-date set of expert consensus statements on the use of tenecteplase in AIS. METHODS Members of the working group were selected by the French Neurovascular Society. RCTs comparing tenecteplase and alteplase in the treatment of AIS were reviewed. Recent meta-analysis and real-life experience data on tenecteplase published until 30th October 2021 were also analyzed. After a description of the available data, we tried to answer the subsequent questions about the use of tenecteplase in AIS: What dosage of tenecteplase should be preferred? How effective is tenecteplase for cerebral artery recanalization? What is the clinical effectiveness of tenecteplase? What is the therapeutic safety of tenecteplase? What are the benefits associated with tenecteplase ease of use? Then expert consensus statements for tenecteplase use were submitted. In October 2021 the working group was asked to review and revise the manuscript. In November 2021, the current version of the manuscript was approved. EXPERT CONSENSUS A set of three expert consensus statements for the use of tenecteplase within 4.5hours of symptom onset in AIS patients were issued: (1) It is reasonable to use tenecteplase 0.25mg/kg when mechanical thrombectomy (MT) is planned. (2) Tenecteplase 0.25mg/kg can be used as an alternative to alteplase 0.9mg/kg in patients with medium- or small-vessel occlusion not retrievable with MT. (3) Tenecteplase 0.25mg/kg could be considered as an alternative to alteplase 0.9mg/kg in patients without vessel occlusion. CONCLUSIONS These expert consensus statements could provide a framework to guide the clinical decision-making process for the use of tenecteplase according to admission characteristics of AIS patients. However, existing data are limited, requiring inclusions in ongoing RCTs or real-life registries.
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Affiliation(s)
- S Olindo
- Service de Neurovasculaire, Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - J-F Albucher
- Unité Neuro-Vasculaire, Hôpital Pierre-Paul-Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Y Bejot
- Service Hospitalo-Universitaire de Neurologie, CHU de Dijon Bourgogne, Dijon, France
| | - J Berge
- Service de Neuro-Radiologie, Hôpital Pellegrin, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | - C Cordonnier
- Université Lille, Inserm, CHU Lille, U1172, LiINCog, Lille Neuroscience and Cognition, Lille, France
| | - B Guillon
- Unité Neurovasculaire, Hôpital G&R Laënnec, CHU de Nantes, Nantes, France
| | - D Sablot
- Service de Neurologie, Hôpital de Perpignan, Perpignan, France
| | - J Tardy
- Unité Neuro-Vasculaire, Clinique des Cèdres, Cornebarrieu, France
| | - S Alamowitch
- Urgences Cérébro-Vasculaires, Hôpital Salpêtrière-Saint Antoine, AP-HP, Sorbonne Université, Stare Team, iCRIN, Institut du cerveau, Inserm UMRS 938, Paris, France
| | - I Sibon
- Service de Neurovasculaire, Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
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10
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Mujanovic A, Kammer C, Kurmann CC, Grunder L, Beyeler M, Lang MF, Piechowiak EI, Meinel TR, Jung S, Almiri W, Pilgram-Pastor S, Hoffmann A, Seiffge DJ, Heldner MR, Dobrocky T, Mordasini P, Arnold M, Gralla J, Fischer U, Kaesmacher J. Association of Intravenous Thrombolysis with Delayed Reperfusion After Incomplete Mechanical Thrombectomy. Clin Neuroradiol 2023; 33:87-98. [PMID: 35833948 PMCID: PMC10014807 DOI: 10.1007/s00062-022-01186-7] [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: 03/04/2022] [Accepted: 05/31/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Treatment of distal vessel occlusions causing incomplete reperfusion after mechanical thrombectomy (MT) is debated. We hypothesized that pretreatment with intravenous thrombolysis (IVT) may facilitate delayed reperfusion (DR) of residual vessel occlusions causing incomplete reperfusion after MT. METHODS Retrospective analysis of patients with incomplete reperfusion after MT, defined as extended thrombolysis in cerebral infarction (eTICI) 2a-2c, and available perfusion follow-up imaging at 24 ± 12 h after MT. DR was defined as absence of any perfusion deficit on time-sensitive perfusion maps, indicating the absence of any residual occlusion. The association of IVT with the occurrence of DR was evaluated using a logistic regression analysis adjusted for confounders. Sensitivity analyses based on IVT timing (time between IVT start and the occurrence incomplete reperfusion following MT) were performed. RESULTS In 368 included patients (median age 73.7 years, 51.1% female), DR occurred in 225 (61.1%). Atrial fibrillation, higher eTICI grade, better collateral status and longer intervention-to-follow-up time were all associated with DR. IVT did not show an association with the occurrence of DR (aOR 0.80, 95% CI 0.44-1.46, even in time-sensitive strata, aOR 2.28 [95% CI 0.65-9.23] and aOR 1.53 [95% CI 0.52-4.73] for IVT to incomplete reperfusion following MT timing <80 and <100 min, respectively). CONCLUSION A DR occurred in 60% of patients with incomplete MT at ~24 h and did not seem to occur more often in patients receiving pretreatment IVT. Further research on potential associations of IVT and DR after MT is required.
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Affiliation(s)
- Adnan Mujanovic
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Christoph Kammer
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Christoph C Kurmann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Lorenz Grunder
- University Institute of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Morin Beyeler
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Matthias F Lang
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Eike I Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - William Almiri
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Sara Pilgram-Pastor
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Angelika Hoffmann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J Seiffge
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland.
- University Institute of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland.
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11
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Yogendrakumar V, Beharry J, Churilov L, Alidin K, Ugalde M, Pesavento L, Weir L, Mitchell PJ, Kleinig TJ, Yassi N, Thijs V, Wu TY, Shah DG, Dewey HM, Wijeratne T, Yan B, Desmond PM, Sharma G, Parsons MW, Donnan GA, Davis SM, Campbell BCV, Bush S, Scroop R, Simpson M, Brooks M, Asadi H, Ang T, Miteff F, Levi C, Rodrigues E, Zhao H, Alemseged F, Ng F, Salvaris P, Garcia‐Esperon C, Bailey P, Rice H, de Villiers L, Choi P, Brown H, Redmond K, Leggett D, Fink J, Collecutt W, Kraemer T, Cordato D, Muller C, Coulthard A, Mitchell K, Clouston J, Mahady K, Field D, O’Brien B, Clissold B, Clissold A, Cloud G, Bolitho L, Bonavia L, Bhattacharya A, Wright A, Mamun A, O’Rourke F, Worthington J, Wong A, Ma H, Phan T, Chong W, Chandra R, Slater L, Krause M, Harrington T, Faulder K, Steinfort B, Bladin C. Tenecteplase Improves Reperfusion across Time in Large Vessel Stroke. Ann Neurol 2023; 93:489-499. [PMID: 36394101 DOI: 10.1002/ana.26547] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/17/2022] [Accepted: 11/08/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Tenecteplase improves reperfusion compared to alteplase in patients with large vessel occlusions. To determine whether this improvement varies across the spectrum of thrombolytic agent to reperfusion assessment times, we performed a comparative analysis of tenecteplase and alteplase reperfusion rates. METHODS Patients with large vessel occlusion and treatment with thrombolysis were pooled from the Melbourne Stroke Registry, and the EXTEND-IA and EXTEND-IA TNK trials. The primary outcome, thrombolytic-induced reperfusion, was defined as the absence of retrievable thrombus or >50% reperfusion at imaging reassessment. We compared the treatment effect of tenecteplase and alteplase, accounting for thrombolytic to assessment exposure times, via Poisson modeling. We compared 90-day outcomes of patients who achieved reperfusion with a thrombolytic to patients who achieved reperfusion via endovascular therapy using ordinal logistic regression. RESULTS Among 893 patients included in the primary analysis, thrombolytic-induced reperfusion was observed in 184 (21%) patients. Tenecteplase was associated with higher rates of reperfusion (adjusted incidence rate ratio [aIRR] = 1.50, 95% confidence interval [CI] = 1.09-2.07, p = 0.01). Findings were consistent in patient subgroups with first segment (aIRR = 1.41, 95% CI = 0.93-2.14) and second segment (aIRR = 2.07, 95% CI = 0.98-4.37) middle cerebral artery occlusions. Increased thrombolytic to reperfusion assessment times were associated with reperfusion (tenecteplase: adjusted risk ratio [aRR] = 1.08 per 15 minutes, 95% CI = 1.04-1.13 vs alteplase: aRR = 1.06 per 15 minutes, 95% CI = 1.00-1.13). No significant treatment-by-time interaction was observed (p = 0.87). Reperfusion via thrombolysis was associated with improved 90-day modified Rankin Scale scores (adjusted common odds ratio = 2.15, 95% CI = 1.54-3.01) compared to patients who achieved reperfusion following endovascular therapy. INTERPRETATION Tenecteplase, compared to alteplase, increases prethrombectomy reperfusion, regardless of the time from administration to reperfusion assessment. Prethrombectomy reperfusion is associated with better clinical outcomes. ANN NEUROL 2023;93:489-499.
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Affiliation(s)
- Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - James Beharry
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Khairunnisa Alidin
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Melissa Ugalde
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Lauren Pesavento
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Louise Weir
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Vincent Thijs
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Darshan G Shah
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, 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, 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, University of Melbourne, Parkville, Victoria, Australia.,Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Liverpool Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
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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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13
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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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14
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Derraz I. The End of Tissue-Type Plasminogen Activator's Reign? Stroke 2022; 53:2683-2694. [PMID: 35506385 DOI: 10.1161/strokeaha.122.039287] [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: 11/16/2022]
Abstract
Mechanical thrombectomy is a highly effective treatment for acute ischemic stroke caused by large-vessel occlusion in the anterior cerebral circulation, significantly increasing the likelihood of recovery to functional independence. Until recently, whether intravenous thrombolysis before mechanical thrombectomy provided additional benefits to patients with acute ischemic stroke-large-vessel occlusion remained unclear. Given that reperfusion is a key factor for clinical outcome in patients with acute ischemic stroke-large-vessel occlusion and the efficacy of both intravenous thrombolysis and mechanical thrombectomy is time-dependent, achieving complete reperfusion with a single pass should be the primary angiographic goal. However, it remains undetermined whether extending the procedure with additional endovascular attempts or local lytics administration safely leads to higher reperfusion grades and whether there are significant public health and cost implications. Here, we outline the current state of knowledge and research avenues that remain to be explored regarding the consistent therapeutic benefit of intravenous thrombolysis in anterior circulation strokes and the potential place of adjunctive intra-arterial lytics administration, including alternative thrombolytic agent place.
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Affiliation(s)
- Imad Derraz
- Department of Neuroradiology, Hôpital Guide Chauliac, Montpellier University Medical Center, France
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15
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Kvistad CE, Næss H, Helleberg BH, Idicula T, Hagberg G, Nordby LM, Jenssen KN, Tobro H, Rörholt DM, Kaur K, Eltoft A, Evensen K, Haasz J, Singaravel G, Fromm A, Thomassen L. Tenecteplase versus alteplase for the management of acute ischaemic stroke in Norway (NOR-TEST 2, part A): a phase 3, randomised, open-label, blinded endpoint, non-inferiority trial. Lancet Neurol 2022; 21:511-519. [DOI: 10.1016/s1474-4422(22)00124-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/14/2022] [Accepted: 03/17/2022] [Indexed: 12/18/2022]
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16
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Li S, Pan Y, Wang Z, Liang Z, Chen H, Wang D, Sui Y, Zhao X, Wang Y, Du W, Zheng H, Wang Y. Safety and efficacy of tenecteplase versus alteplase in patients with acute ischaemic stroke (TRACE): a multicentre, randomised, open label, blinded-endpoint (PROBE) controlled phase II study. Stroke Vasc Neurol 2021; 7:47-53. [PMID: 34429364 PMCID: PMC8899644 DOI: 10.1136/svn-2021-000978] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/02/2021] [Indexed: 12/02/2022] Open
Abstract
Background Tenecteplase (TNK) possesses several pharmacological characteristics superior to conventional alteplase (rt-PA), with well-established safety and efficacy profile in Caucasians. There exists controversy over the optimal dose of intravenous rt-PA for East Asians with acute ischaemic stroke (AIS). Current study aimed to determine the safety dose range of recombinant human TNK tissue-type plasminogen activator (rhTNK-tPA) for patients with AIS in China. Methods This multicentre, prospective, randomised, open-label, blinded end-point, phase II study compared three tiers of 0.1, 0.25, 0.32 mg/kg rhTNK-tPA (to a maximum of 40 mg) with standard 0.9 mg/kg rt-PA (to a maximum of 90 mg) in patients who were eligible for intravenous thrombolysis. The safety outcome were symptomatic intracranial haemorrhage (sICH) within 36 hours. Results Between May 2018 and February 2020, 240 patients were randomly assigned to four group, 4 of whom did not receive study treatment. The intention-to-treat analysis included 236 patients. There was no difference in the improvement on National Institutes of Health Stroke Scale at day 14 in the 3 tiers and control group (63.3%, 77.2%, 66.7% vs 62.7%). The number of sICH was 3 of 60 (5.0%) in the 0.1 mg/kg group, none in the 0.25 mg/kg group, 2 of 60 (3.3%) in the 0.32 mg/kg group and 1 (1.7%) of 59 in the rt-PA group. There were no significant between-group differences in severe adverse events. Conclusions Similar to the Caucasians, rhTNK-tPA was well tolerated in Chinese patients with AIS at all doses administered within 3 hours of symptom onset. The dose-efficacy profile of rhTNK-tPA needs to be established with future investigations. Trial registration number NCT04676659.
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Affiliation(s)
- Shuya Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Ziran Wang
- Department of Neurology, Linyi People's Hospital, Linyi, China
| | - Zhigang Liang
- Department of Neurology, Affiliated Yantai Yuhuangding Hospital of Qingdao University Medical College, YanTai, China
| | - Huisheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, Liaoning, China
| | - Dong Wang
- Department of Neurology, Baogang Hospital of Inner Monglia, Inner Monglia, China
| | - Yi Sui
- Department of Neurology, The First People's Hospital of Shenyang, Shenyang, China
| | | | - Yilong Wang
- Neurology, Beijing Tiantan Hospital, Beijing, China
| | - WanLiang Du
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
| | | | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China .,Department of Neurology, Beijing Tiantan Hospital, Beijing, China
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17
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Psychogios K, Palaiodimou L, Katsanos AH, Magoufis G, Safouris A, Kargiotis O, Spiliopoulos S, Papageorgiou E, Theodorou A, Voumvourakis K, Broutzos E, Stamboulis E, Tsivgoulis G. Real-world comparative safety and efficacy of tenecteplase versus alteplase in acute ischemic stroke patients with large vessel occlusion. Ther Adv Neurol Disord 2021; 14:1756286420986727. [PMID: 33488774 PMCID: PMC7809628 DOI: 10.1177/1756286420986727] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/15/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND AIMS Tenecteplase has recently emerged as an alternative thrombolytic agent in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO), possibly superior in achieving early reperfusion compared with alteplase. We aimed to compare the safety and efficacy of intravenous tenecteplase with intravenous alteplase for AIS patients with LVO in everyday clinical practice settings. METHODS We prospectively evaluated patients with AIS due to LVO, treated with intravenous thrombolysis (IVT) with or without mechanical thrombectomy in two tertiary stroke centers. Patients were treated with standard-dose alteplase (0.9 mg/kg) or 0.25 mg/kg tenecteplase. Safety outcomes included prevalence of symptomatic intracranial hemorrhage (sICH) and mortality. Efficacy outcomes included averted thrombectomy, major neurological improvement at 24 h (defined as decrease in baseline NIHSS score of 8 points or greater) and functional status on discharge and on 3 months assessed by modified Rankin Scale (mRS). RESULTS Nineteen AIS patients with LVO received tenecteplase and 39 received alteplase. We observed a non-significant higher rate of averted thrombectomies (32% versus 18%, p = 0.243) and a non-significant higher rate of sICH (16% versus 5%, p = 0.201) in the tenecteplase group. The rate of 24 h major neurological improvement was higher in the tenecteplase group (64% versus 33%, p = 0.046) but this was marginally attenuated in multivariable analyses (adjusted OR 10.22, 95% CI: 0.73-142.98; p = 0.084). Discharge mRS, 3-months mRS, and 3-month functional independence (mRS scores of 0-2) did not differ (p > 0.2) between the two groups. The rates of 3-month mortality (11% versus 18%, p = 0.703) were similar in the two groups. No independent association between thrombolytic agent and safety or efficacy outcomes emerged in multivariable regression analyses. CONCLUSION The present pilot observational study highlights that AIS patients with LVO treated with 0.25 mg/kg bolus administration of tenecteplase had increased likelihood to achieve early neurological improvement compared with AIS patients treated with alteplase, but this association was attenuated after adjustment for potential confounders. There were no significant differences in 3-month functional or safety outcomes between the two groups. This preliminary real-world observation requires independent confirmation in larger, multicenter studies.
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Affiliation(s)
- Klearchos Psychogios
- Acute Stroke Unit, Metropolitan Hospital, Ethnarhou Makariou 9, Athens, Piraeus 18547, Greece
- Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Lina Palaiodimou
- Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Aristeidis H. Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Georgios Magoufis
- Department of Interventional Neuroradiology, Metropolitan Hospital, Piraeus, Greece
| | | | | | - Stavros Spiliopoulos
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | | | - Aikaterini Theodorou
- Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Elias Broutzos
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
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18
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Rabinstein AA, Golombievski E, Biller J. Tenecteplase for Acute Ischemic Stroke: Current Evidence and Practical Considerations. CNS Drugs 2020; 34:1009-1014. [PMID: 32785891 DOI: 10.1007/s40263-020-00757-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Tenecteplase offers pharmacological advantages over alteplase, and growing evidence supports its consideration for the treatment of patients with acute ischemic stroke. Its ease of administration as a single bolus makes it a preferable agent for patients who need to be urgently transported to a comprehensive stroke center for endovascular therapy (drip and ship) and for patients first evaluated at comprehensive stroke centers who are eligible for endovascular intervention (combined intravenous and endovascular approach). Recent randomized controlled trials indicated that the efficacy of tenecteplase may be similar to that of alteplase in patients with mild strokes and that it is superior to alteplase for patients with more severe strokes from a large vessel occlusion. Cumulative evidence currently favors the use of the 0.25 mg/kg dose. While tenecteplase has not been approved by regulatory agencies in the USA or the EU for the treatment of acute ischemic stroke, ongoing trials and additional clinical experience from countries where it is already being used in practice will likely clarify the role of tenecteplase for the acute management of ischemic stroke in the near future.
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Affiliation(s)
- Alejandro A Rabinstein
- Department of Neurology, Mayo Clinic, 200 First Street SW, Mayo W8B, Rochester, MN, USA.
| | - Esteban Golombievski
- Department of Neurology, Stritch School of Medicine, Loyola University, Chicago, IL, USA
| | - Jose Biller
- Department of Neurology, Stritch School of Medicine, Loyola University, Chicago, IL, USA
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19
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Thommessen B, Næss H, Logallo N, Kvistad CE, Waje-Andreassen U, Ihle-Hansen H, Ihle-Hansen H, Thomassen L, Morten Rønning O. Tenecteplase versus alteplase after acute ischemic stroke at high age. Int J Stroke 2020; 16:295-299. [PMID: 32631157 DOI: 10.1177/1747493020938306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Stroke prevalence is increasing with age. Alteplase is the only agent approved for thrombolytic treatment for patients with ischemic stroke, including patients ≥80 years. In the present study, the aim was to compare efficacy and safety of tenecteplase and alteplase in patients ≥80 years. METHODS Data from the Norwegian Tenecteplase Stroke Trial, a randomized controlled trial comparing alteplase and tenecteplase, were assessed. RESULTS Of the 273 patients ≥80 years included, mean age was 85.5 years.In the intention-to-treat analyses, 43.1% receiving tenecteplase and 39.9% receiving alteplase reached excellent functional outcome (modified Rankin Scale score 0-1) after 3 months (odds ratio (OR) 1.14, 95% confidence interval (CI) 0.70-1.85, p=0.59). No significant differences among patients in the two treatment groups regarding frequency of symptomatic intracranial hemorrhage during the first 48 h were identified (11 (8.5%) in the tenecteplase group, 10 (7.0%) in the alteplase group, OR 1.23, 95% CI 0.50-3.00, p 0.65). Death within 3 months occurred in 18 patients (14.3%) in the tenecteplase group and in 21 (15.3%) in the alteplase group (p 0.84). After excluding stroke mimics, the proportion of patients with excellent functional outcome was 44.1% in the tenecteplase group and 34.4% in the alteplase group (OR 1.50 CI 0.90-2.52, p 0.12). CONCLUSION No differences in the efficacy and safety of tenecteplase versus alteplase in patients ≥80 years were identified. TRIAL REGISTRATION Clinicaltrials.gov (NCT01949948).
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Affiliation(s)
- Bente Thommessen
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lorenskog, Norway
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Center for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Nicola Logallo
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Christopher E Kvistad
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Hege Ihle-Hansen
- Department of Internal Medicine, Bærum Hospital, Drammen, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Håkon Ihle-Hansen
- Department of Internal Medicine, Bærum Hospital, Drammen, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ole Morten Rønning
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lorenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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20
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Abstract
INTRODUCTION Tenecteplase has recently been studied as an alternative thrombolytic agent in acute stroke, with a possible superior effect in achieving reperfusion of large intracranial vessels. CASE REPORT A 90-year-old female patient was admitted to our stroke unit because of acute onset of dysarthria, left-sided neglect, and hemiparesis. Brain computed tomography (CT) coupled with CT angiography and CT perfusion (postprocessed with the use of RAPID software) demonstrated right proximal middle cerebral artery occlusion with a large penumbra/small ischemic core pattern. The patient was subsequently treated with bolus tenecteplase infusion (0.25 mg/kg). Mechanical thrombectomy was abandoned because the patient has rapidly improved. The patient was discharged to her own home 4 days later with no neurological deficit and functionally independent (modified Rankin scale of 0). CONCLUSION This case exemplifies the potential of tenecteplase in achieving swift reperfusion in patients with large vessel occlusion associated with a substantial mismatch penumbral pattern.
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Rønning OM, Logallo N, Thommessen B, Tobro H, Novotny V, Kvistad CE, Aamodt AH, Næss H, Waje-Andreassen U, Thomassen L. Tenecteplase Versus Alteplase Between 3 and 4.5 Hours in Low National Institutes of Health Stroke Scale. Stroke 2019; 50:498-500. [PMID: 30602354 DOI: 10.1161/strokeaha.118.024223] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Thrombolysis with alteplase has beneficial effect on outcome and is safe within 4.5 hours. The present study compares the efficacy and safety of tenecteplase and alteplase in patients treated 3 to 4.5 hours after ischemic stroke. Methods- The data are from a prespecified substudy of patients included in The NOR-TEST (Norwegian Tenecteplase Stroke Trial), a randomized control trial comparing tenecteplase with alteplase. Results- The median admission National Institutes of Health Stroke Scale for this study population was 3 (interquartile range, 2-6). In the intention-to-treat analysis, 57% of patients that received tenecteplase and 53% of patients that received alteplase reached good functional outcome (modified Rankin Scale score of 0-1) at 3 months (odds ratio, 1.19; 95% CI, 0.68-2.10). The rates of intracranial hemorrhage in the first 48 hours were 5.7% in the tenecteplase group and 6.7% in the alteplase group (odds ratio, 0.84; 95% CI, 0.26-2.70). At 3 months, mortality was 5.7% and 4.5%, respectively. After excluding stroke mimics and patients with modified Rankin Scale score of >1 before stroke, the proportion of patients with good functional outcome was 61% in the tenecteplase group and 57% in the alteplase group (odds ratio, 1.24; 95% CI, 0.65-2.37). Conclusions- Tenecteplase is at least as effective as alteplase to achieve a good clinical outcome in patients with mild stroke treated between 3 and 4.5 hours after ischemic stroke. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT01949948.
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Affiliation(s)
- Ole Morten Rønning
- From the Division of Medicine, Department of Neurology, Akershus University Hospital, Lorenskog, Norway (O.M.R., B.T).,Institute of Clinical Medicine, University of Oslo, Norway (O.M.R.)
| | - Nicola Logallo
- Department of Neurosurgery (N.L.), Haukeland University Hospital, Bergen, Norway
| | - Bente Thommessen
- From the Division of Medicine, Department of Neurology, Akershus University Hospital, Lorenskog, Norway (O.M.R., B.T)
| | - Håkon Tobro
- Department of Neurology, Telemark Hospital, Skien, Norway (H.T.)
| | - Vojtech Novotny
- Department of Neurology (V.N., C.E.K., H.N., U.W.-A., L.T.), Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Norway (V.N., C.E.K., H.N., L.T.)
| | - Christopher E Kvistad
- Department of Neurology (V.N., C.E.K., H.N., U.W.-A., L.T.), Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Norway (V.N., C.E.K., H.N., L.T.)
| | - Anne Hege Aamodt
- Department of Neurology, Oslo University Hospital, Norway (A.H.A.)
| | - Halvor Næss
- Department of Neurology (V.N., C.E.K., H.N., U.W.-A., L.T.), Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Norway (V.N., C.E.K., H.N., L.T.).,Center for Age-Related Medicine, Stavanger University Hospital, Norway (H.N.)
| | - Ulrike Waje-Andreassen
- Department of Neurology (V.N., C.E.K., H.N., U.W.-A., L.T.), Haukeland University Hospital, Bergen, Norway
| | - Lars Thomassen
- Department of Neurology (V.N., C.E.K., H.N., U.W.-A., L.T.), Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Norway (V.N., C.E.K., H.N., L.T.)
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22
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Frühwald T, Gärtner U, Stöckmann N, Marxsen JH, Gramsch C, Roessler FC. In vitro examination of the thrombolytic efficacy of tenecteplase and therapeutic ultrasound compared to rt-PA. BMC Neurol 2019; 19:181. [PMID: 31375069 PMCID: PMC6676584 DOI: 10.1186/s12883-019-1404-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 07/18/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Optimizing thrombolytic therapy is vital for improving stroke outcomes. We aimed to develop standardized thrombolysis conditions to evaluate the efficacy of tenecteplase (TNK) compared to the current gold standard rt-PA (alteplase), with and without additional ultrasound treatment. We also wanted to introduce a new analytical approach to quantify fibrin fiber density in transmission electron microscopy (TEM). METHODS In vitro clots that are similar to ex vivo clots concerning their histological condition and their durability were generated from whole blood. For five treatment groups we compared relative clot weight loss (each n = 60) and fibrin fiber density in TEM (each n = 5). The control group (A) was treated only with plasma. Two groups were designated for each rt-PA (B + C) and TNK (D + E). Groups C and E were additionally treated with ultrasound. Dosages were 50 μg/ml for rt-PA and 30 μg/ml for TNK. Results were evaluated by using analyses of variance (ANOVA) and post-hoc t-tests. RESULTS Weight loss was increased significantly for all groups compared to the control group. Both TNK groups showed significantly increased weight loss compared to their counterpart rt-PA group (p ≤ 0.001). For TEM only group D showed significantly decreased fibrin fiber density (p < 0.05) compared to both rt-PA groups. Ultrasound did not significantly increase dissolution of clots with either method (best p = 0.16). CONCLUSIONS Tenecteplase dissolved clots more effectively than rt-PA with and without ultrasound. A higher sample size could provide more convincing results for TEM.
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Affiliation(s)
- Tobias Frühwald
- Department of Neurology, Justus-Liebig-University Gießen, Klinikstraße 33, 35385 Gießen, Germany
| | - Ulrich Gärtner
- Institute of Anatomy and Cell Biology, Justus-Liebig-University Gießen, Aulweg 123, 35392 Gießen, Germany
| | - Nils Stöckmann
- Department of Neurology, Justus-Liebig-University Gießen, Klinikstraße 33, 35385 Gießen, Germany
| | | | - Carolin Gramsch
- Department of Neuroradiology, Justus-Liebig-University Gießen, Klinikstraße 33, 35385 Gießen, Germany
| | - Florian C. Roessler
- Department of Neurology, Justus-Liebig-University Gießen, Klinikstraße 33, 35385 Gießen, Germany
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Standort Gießen, Klinikstraße 33, 35385 Gießen, Germany
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23
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Tenecteplase versus alteplase for management of acute ischemic stroke: a pairwise and network meta-analysis of randomized clinical trials. J Thromb Thrombolysis 2018; 46:440-450. [PMID: 30117036 DOI: 10.1007/s11239-018-1721-3] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Tenecteplase is a genetically mutated variant of alteplase with superior pharmacodynamic and pharmacokinetic properties. However, its efficacy and safety in acute ischemic strokes are limited. Hence, we conducted a study to evaluate the efficacy and safety of tenecteplase compared with alteplase in acute ischemic stroke. Electronic databases were searched for randomized clinical trials (RCTs) comparing tenecteplase with alteplase in acute ischemic stroke patients eligible for thrombolysis. We evaluated various efficacy and safety outcomes using random-effects models for both pairwise and Bayesian network meta-analyses along with meta-regression analyses. We included 5 RCTs with a total of 1585 patients. Compared with alteplase, tenecteplase treatment was associated with significantly greater complete recanalization (odd ratio [OR] 2.01; 95% confidence interval [CI] 1.04-3.87; p = 0.04) and early neurological improvement (OR 1.43; 95% CI 1.01-2.03; p = 0.05). There were no differences between the two thrombolytics in terms of excellent recovery (modified Rankin Scale [mRS] 0-1; OR 1.17; 95% CI 0.95-1.44; p = 0.13), functional independence (mRS 0-2; OR 1.24; 95% CI 0.78-1.98), poor recovery (mRS 4-6; OR 0.78; 95% CI 0.49-1.25; p = 0.31), complete/partial recanalization (OR 1.51; 95% CI 0.70-3.26; p = 0.30), any intracerebral hemorrhage (OR 0.81; 95% CI 0.56-1.17; p = 0.26), symptomatic intracerebral hemorrhage (OR 0.98; 95% CI 0.52-1.83; p = 0.94), or mortality (OR 0.83; 95% CI 0.54-1.26; p = 0.38). In network meta-analysis, there were better efficacy and imaging-based outcomes with tenecteplase 0.25 mg/kg without increased risk of safety outcomes. Our results demonstrate that in acute ischemic stroke, thrombolysis with tenecteplase is at least as effective and safe as alteplase.
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Xiang X, Cao F. Time window and "tissue window": two approaches to assist decision-making in strokes. J Neurol 2018; 266:283-288. [PMID: 29922951 DOI: 10.1007/s00415-018-8933-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/04/2018] [Accepted: 06/07/2018] [Indexed: 01/22/2023]
Abstract
Intravenous alteplase given in an appropriate time window has been recommended in guidelines and effects are on the decline over time. In general, the clinical decision is primarily based on whether ischemic stroke patients are sent to hospitals within the time window. However, some patients sent to the hospital over time limitations are eligible to receive intervention for recanalization due to good collateral circulation. In this dilemma, "tissue window" can be more reliable, which means using the penumbra as a major criterion for patient recruitment. Hence, we herein aim to address how could "tissue window" be a complementary approach when it does not conform to the time window's indication and affirming value of the later one. Some efforts obeying the time window are discussed first. In the later sections, we give the details of the definition of "tissue window", and then compare various neuroimaging techniques to determine the penumbra and summarize favorable patterns. Finally, we will focus on how the "tissue window" extends the therapeutic time window under specific circumstances.
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Affiliation(s)
- XuYing Xiang
- Department of Neurology, Union Hospital Affiliated with Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue in Hankou, Wuhan, 430022, China
| | - Fei Cao
- Department of Neurology, Union Hospital Affiliated with Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue in Hankou, Wuhan, 430022, China.
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Logallo N, Novotny V, Assmus J, Kvistad CE, Alteheld L, Rønning OM, Thommessen B, Amthor KF, Ihle-Hansen H, Kurz M, Tobro H, Kaur K, Stankiewicz M, Carlsson M, Morsund Å, Idicula T, Aamodt AH, Lund C, Næss H, Waje-Andreassen U, Thomassen L. Tenecteplase versus alteplase for management of acute ischaemic stroke (NOR-TEST): a phase 3, randomised, open-label, blinded endpoint trial. Lancet Neurol 2017; 16:781-788. [DOI: 10.1016/s1474-4422(17)30253-3] [Citation(s) in RCA: 205] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 11/24/2022]
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Escobar-Peso A, Chioua M, Frezza V, Martínez-Alonso E, Marco-Contelles J, Alcázar A. Nitrones, Old Fellows for New Therapies in Ischemic Stroke. SPRINGER SERIES IN TRANSLATIONAL STROKE RESEARCH 2017. [DOI: 10.1007/978-3-319-45345-3_9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
Progress in finding a better alternative to alteplase has been slow. Tenecteplase and desmoteplase have better pharmacological profiles compared with alteplase, but definite clinical evidence of their superiority is lacking. The two major phase III studies that have tested the efficacy and safety of desmoteplase in ischemic stroke patients have shown neutral results and a promising safety profile, but the trials compared desmoteplase with placebo only in late admitted patients. Future trials should focus on testing novel thrombolytics in the early time window either as the sole acute recanalizing treatment or combined with thrombectomy.
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