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Bala F, Singh N, Ignacio K, Alhabli I, Ademola A, Alrohimi A, Khosravani H, Tkach A, Catanese L, Dowlatshahi D, Field T, Hunter G, Benali F, Horn M, Demchuk A, Hill M, Sajobi T, Buck B, Swartz R, Almekhlafi M, Menon BK. Tenecteplase Versus Alteplase in Medium Vessel Occlusion Ischemic Stroke: A Secondary Analysis of the Alteplase Compared to Tenecteplase Randomized Trial. J Stroke 2024; 26:280-289. [PMID: 38836275 PMCID: PMC11164589 DOI: 10.5853/jos.2023.03713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/24/2024] [Accepted: 03/11/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND PURPOSE The safety and efficacy of tenecteplase in patients with ischemic stroke due to medium vessel occlusion (MeVO) are not well studied. We aimed to compare tenecteplase with alteplase in stroke due to MeVO. METHODS Patients with baseline M2-middle cerebral artery (MCA), M3/M4-MCA, P2/P3/P4-posterior cerebral artery (PCA), A2/A3/A4-anterior cerebral artery (ACA) occlusions from the Alteplase Compared to Tenecteplase (AcT) trial were included. Primary outcome was the proportion of 90-day modified Rankin Scale (mRS) 0-1. Secondary outcomes were 90-day mRS 0-2, ordinal mRS, mortality, quality of life measures (EuroQol 5-Dimension 5-Level, EuroQol visual analog scale), and symptomatic intracerebral hemorrhage (sICH). Initial and final successful reperfusion were reported in patients undergoing endovascular thrombectomy (EVT). RESULTS Among 1,558 patients with available baseline computed tomography angiography; 455 (29.2%) had MeVO of which 27.5% (125/455) were proximal M2; 16.3% (74/455) were distal M2; 35.2% (160/455) were M3/M4; 7.5% (34/455) were A2/A3/A4; and 13.6% (62/455) were P2/P3/P4 occlusions. EVT was performed in 87/455 (19.1%) patients. mRS 0-1 at 90 days was achieved in 37.9% in the tenecteplase versus 34.7% in the alteplase group (adjusted risk ratio [aRR] 1.07; 95% confidence interval [CI] 0.91-1.25). Rates of 90-day mRS 0-2, sICH, and mortality were similar in both groups. No statistical difference was noted in initial successful reperfusion rates (13.0% vs. 7.5%) among the 87 patients who underwent endovascular thrombectomy. However, final successful reperfusion was higher in the tenecteplase group (71.7% vs. 60.0%, aRR 1.29, 95% CI 1.04-1.61). CONCLUSION Intravenous tenecteplase had comparable safety, functional outcomes and quality of life compared to intravenous alteplase among patients with MeVO. Among those treated with EVT, tenecteplase was associated with higher successful reperfusion rates than alteplase.
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Affiliation(s)
- Fouzi Bala
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Internal Medicine (Neurology Division), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Katrina Ignacio
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ayoola Ademola
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Anas Alrohimi
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
- Department of Medicine (Neurology), King Saud University, Riyadh, Saudi Arabia
| | - Houman Khosravani
- Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Canada
| | | | - Luciana Catanese
- Hamilton Health Sciences Centre and McMaster University, Hamilton, Canada
| | - Dariush Dowlatshahi
- Department of Medicine, University of Ottawa, and the Ottawa Heart Research Institute, Ottawa, Canada
| | - Thalia Field
- Vancouver Stroke Program and the Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Gary Hunter
- University of Saskatchewan, Saskatoon, Canada
| | - Faysal Benali
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
| | - MacKenzie Horn
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Andrew Demchuk
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Michael Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Tolulope Sajobi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Richard Swartz
- Department of Medicine (Neurology), King Saud University, Riyadh, Saudi Arabia
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Bijoy K. Menon
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
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Singh N, Almekhlafi MA, Bala F, Ademola A, Coutts SB, Deschaintre Y, Khosravani H, Buck B, Appireddy R, Moreau F, Gubitz G, Tkach A, Catanese L, Dowlatshahi D, Medvedev G, Mandzia J, Pikula A, Shankar JJ, Ghrooda E, Poppe AY, Williams H, Field TS, Manosalva A, Siddiqui MM, Zafar A, Imoukhoude O, Hunter G, Shamy M, Demchuk AM, Claggett BL, Hill MD, Sajobi TT, Swartz RH, Menon BK. Effect of Time to Thrombolysis on Clinical Outcomes in Patients With Acute Ischemic Stroke Treated With Tenecteplase Compared to Alteplase: Analysis From the AcT Randomized Controlled Trial. Stroke 2023; 54:2766-2775. [PMID: 37800372 DOI: 10.1161/strokeaha.123.044267] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/23/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND The AcT (Alteplase Compared to Tenecteplase) randomized controlled trial showed that tenecteplase is noninferior to alteplase in treating patients with acute ischemic stroke within 4.5 hours of symptom onset. The effect of time to treatment on clinical outcomes with alteplase is well known; however, the nature of this relationship is yet to be described with tenecteplase. We assessed whether the association of time to thrombolysis treatment with clinical outcomes in patients with acute ischemic stroke differs by whether they receive intravenous tenecteplase versus alteplase. METHODS Patients included were from AcT, a pragmatic, registry-linked, phase 3 randomized controlled trial comparing intravenous tenecteplase to alteplase in patients with acute ischemic stroke. Eligible patients were >18 years old, with disabling neurological deficits, presenting within 4.5 hours of symptom onset, and eligible for thrombolysis. Primary outcome was modified Rankin Scale score 0 to 1 at 90 days. Safety outcomes included 24-hour symptomatic intracerebral hemorrhage and 90-day mortality rates. Mixed-effects logistic regression was used to assess the following: (a) the association of stroke symptom onset to needle time; (b) door (hospital arrival) to needle time with outcomes; and (c) if these associations were modified by type of thrombolytic administered (tenecteplase versus alteplase), after adjusting for age, sex, baseline stroke severity, and site of intracranial occlusion. RESULTS Of the 1538 patients included in this analysis, 1146 (74.5%; 591 tenecteplase and 555 alteplase) presented within 3 hours versus 392 (25.5%; 196: TNK and 196 alteplase) who presented within 3 to 4.5 hours of symptom onset. Baseline patient characteristics in the 0 to 3 hours versus 3- to 4.5-hour time window were similar, except patients in the 3- to 4.5-hour window had lower median baseline National Institutes of Health Stroke Severity Scale (10 versus 7, respectively) and lower proportion of patients with large vessel occlusion on baseline CT angiography (26.9% versus 18.7%, respectively). Type of thrombolytic agent (tenecteplase versus alteplase) did not modify the association between continuous onset to needle time (Pinteraction=0.161) or door-to-needle time (Pinteraction=0.972) and primary clinical outcome. Irrespective of the thrombolytic agent used, each 30-minute reduction in onset to needle time was associated with a 1.8% increase while every 10 minutes reduction in door-to-needle time was associated with a 0.2% increase in the probability of achieving 90-day modified Rankin Scale score 0 to 1, respectively. CONCLUSIONS The effect of time to tenecteplase administration on clinical outcomes is like that of alteplase, with faster administration resulting in better clinical outcomes. REGISTRATION URL: https://classic. CLINICALTRIALS gov; Unique identifier: NCT03889249.
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Affiliation(s)
- Nishita Singh
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Internal Medicine (Neurology Division), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada (N.S., E.G.)
| | - Mohammed A Almekhlafi
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
| | - Fouzi Bala
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
- Diagnostic and Interventional Neuroradiology, Tours University Hospital, France (F.B.)
| | - Ayoola Ademola
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
| | - Shelagh B Coutts
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
| | - Yan Deschaintre
- Department of Clinical Neurosciences, Université de Montréal, Canada (Y.D., A.Y.P.)
| | - Houman Khosravani
- Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, Canada (H.K., R.H.S.)
| | - Brian Buck
- Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Canada (B.B.)
| | - Ramana Appireddy
- Department of Medicine, Division of Neurology, Queen's University, Kingston, ON, Canada (R.A.)
| | - Francois Moreau
- Department of Internal Medicine, Université de Sherbrooke, QC, Canada (F.M.)
| | - Gord Gubitz
- Queen Elizabeth Health Sciences Centre, Halifax, NS, Canada (G.G.)
| | - Aleksander Tkach
- Department of Neurosciences, Kelowna General Hospital, Canada (A.T.)
| | - Luciana Catanese
- Department of Medicine, McMaster University, Hamilton, Canada (L.C.)
| | - Dar Dowlatshahi
- Department of Medicine, and Ottawa Hospital Research Institute, University of Ottawa, Canada (D.D., M.S.)
| | - George Medvedev
- Department of Neurosciences, University of British Columbia, Vancouver, Canada (G.M., T.S.F.)
| | - Jennifer Mandzia
- London Health Sciences Centre and Western University, ON, Canada (J.M.)
| | - Aleksandra Pikula
- London Health Sciences Centre and Western University, ON, Canada (J.M.)
| | - Jai Jai Shankar
- Department of Radiology, Health Sciences Center, University of Manitoba, Winnipeg, Canada (J.J.S.)
| | - Esseeddeegg Ghrooda
- Department of Internal Medicine (Neurology Division), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada (N.S., E.G.)
| | - Alexandre Y Poppe
- Department of Clinical Neurosciences, Université de Montréal, Canada (Y.D., A.Y.P.)
| | - Heather Williams
- Department of Medicine, Queen Elizabeth Health Sciences Centre, Charlottetown, Canada (H.W.)
| | - Thalia S Field
- Department of Neurosciences, University of British Columbia, Vancouver, Canada (G.M., T.S.F.)
| | - Alejandro Manosalva
- Department of Medicine, Medicine Hat Regional Hospital, Calgary, Canada (A.M.)
| | | | - Atif Zafar
- St Michael's Hospital, Toronto, ON, Canada (A.Z.)
| | - Oje Imoukhoude
- Department of Medicine, Red Deer Regional Hospital, Calgary, Canada (O.I.)
| | - Gary Hunter
- Department of Medicine, University of Saskatoon, Canada (G.H.)
| | - Michel Shamy
- Department of Medicine, and Ottawa Hospital Research Institute, University of Ottawa, Canada (D.D., M.S.)
| | - Andrew M Demchuk
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
| | - Brian L Claggett
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA (B.L.C.)
| | - Michael D Hill
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
| | - Tolulope T Sajobi
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
| | - Richard H Swartz
- Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, Canada (H.K., R.H.S.)
| | - Bijoy K Menon
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
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Prvu Bettger J, Cadilhac DA. Advances in Stroke: A Focus on Health Policy Literature From 2022. Stroke 2023; 54:2449-2452. [PMID: 37639515 DOI: 10.1161/strokeaha.123.042701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
- Janet Prvu Bettger
- Department of Health and Rehabilitation Sciences, Temple University, Philadelphia, PA (J.P.B.)
| | - Dominique A Cadilhac
- Department of Medicine, Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (D.A.C.)
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Bala F, Singh N, Buck B, Ademola A, Coutts SB, Deschaintre Y, Khosravani H, Appireddy R, Moreau F, Phillips S, Gubitz G, Tkach A, Catanese L, Dowlatshahi D, Medvedev G, Mandzia J, Pikula A, Shankar JJ, Williams H, Field TS, Manosalva Alzate A, Siddiqui M, Zafar A, Imoukhoude O, Hunter G, Alhabli I, Benali F, Horn M, Hill MD, Shamy M, Sajobi TT, Swartz RH, Menon BK, Almekhlafi M. Safety and Efficacy of Tenecteplase Compared With Alteplase in Patients With Large Vessel Occlusion Stroke: A Prespecified Secondary Analysis of the ACT Randomized Clinical Trial. JAMA Neurol 2023; 80:824-832. [PMID: 37428494 PMCID: PMC10334294 DOI: 10.1001/jamaneurol.2023.2094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/28/2023] [Indexed: 07/11/2023]
Abstract
Importance It is unknown whether intravenous thrombolysis using tenecteplase is noninferior or preferable compared with alteplase for patients with acute ischemic stroke. Objective To examine the safety and efficacy of tenecteplase compared to alteplase among patients with large vessel occlusion (LVO) stroke. Design, Setting, and Participants This was a prespecified analysis of the Intravenous Tenecteplase Compared With Alteplase for Acute Ischaemic Stroke in Canada (ACT) randomized clinical trial that enrolled patients from 22 primary and comprehensive stroke centers across Canada between December 10, 2019, and January 25, 2022. Patients 18 years and older with a disabling ischemic stroke within 4.5 hours of symptom onset were randomly assigned (1:1) to either intravenous tenecteplase or alteplase and were monitored for up to 120 days. Patients with baseline intracranial internal carotid artery (ICA), M1-middle cerebral artery (MCA), M2-MCA, and basilar occlusions were included in this analysis. A total of 1600 patients were enrolled, and 23 withdrew consent. Exposures Intravenous tenecteplase (0.25 mg/kg) vs intravenous alteplase (0.9 mg/kg). Main Outcomes and Measures The primary outcome was the proportion of modified Rankin scale (mRS) score 0-1 at 90 days. Secondary outcomes were an mRS score from 0 to 2, mortality, and symptomatic intracerebral hemorrhage. Angiographic outcomes were successful reperfusion (extended Thrombolysis in Cerebral Infarction scale score 2b-3) on first and final angiographic acquisitions. Multivariable analyses (adjusting for age, sex, National Institute of Health Stroke Scale score, onset-to-needle time, and occlusion location) were carried out. Results Among 1577 patients, 520 (33.0%) had LVO (median [IQR] age, 74 [64-83] years; 283 [54.4%] women): 135 (26.0%) with ICA occlusion, 237 (45.6%) with M1-MCA, 117 (22.5%) with M2-MCA, and 31 (6.0%) with basilar occlusions. The primary outcome (mRS score 0-1) was achieved in 86 participants (32.7%) in the tenecteplase group vs 76 (29.6%) in the alteplase group. Rates of mRS 0-2 (129 [49.0%] vs 131 [51.0%]), symptomatic intracerebral hemorrhage (16 [6.1%] vs 11 [4.3%]), and mortality (19.9% vs 18.1%) were similar in the tenecteplase and alteplase groups, respectively. No difference was noted in successful reperfusion rates in the first (19 [9.2%] vs 21 [10.5%]) and final angiogram (174 [84.5%] vs 177 [88.9%]) among 405 patients who underwent thrombectomy. Conclusions and Relevance The findings in this study indicate that intravenous tenecteplase conferred similar reperfusion, safety, and functional outcomes compared to alteplase among patients with LVO.
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Affiliation(s)
- Fouzi Bala
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Nishita Singh
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Internal Medicine, Neurology Division, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ayoola Ademola
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Shelagh B. Coutts
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Yan Deschaintre
- Department of Neurosciences, Université de Montréal, Montréal, Québec, Canada
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Houman Khosravani
- Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | | | - Stephen Phillips
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Luciana Catanese
- Hamilton Health Sciences Centre and McMaster University, Hamilton, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa, and the Ottawa Heart Research Institute, Ottawa, Ontario, Canada
| | - George Medvedev
- University of British Columbia and the Fraser Health Authority, New Westminster, British Columbia, Canada
| | - Jennifer Mandzia
- London Health Sciences Centre and Western University, London, Ontario, Canada
| | - Aleksandra Pikula
- Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Jai Jai Shankar
- Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Heather Williams
- Queen Elizabeth Hospital, Charlottetown, Prince Edward Island, Canada
| | - Thalia S. Field
- Vancouver Stroke Program and the Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Atif Zafar
- St Michael’s Hospital, Toronto, Ontario, Canada
| | | | - Gary Hunter
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Faysal Benali
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - MacKenzie Horn
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael D. Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Michel Shamy
- Department of Medicine, University of Ottawa, and the Ottawa Heart Research Institute, Ottawa, Ontario, Canada
| | - Tolulope T. Sajobi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Richard H. Swartz
- Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Bijoy K. Menon
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
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Faris H, Dewar B, Fedyk M, Dowlatshahi D, Menon B, Swartz RH, Hill MD, Shamy M. Protocol for Deferral of Consent in Acute Stroke Trials. Neurology 2023; 100:292-300. [PMID: 36414423 PMCID: PMC9946194 DOI: 10.1212/wnl.0000000000201533] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/23/2022] [Indexed: 11/23/2022] Open
Abstract
The challenges of conducting hyperacute stroke research and obtaining informed consent have been increasingly recognized within the stroke research community in recent years. Deferral of consent, in which a patient is enrolled in a trial and then provides consent at some point thereafter, is increasingly used to enroll patients into hyperacute stroke trials in Canada and Europe, although it is not permitted in the United States. Deferral of consent offers several potential advantages-quicker door-to-randomization, increased enrolment, decreased selection bias-but these must be balanced against the risk of enrolling patients against their wishes. We seek to minimize the attendant risks of deferral of consent by offering practical guidance regarding how to conduct acute stroke trials using deferral of consent. Building on existing guidelines and recent experiences with deferral of consent in acute stroke trials, we have developed a protocol for the use of deferral of consent that aims to maximize patient involvement while minimizing ethical and scientific risks.
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Affiliation(s)
| | | | | | | | | | | | | | - Michel Shamy
- From the Ottawa Hospital Research Institute (H.F., B.D., D.D., M.S.), Ottawa, Ontario, Canada; School of Medicine (M.F.), University of California, Davis; Department of Medicine (D.D., M.S.), University of Ottawa & the Ottawa Hospital, Ontario; Department of Clinical Neurosciences (B.M., M.D.H.), University of Calgary and Calgary Stroke Program, Alberta; and Department of Medicine (R.H.S.), University of Toronto & Sunnybrook Health Sciences Centre, Ontario, Canada.
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Menon BK, Buck BH, Singh N, Deschaintre Y, Almekhlafi MA, Coutts SB, Thirunavukkarasu S, Khosravani H, Appireddy R, Moreau F, Gubitz G, Tkach A, Catanese L, Dowlatshahi D, Medvedev G, Mandzia J, Pikula A, Shankar J, Williams H, Field TS, Manosalva A, Siddiqui M, Zafar A, Imoukhuede O, Hunter G, Demchuk AM, Mishra S, Gioia LC, Jalini S, Cayer C, Phillips S, Elamin E, Shoamanesh A, Subramaniam S, Kate M, Jacquin G, Camden MC, Benali F, Alhabli I, Bala F, Horn M, Stotts G, Hill MD, Gladstone DJ, Poppe A, Sehgal A, Zhang Q, Lethebe BC, Doram C, Ademola A, Shamy M, Kenney C, Sajobi TT, Swartz RH. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial. Lancet 2022; 400:161-169. [PMID: 35779553 DOI: 10.1016/s0140-6736(22)01054-6] [Citation(s) in RCA: 143] [Impact Index Per Article: 71.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 05/30/2022] [Accepted: 06/08/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Intravenous thrombolysis with alteplase bolus followed by infusion is a global standard of care for patients with acute ischaemic stroke. We aimed to determine whether tenecteplase given as a single bolus might increase reperfusion compared with this standard of care. METHODS In this multicentre, open-label, parallel-group, registry-linked, randomised, controlled trial (AcT), patients were enrolled from 22 primary and comprehensive stroke centres across Canada. Patients were eligible for inclusion if they were aged 18 years or older, with a diagnosis of ischaemic stroke causing disabling neurological deficit, presenting within 4·5 h of symptom onset, and eligible for thrombolysis per Canadian guidelines. Eligible patients were randomly assigned (1:1), using a previously validated minimal sufficient balance algorithm to balance allocation by site and a secure real-time web-based server, to either intravenous tenecteplase (0·25 mg/kg to a maximum of 25 mg) or alteplase (0·9 mg/kg to a maximum of 90mg; 0·09 mg/kg as a bolus and then a 60 min infusion of the remaining 0·81 mg/kg). The primary outcome was the proportion of patients who had a modified Rankin Scale (mRS) score of 0-1 at 90-120 days after treatment, assessed via blinded review in the intention-to-treat (ITT) population (ie, all patients randomly assigned to treatment who did not withdraw consent). Non-inferiority was met if the lower 95% CI of the difference in the proportion of patients who met the primary outcome between the tenecteplase and alteplase groups was more than -5%. Safety was assessed in all patients who received any of either thrombolytic agent and who were reported as treated. The trial is registered with ClinicalTrials.gov, NCT03889249, and is closed to accrual. FINDINGS Between Dec 10, 2019, and Jan 25, 2022, 1600 patients were enrolled and randomly assigned to tenecteplase (n=816) or alteplase (n=784), of whom 1577 were included in the ITT population (n=806 tenecteplase; n=771 alteplase). The median age was 74 years (IQR 63-83), 755 (47·9%) of 1577 patients were female and 822 (52·1%) were male. As of data cutoff (Jan 21, 2022), 296 (36·9%) of 802 patients in the tenecteplase group and 266 (34·8%) of 765 in the alteplase group had an mRS score of 0-1 at 90-120 days (unadjusted risk difference 2·1% [95% CI - 2·6 to 6·9], meeting the prespecified non-inferiority threshold). In safety analyses, 27 (3·4%) of 800 patients in the tenecteplase group and 24 (3·2%) of 763 in the alteplase group had 24 h symptomatic intracerebral haemorrhage and 122 (15·3%) of 796 and 117 (15·4%) of 763 died within 90 days of starting treatment INTERPRETATION: Intravenous tenecteplase (0·25 mg/kg) is a reasonable alternative to alteplase for all patients presenting with acute ischaemic stroke who meet standard criteria for thrombolysis. FUNDING Canadian Institutes of Health Research, Alberta Strategy for Patient Oriented Research Support Unit.
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Affiliation(s)
- Bijoy K Menon
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada; Department of Radiology, University of Calgary, Calgary, AB, Canada; Cumming School of Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, Calgary, Canada.
| | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Yan Deschaintre
- Department of Neurosciences, Université de Montréal, Montreal, QC, Canada; Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada; Department of Radiology, University of Calgary, Calgary, AB, Canada; Cumming School of Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, Calgary, Canada
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada; Department of Radiology, University of Calgary, Calgary, AB, Canada; Cumming School of Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, Calgary, Canada
| | - Sibi Thirunavukkarasu
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Houman Khosravani
- Department of Medicine (Division of Neurology), Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Gord Gubitz
- Queen Elizabeth Health Sciences Centre, Halifax, NS, Canada
| | | | - Luciana Catanese
- Hamilton Health Sciences Centre and McMaster University, Hamilton, ON, Canada
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa and the Ottawa Heart Research Institute, Ottawa, ON, Canada
| | - George Medvedev
- University of British Columbia and the Fraser Health Authority, New Westminster, BC, Canada
| | - Jennifer Mandzia
- London Health Sciences Centre and Western University, London, ON, Canada
| | - Aleksandra Pikula
- Toronto Western Hospital and the University of Toronto, Toronto, ON, Canada
| | - Jai Shankar
- University of Manitoba, Winnipeg, MB, Canada
| | | | - Thalia S Field
- Vancouver Stroke Program and the Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | | | | | - Atif Zafar
- St Michael's Hospital, Toronto, ON, Canada
| | | | - Gary Hunter
- University of Saskatchewan, Saskatoon, SK, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada; Department of Radiology, University of Calgary, Calgary, AB, Canada; Cumming School of Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, Calgary, Canada
| | - Sachin Mishra
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Laura C Gioia
- Department of Neurosciences, Université de Montréal, Montreal, QC, Canada; Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Shirin Jalini
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Caroline Cayer
- Centre de recherche du CHUS, Centre intégré Universitaire de Santé et des Services Sociaux de l'Estrie, Sherbrooke, QC, Canada
| | | | | | - Ashkan Shoamanesh
- Hamilton Health Sciences Centre and McMaster University, Hamilton, ON, Canada
| | - Suresh Subramaniam
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Mahesh Kate
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Gregory Jacquin
- Department of Neurosciences, Université de Montréal, Montreal, QC, Canada; Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Marie-Christine Camden
- Enfant-Jésus Hospital, Centre Hospitalier Universitaire de Québec, Laval University, Québec City, QC, Canada
| | - Faysal Benali
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Fouzi Bala
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - MacKenzie Horn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Grant Stotts
- Department of Medicine, University of Ottawa and the Ottawa Heart Research Institute, Ottawa, ON, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada; Department of Radiology, University of Calgary, Calgary, AB, Canada; Cumming School of Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, Calgary, Canada
| | - David J Gladstone
- Department of Medicine (Division of Neurology), Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Alexandre Poppe
- Department of Neurosciences, Université de Montréal, Montreal, QC, Canada; Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Arshia Sehgal
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Qiao Zhang
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Brendan Cord Lethebe
- Cumming School of Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Craig Doram
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Ayoola Ademola
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada; Cumming School of Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Michel Shamy
- Department of Medicine, University of Ottawa and the Ottawa Heart Research Institute, Ottawa, ON, Canada
| | - Carol Kenney
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Tolulope T Sajobi
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada; Cumming School of Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Richard H Swartz
- Department of Medicine (Division of Neurology), Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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