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Walton MN, Hamilton LA, Salyer S, Wiseman BF, Forster AM, Rowe AS. Major Bleeding Postadministration of Tenecteplase Versus Alteplase in Acute Ischemic Stroke. Ann Pharmacother 2022; 57:535-543. [PMID: 36004394 DOI: 10.1177/10600280221120211] [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: 11/15/2022] Open
Abstract
BACKGROUND Tenecteplase is a genetically engineered fibrinolytic with growing interest in the treatment of acute ischemic stroke. Compared to alteplase, tenecteplase is effective for neurologic improvement following ischemic stroke in patients with large vessel occlusions who are eligible for thrombectomy and for mild ischemic strokes with National Institutes of Health Stroke Scale of 0 to 5. OBJECTIVE The purpose of this study is to determine if safety outcomes are different in patients receiving tenecteplase and alteplase for acute ischemic stroke. METHODS This retrospective cohort reviewed all patients who received alteplase or tenecteplase from January 2019 to December 2020. Patients admitted before April 28, 2020, received alteplase intravenous bolus over 1 minute followed by an infusion over 1 hour, for a total of 0.9 mg/kg. Patients admitted after this date received tenecteplase 0.25 mg/kg as an intravenous bolus over 5 to 10 seconds. Any patient transferring from an outside facility was excluded. The primary outcome was major bleeding. RESULTS There was no significant difference in major bleeding between alteplase and tenecteplase (40 [18%] vs 21 [18.1%], P = 0.985). There was no significant difference in all-cause inpatient mortality for alteplase versus tenecteplase (10 [5%] vs 5 [4%], P = 0.934) or in adverse events between the groups (22 [9%] vs 14 [12%], P = 0.541) for alteplase and tenecteplase, respectively. CONCLUSIONS AND RELEVANCE Tenecteplase had similar rates of major bleeding versus alteplase and may be a reasonable alternative in the treatment of acute ischemic stroke.
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Affiliation(s)
- Mary N Walton
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, TN, USA.,Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA
| | - Leslie A Hamilton
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, TN, USA.,Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA
| | - Sonia Salyer
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA
| | - Brian F Wiseman
- Brain and Spine Institute, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Ann M Forster
- Brain and Spine Institute, University of Tennessee Medical Center, Knoxville, TN, USA
| | - A Shaun Rowe
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, TN, USA.,Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA
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Li G, Wang C, Wang S, Xiong Y, Zhao X. Tenecteplase in Ischemic Stroke: Challenge and Opportunity. Neuropsychiatr Dis Treat 2022; 18:1013-1026. [PMID: 35586365 PMCID: PMC9109727 DOI: 10.2147/ndt.s360967] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/15/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE OF REVIEW Intravenous thrombolysis is the first-line therapy for ischemic stroke, and alteplase has been used as an intravenous thrombolysis drug for over 20 years. However, considering its low rate of recanalization and risk of intracerebral hemorrhage, alteplase may not be the optimal thrombolytic drug of choice for ischemic stroke. Tenecteplase (TNK) is a genetically engineered, mutant, tissue plasminogen activator that is a potential substitute to alteplase in ischemic stroke. The pharmacokinetic advantages of TNK include greater fibrin selectivity than alteplase and prolonged half-life time. In this review, we have summarized the clinical trials of TNK in ischemic stroke. RECENT FINDINGS Clinical trials showed a higher recanalization rate of TNK over alteplase without increasing the rate of intracerebral hemorrhage. However, not all clinical trials showed superiority of TNK over alteplase in functional outcomes and early neurological improvement. TNK was superior to alteplase in terms of recanalization in patients who fulfilled the imaging mismatch criteria and in those planning to undergo mechanical thrombectomy. SUMMARY TNK has the potential to substitute alteplase for ischemic stroke therapy. Future TNK clinical trials that target functional outcomes are warranted.
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Affiliation(s)
- Guangshuo Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Chuanying Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Shang Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Chinese Institute of Brain Research, Beijing, People's Republic of China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
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Hemodynamics in acute stroke: Cerebral and cardiac complications. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:295-317. [PMID: 33632449 DOI: 10.1016/b978-0-12-819814-8.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hemodynamics is the study of blood flow, where parameters have been defined to quantify blood flow and the relationship with systemic circulatory changes. Understanding these perfusion parameters, the relationship between different blood flow variables and the implications for ischemic injury are outlined in the ensuing discussion. This chapter focuses on the hemodynamic changes that occur in ischemic stroke, and their contribution to ischemic stroke pathophysiology. We discuss the interaction between cardiovascular response and hemodynamic changes in stroke. Studying hemodynamic changes has a key role in stroke prevention, therapeutic implications and prognostic importance in acute ischemic stroke: preexisting hemodynamic and autoregulatory impairments predict the occurrence of stroke. Hemodynamic failure predisposes to the formation of thromboemboli and accelerates infarction due to impairing compensatory mechanisms. In ischemic stroke involving occlusion of a large vessel, persistent collateral circulation leads to preservation of ischemic penumbra and therefore justifying endovascular thrombectomy. Following thrombectomy, impaired autoregulation may lead to reperfusion injury and hemorrhage.
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Katsanos AH, Safouris A, Sarraj A, Magoufis G, Leker RR, Khatri P, Cordonnier C, Leys D, Shoamanesh A, Ahmed N, Alexandrov AV, Tsivgoulis G. Intravenous Thrombolysis With Tenecteplase in Patients With Large Vessel Occlusions: Systematic Review and Meta-Analysis. Stroke 2020; 52:308-312. [PMID: 33272127 DOI: 10.1161/strokeaha.120.030220] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Accumulating evidence from randomized controlled clinical trials suggests that tenecteplase may represent an effective treatment alternative to alteplase for acute ischemic stroke. In the present systematic review and meta-analysis, we sought to compare the efficacy and safety outcomes of intravenous tenecteplase to intravenous alteplase administration for acute ischemic stroke patients with large vessel occlusions (LVOs). METHODS We searched MEDLINE (Medical Literature Analysis and Retrieval System Online) and Scopus for published randomized controlled clinical trials providing outcomes of acute ischemic stroke with confirmed LVO receiving intravenous thrombolysis with either tenecteplase at different doses or alteplase at a standard dose of 0.9 mg/kg. The primary outcome was the odds of modified Rankin Scale score of 0 to 2 at 3 months. RESULTS We included 4 randomized controlled clinical trials including a total of 433 patients. Patients with confirmed LVO receiving tenecteplase had higher odds of modified Rankin Scale scores of 0 to 2 (odds ratio, 2.06 [95% CI, 1.15-3.69]), successful recanalization (odds ratio, 3.05 [95% CI, 1.73-5.40]), and functional improvement defined as 1-point decrease across all modified Rankin Scale grades (common odds ratio, 1.84 [95% CI, 1.18-2.87]) at 3 months compared with patients with confirmed LVO receiving alteplase. There was little or no heterogeneity between the results provided from included studies regarding the aforementioned outcomes (I2≤20%). No difference in the outcomes of early neurological improvement, symptomatic intracranial hemorrhage, any intracranial hemorrhage, and the rates of modified Rankin Scale score 0 to 1 or all-cause mortality at 3 months was detected between patients with LVO receiving intravenous thrombolysis with either tenecteplase or alteplase. CONCLUSIONS Acute ischemic stroke patients with LVO receiving intravenous thrombolysis with tenecteplase have significantly better recanalization and clinical outcomes compared with patients receiving intravenous alteplase.
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Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., A.S.)
| | - Apostolos Safouris
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Greece (A. Safouris, G.T.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (A. Safouris, G.M.)
| | - Amrou Sarraj
- Department of Neurology, UT Houston, TX (A. Sarraj)
| | - Georgios Magoufis
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece (A. Safouris, G.M.)
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel (R.R.L.)
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, OH (P.K.)
| | - Charlotte Cordonnier
- University of Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience and Cognition, France (C.C., D.L.)
| | - Didier Leys
- University of Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience and Cognition, France (C.C., D.L.)
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., A.S.)
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.A.).,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden (N.A.)
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis (A.V.A., G.T.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Greece (A. Safouris, G.T.).,Department of Neurology, University of Tennessee Health Science Center, Memphis (A.V.A., G.T.)
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Moshayedi P, Liebeskind DS, Jadhav A, Jahan R, Lansberg M, Sharma L, Nogueira RG, Saver JL. Decision-Making Visual Aids for Late, Imaging-Guided Endovascular Thrombectomy for Acute Ischemic Stroke. J Stroke 2020; 22:377-386. [PMID: 33053953 PMCID: PMC7568977 DOI: 10.5853/jos.2019.03503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 06/22/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND PURPOSE Speedy decision-making is important for optimal outcomes from endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Figural decision aids facilitate rapid review of treatment benefits and harms, but have not yet been developed for late-presenting patients selected for EVT based on multimodal computed tomography or magnetic resonance imaging. METHODS For combined pooled study-level randomized trial (DAWN and DEFUSE 3) data, as well as each trial singly, 100 person-icon arrays (Kuiper-Marshall personographs) were generated showing beneficial and adverse effects of EVT for patients with AIS and large vessel occlusion using automated (algorithmic) and expert-guided joint outcome table specification. RESULTS Among imaging-selected patients 6 to 24 hours from last known well, for the full 7-category modified Rankin Scale (mRS), EVT had number needed to treat to benefit 1.9 (interquartile range [IQR], 1.9 to 2.1) and number needed to harm 40.0 (IQR, 29.2 to 58.3). Visual displays of treatment effects among 100 patients showed that, with EVT: 52 patients have better disability outcome, including 32 more achieving functional independence (mRS 0 to 2); three patients have worse disability outcome, including one more experiencing severe disability or death (mRS 5 to 6), mediated by symptomatic intracranial hemorrhage and infarct in new territory. Similar features were present in person-icon figures based on a 6-level mRS (levels 5 and 6 combined) rather than 7-level mRS, and based on the DAWN trial alone and DEFUSE 3 trial alone. CONCLUSIONS Personograph visual decision aids are now available to rapidly educate patients, family, and healthcare providers regarding benefits and risks of EVT for late-presenting, imaging-selected AIS patients.
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Affiliation(s)
- Pouria Moshayedi
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Ashutosh Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Reza Jahan
- Department of Radiology and Comprehensive Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Latisha Sharma
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
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Moshayedi P, Saber H, Liebeskind DS. Is there Still a Time Window in the Treatment of Acute Stroke? Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00628-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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