A Phase III, prospective, double-blind, randomized, placebo-controlled trial of thrombolysis in imaging-eligible, late-window patients to assess the efficacy and safety of tenecteplase (TIMELESS): Rationale and design

RATIONALE

While thrombolysis is standard of care for patients with acute ischemic stroke (AIS) within 4.5 h of symptom onset, the benefit of tenecteplase beyond this time window is less certain.

AIM

The TIMELESS trial (NCT03785678) aims to determine if treatment with tenecteplase increases the proportion of good clinical outcomes among patients with stroke due to a large vessel occlusion who present beyond 4.5 h after symptom onset.

SAMPLE SIZE ESTIMATES

A total of 456 patients will provide ⩾90% power to detect differences in the distribution of modified Rankin Scale scores at Day 90 at the two-sided 0.049 significance level.

METHODS AND DESIGN

TIMELESS is a Phase III, double-blind, randomized, placebo-controlled trial of tenecteplase with or without endovascular thrombectomy in patients with AIS and evidence of salvageable tissue via imaging who present within the 4.5- to 24-h time window with an internal carotid artery (ICA) or middle cerebral artery (MCA) (M1/M2) occlusion.

STUDY OUTCOMES

The primary efficacy objective of tenecteplase compared with placebo will be evaluated with ordinal modified Rankin Scale scores at Day 90. Safety will be evaluated via incidence of symptomatic intracranial hemorrhage, incidence and severity of adverse events, and mortality rate.

DISCUSSION

Results from TIMELESS will contribute to understanding of the safety and efficacy of tenecteplase administered 4.5-24 h following symptom onset for patients with an ICA or MCA occlusion.

Making a case for the right '-ase' in acute ischemic stroke: alteplase, tenecteplase, and reteplase

INTRODUCTION

Alteplase, reteplase, and tenecteplase are tissue plasminogen activators (TPA) approved for the management of acute myocardial infarction. Only alteplase is also approved for the treatment of acute ischemic stroke (AIS). The US Food and Drug Administration has received reports of accidental administration of tenecteplase or reteplase instead of alteplase in patients with AIS, which can result in failure to treat patients with the intended agent and lead to potential overdose.

AREAS COVERED

This review compares the molecular and clinical features of alteplase, reteplase, and tenecteplase (TNK), identifies factors contributing to medication errors among these agents, and provides steps to reduce medication errors.

EXPERT OPINION

Primary factors contributing to medication errors among tissue plasminogen activators include the use of the abbreviations 'TPA,' 'tPA,' or 'TNK' in written or verbal orders and use of these agents in similar settings (e.g. emergency departments and critical care areas). Steps to reduce the likelihood of accidental substitution of tenecteplase or reteplase for alteplase in patients with AIS include the use of full brand or generic names and inclusion of the indication in written and verbal orders, the addition of alerts in automated dispensing machines and ordering systems and use of stroke boxes containing alteplase and materials for administration.

Reasons for early recurrence following laparoscopic hernioplasty

The incidence and reasons for early recurrences following laparoscopic hernioplasty have not been studied. Because the incidence is small and the follow up is short, a multi-institutional study was performed among the pioneers in the field. The incidence figures were obtained by survey of surgeons who had significant experience (over 100 cases) and kept concurrent records. Fifty-four recurrences (1.7%) occurred after 3229 laparoscopic hernia repairs. There were 1944 transabdominal preperitoneal (TAPP) repairs with 19 recurrences (1%) and 578 preperitoneal repairs with no recurrences. There were 345 onlay mesh (IPOM) repairs with seven recurrences (2%), and 286 plug and patch repairs with 26 recurrences (9%). Simple closures were performed 76 times with two recurrences (2.6%). Fifty-seven patients (three cases were referred to the author without incidence data but complete records for analysis) had 60 recurrent hernias. Recurrences were noted, on average, 5.1 months postoperatively (range 0-30 months). The most common reason for recurrence was that the mesh was too small - 36 (60%). The mesh was never stapled in 19 instances (32%), and the hernia was never repaired in three cases (20%). The clips pulled through the tissue in six cases (8%), and in 10 cases (15%) the repair has not yet been undertaken because the etiology was unclear. There was more than one reason in 19 patients. Technical factors were responsible for nearly all recurrences.