Standard-dose tenecteplase a promising alternative to low-dose alteplase in stroke

In patients with stroke, administering standard-dose tenecteplase before mechanical thrombectomy is associated with a higher rate of early substantial reperfusion compared with low-dose alteplase, without compromising functional and safety outcomes, according to a study.

The study included 218 patients (mean age 77.1 years, 57.8 percent male) with large-vessel-occlusion stroke eligible for intravenous thrombolysis within 4.5 h of symptom onset followed by mechanical thrombectomy. These patients were randomly assigned to receive tenecteplase at 0.25 mg/kg (n=107) or alteplase at 0.6 mg/kg (n=111).

The primary outcome was substantial reperfusion, defined as modified Treatment in Cerebral Ischemia grade of 2b to 3 or no retrievable thrombus, on the initial angiogram. Secondary outcomes were modified Rankin Scale (mRS) score at 90 days and early neurological improvement (reduction of ≥8 points in the NIHSS score or an NIHSS score of 0–1 at 72 h after thrombolysis). Safety outcomes included symptomatic intracranial haemorrhage within 24 to 36 h and mortality at 90 days.

Substantial reperfusion occurred in 10.3 percent of patients who received tenecteplase vs 3.6 percent of those who received alteplase (absolute difference, 6.5 percentage points, 90 percent confidence interval [CI], 0.89–12.1).

Results for the secondary outcomes did not significantly differ between the tenecteplase and alteplase groups. The median mRS score was 2 vs 3, respectively (odds ratio for better functional outcome, 1.47, 95 percent CI, 0.92–2.35; p=0.11). Early neurological improvement occurred in 67.3 percent of patients in the tenecteplase group vs 55.9 percent in the alteplase group (p=0.08).

The rate of symptomatic intracranial haemorrhage was 2.8 percent in the tenecteplase group vs 1.8 percent in the alteplase group, while the rate of mortality was 6.5 percent vs 9.9 percent, respectively.

The findings highlight the potential of standard-dose tenecteplase as a thrombolytic alternative in regions where low-dose alteplase is currently the standard of care.