Battle of the Lytics - Tenecteplase vs Alteplase Prior to Thrombectomy

Written by Clay Smith

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Tenecteplase was superior to alteplase when given for acute ischemic stroke prior to thrombectomy.

Why does this matter?
Thrombectomy has emerged as the treatment of choice for proximal acute ischemic stroke.  Thrombolysis is given prior to thrombectomy.  Alteplase is given as an initial bolus followed by an infusion.  Tenecteplase is conveniently given all at once as a one-time IV bolus and is more fibrin-specific, which may theoretically have an advantage over alteplase.

Clash of the clot-busters
This was a RCT of 202 patients from 13 locations in Australia and New Zealand, evenly randomized to either alteplase 0.9mg/kg, max 90mg, loading dose over one hour or tenecteplase 0.25mg/kg, max 25mg as a rapid bolus in patients presenting < 4.5 hours from stroke onset who were to undergo thrombectomy.  For the primary outcome of 50% reperfusion of the ischemic area or no retrievable clot on angiography, tenecteplase was clearly superior, with 22% vs only 10% with alteplase.  For the secondary outcome of neurological outcome at 90 days, modified Rankin scale was 2 for tenecteplase vs 3 for alteplase, which meant tenecteplase was clinically and statistically superior (p = 0.04).  But it didn't have a statistically significant change in either functional (p = 0.06) or excellent (p = 0.2) neurological outcome, though there was a trend favoring tenecteplase.  There was also a trend to increased mortality with alteplase that was not statistically significant. Rate of intracranial bleeding was 1% for each group.

Source
Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke.  N Engl J Med. 2018 Apr 26;378(17):1573-1582. doi: 10.1056/NEJMoa1716405.

Reviewed by Thomas Davis

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