Written by Clay Smith
Spoon Feed
Patients with delayed presentation, 4.5 to 24 hours after onset of ischemic stroke, still had significant benefit from tenecteplase (TNK): NNT = 17, NNH = 72.
Better late than never?
We recently covered the HOPE RCT, which found benefit in patients with ischemic stroke who received alteplase (tPA) between 4.5 to 24 hours after onset. What about TNK?
This is a meta-analysis of 4 RCTs, 1,278 adult patients with acute ischemic stroke, who received TNK in the 4.5 to 24-hour time frame. Three studies were based in China, one in the U.S. and Canada. For the primary outcome of excellent 90-day neurological status (modified Rankin scale 0-1), there was marked improvement in patients who received TNK: OR 1.34 (95%CI 1.06–1.71). I find it so frustrating when authors can calculate RR and don’t; so, calculating it myself, the RR is 1.22 (95%CI 1.03-1.43), NNT = 17, which is so much more intuitive. There was an increased risk of symptomatic intracerebral hemorrhage: NNH = 72.
Three studies based TNK administration on CT perfusion criteria; one used MRI diffusion-weighted imaging mismatch. They performed a pre-planned subgroup analysis. Those in the non-endovascular (EVT) therapy subgroup still had benefit: NNT = 13, NNH = 51.
How will this change my practice?
I have spoken to our stroke neurologists at Vanderbilt about this research. Although they find it interesting, they don’t yet find it compelling enough to change practice and would like to see more data. In the event of a bad outcome, there is no medico-legal “cover” at this point from national guidelines or institutional protocols. It seems there is a select population with collaterals and enough flow to keep an ischemic penumbra alive for quite a long time. If there is the right perfusion mismatch in the 4.5–24-hour window, I would want the drug and would want my family to get it as well.
Source
Tenecteplase for Acute Ischemic Stroke at 4.5 to 24 Hours: A Meta-Analysis of Randomized Controlled Trials. Stroke. 2025 Oct 13. doi: 10.1161/STROKEAHA.125.053256. Epub ahead of print. PMID: 41078125.
