Early Recanalization Among Patients Undergoing Bridging Therapy With Tenecteplase or Alteplase.

Background: Intravenous thrombolysis (IVT) with alteplase or tenecteplase before mechanical thrombectomy is the recommended treatment for large-vessel occlusion acute ischemic stroke. There are divergent data on whether these agents differ in terms of early recanalization (ER) rates before mechanical thrombectomy, and little data on their potential differences stratified by ER predictors such as IVT to ER evaluation (IVT-to-ER _eval ) time, occlusion site and thrombus length.
Methods: We retrospectively compared the likelihood of ER after IVT with tenecteplase or alteplase in anterior circulation large-vessel occlusion acute ischemic stroke patients from the PREDICT-RECANAL (alteplase) and Tenecteplase Treatment in Ischemic Stroke (tenecteplase) French multicenter registries. ER was defined as a modified Thrombolysis in Cerebral Infarction score 2b-3 on the first angiographic run, or noninvasive vascular imaging in patients with early neurological improvement. Analyses were based on propensity score overlap weighting (leading to exact balance in patient history, stroke characteristics, and initial management between groups) and confirmed with adjusted logistic regression (sensitivity analysis). A stratified analysis based on pre-established ER predictors (IVT-to-ER _eval time, occlusion site, and thrombus length) was conducted.
Results: Overall, 1865 patients were included. ER occurred in 156/787 (19.8%) and 199/1078 (18.5%) patients treated with tenecteplase or alteplase, respectively (odds ratio, 1.09 [95% CI, 0.83-1.44]; P =0.52). A differential effect of tenecteplase versus alteplase on the probability of ER according to thrombus length was observed ( P _interaction =0.003), with tenecteplase being associated with higher odds of ER in thrombi >10 mm (odds ratio, 2.43 [95% CI, 1.02-5.81]; P =0.04). There was no differential effect of tenecteplase versus alteplase on the likelihood of ER according to the IVT-to-ER _eval time ( P _interaction =0.40) or occlusion site ( P _interaction =0.80).
Conclusions: Both thrombolytics achieved ER in one-fifth of patients with large-vessel occlusion acute ischemic stroke without significant interaction with IVT-to-ER _eval time and occlusion site. Compared with alteplase, tenecteplase was associated with a 2-fold higher likelihood of ER in larger thrombi.
Competing Interests: Disclosures All reported disclosures were outside the submitted work. Dr Yger reported reimbursement for conference registration fees from Pfizer and Boehringer-Ingelheim. Dr Chausson received a grant and personal fees (consultancy, lectures) from Boehringer Ingelheim and Bristol-Myers-Squibb. Dr Marnat reported consulting fees from Stryker neurovascular, Microvention Europe, Balt Extrusion; paid lectures for Medtronic and Johnson & Johnson, compensation from Phenox Inc. Dr Clarençon received personal fees from Medtronic, Stryker, Balt Extrusion, Microvention (consultant) and Penumbra (lectures); from ClinSearch (study core laboratory); from Artedrone (board member) and a conflict of interest with Intradys and Collavidence (stock options). Dr Turc received lecturing fees from Guerbet France. Dr Alamowitch received lecturing fees from Boehringer-Ingelheim, Astra-Zeneca, Pfizer and Amgen, and research grants from Boehringer-Ingelheim and Roche-Shugai. Drs Alamowitch and Turc were members of the module writing groups of the European Stroke Organisation (ESO) expedited recommendation on tenecteplase for acute ischemic stroke. Dr Turc was also a member of the module writing groups of the ESO - European Society for Minimally Invasive Neurological Therapy (ESMINT) expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischemic stroke and anterior circulation large-vessel occlusion. No other disclosures were reported.