Early Recanalization Among Patients Undergoing Bridging Therapy With Tenecteplase or Alteplase
Authors: Checkouri Thomas , Gerschenfeld Gaspard , Seners Pierre , Yger Marion , Ben Hassen Wagih , Chausson Nicolas , Olindo Stéphane , Caroff Jildaz , Marnat Gaultier , Clarençon Frédéric , Baron Jean-Claude , Turc Guillaume , Alamowitch Sonia , Arquizan Caroline , Berthezene Yves , Boulouis Grégoire , Bracard Serge , Bricout Nicolas , Cho Tae-Hee , Consoli Arturo , Costalat Vincent , Cottier Jean-Philippe , Debiais Séverine , Gory Benjamin , Henon Hilde , Lapergue Bertrand , Obadia Michael , Oppenheim Catherine , Pico Fernando , Piotin Michel , Richard Sébastien , Zuber Mathieu , Blanc Clémence , Calvet David , Denier Christian , Ghazanfari Sam , Kalsoum Erwah , L’Hermitte Yann , Legrand Laurence , Liegey Jean-Sebastien , Milnerowicz Malgorzata , Naggara Olivier , Poli Mathilde , Premat Kévin , Sibon Igor , Sabben Candice , Shotar Eimad , Smadja Didier , Spelle Laurent 
Published: August 2023

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.