Safety and Efficacy of Tenecteplase Compared With Alteplase in Patients With Large Vessel Occlusion Stroke
Authors: Bala Fouzi , Singh Nishita , Buck Brian , Ademola Ayoola , Coutts Shelagh B. , Deschaintre Yan , Khosravani Houman , Appireddy Ramana , Moreau Francois , Phillips Stephen , Gubitz Gord , Tkach Aleksander , Catanese Luciana , Dowlatshahi Dar , Medvedev George , Mandzia Jennifer , Pikula Aleksandra , Shankar Jai Jai , Williams Heather , Field Thalia S. , Manosalva Alzate Alejandro , Siddiqui Muzaffar , Zafar Atif , Imoukhoude Oje , Hunter Gary , Alhabli Ibrahim , Benali Faysal , Horn MacKenzie , Hill Michael D. , Shamy Michel , Sajobi Tolulope T. , Swartz Richard H. , Menon Bijoy K. , Almekhlafi Mohammed 
Published: July 2023

ImportanceIt is unknown whether intravenous thrombolysis using tenecteplase is noninferior or preferable compared with alteplase for patients with acute ischemic stroke.ObjectiveTo examine the safety and efficacy of tenecteplase compared to alteplase among patients with large vessel occlusion (LVO) stroke.Design, Setting, and ParticipantsThis was a prespecified analysis of the Intravenous Tenecteplase Compared With Alteplase for Acute Ischaemic Stroke in Canada (ACT) randomized clinical trial that enrolled patients from 22 primary and comprehensive stroke centers across Canada between December 10, 2019, and January 25, 2022. Patients 18 years and older with a disabling ischemic stroke within 4.5 hours of symptom onset were randomly assigned (1:1) to either intravenous tenecteplase or alteplase and were monitored for up to 120 days. Patients with baseline intracranial internal carotid artery (ICA), M1-middle cerebral artery (MCA), M2-MCA, and basilar occlusions were included in this analysis. A total of 1600 patients were enrolled, and 23 withdrew consent.ExposuresIntravenous tenecteplase (0.25 mg/kg) vs intravenous alteplase (0.9 mg/kg).Main Outcomes and MeasuresThe primary outcome was the proportion of modified Rankin scale (mRS) score 0-1 at 90 days. Secondary outcomes were an mRS score from 0 to 2, mortality, and symptomatic intracerebral hemorrhage. Angiographic outcomes were successful reperfusion (extended Thrombolysis in Cerebral Infarction scale score 2b-3) on first and final angiographic acquisitions. Multivariable analyses (adjusting for age, sex, National Institute of Health Stroke Scale score, onset-to-needle time, and occlusion location) were carried out.ResultsAmong 1577 patients, 520 (33.0%) had LVO (median [IQR] age, 74 [64-83] years; 283 [54.4%] women): 135 (26.0%) with ICA occlusion, 237 (45.6%) with M1-MCA, 117 (22.5%) with M2-MCA, and 31 (6.0%) with basilar occlusions. The primary outcome (mRS score 0-1) was achieved in 86 participants (32.7%) in the tenecteplase group vs 76 (29.6%) in the alteplase group. Rates of mRS 0-2 (129 [49.0%] vs 131 [51.0%]), symptomatic intracerebral hemorrhage (16 [6.1%] vs 11 [4.3%]), and mortality (19.9% vs 18.1%) were similar in the tenecteplase and alteplase groups, respectively. No difference was noted in successful reperfusion rates in the first (19 [9.2%] vs 21 [10.5%]) and final angiogram (174 [84.5%] vs 177 [88.9%]) among 405 patients who underwent thrombectomy.Conclusions and RelevanceThe findings in this study indicate that intravenous tenecteplase conferred similar reperfusion, safety, and functional outcomes compared to alteplase among patients with LVO.