Campbell BCV et al. Tenecteplase versus altepalse before thrombectomy for ischemic stroke. NEJM 378: 1573-1582.
Tenecteplase is more fibrin specific and has longer activity than alteplase. 101 patients were assigned to .25 mg/kgof tenecteplase and 101 to 0.9 mg/kg alteplase within 4.5 hours of onset. . The primary outcome was repercussion of more than 50 percent of the involved ischemic territory or absent retrievable thrombus at time of angiography. Secondary outcome was mRS at ninety days.
Primary outcome was achieved in 22 % of tenecteplase patients, ten percent of altepalse patients p= 0.002, clinical difference of twelve percentage points. sICH occurred in 1 percent of each group. 90 day mRS was also better , 2 v. 3 (p=0.04).
EXTEND 1A, NIH sponsored trial.
editorial Baird AE. Paving the way for improved treatment of acute stroke with tenecteplase. NEJM 378: 1635-6.
Notes that alteplase helps only a small portion of the patients with large clots, so time between tap and groin puncture is key. Drug has a long half life, can be administed as a bolus, doubled the rate of recanalization and averted the need for some thrombectomies. This is a second phase two trial and a phase 3 trial is needed.
In a study of patients with mild stroke who were not expected to proceed to thrombectomy, superiority of tenecteplase at a dose of .4 mg/kg v. alteplase was NOT shown. Additional ongoing trials including TASTE and ATTEST2 have not reported. Campbell also did NOT show a decrease between thrombolysis and thrombectomy in tenecteplase treated patients in another trial.
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