Intravenous alteplase versus tenecteplase in patients with acute posterior circulation strokes: A secondary analysis from the AcT randomized controlled trial

Petra Cimflova; Ibrahim Alhabli; Fouzi Bala; MacKenzie Horn; Faysal Benali; Brian H Buck; Luciana Catanese; Prof Shelagh B Coutts; Houman Khosravani; Ramana Appireddy; Aleksander Tkach; Dar Dowlatshahi; Federico Carpani; Thalia Field; Gary Hunter; Prof Michael D Hill; Alexandre Y Poppe; Ayoola Ademola; Michel Shamy; Tolulope T Sajobi; Richard H Swartz; Mohammed A Almekhlafi; Prof Bijoy K Menon; Nishita Singh

doi:10.1016/j.jstrokecerebrovasdis.2024.107985

Intravenous alteplase versus tenecteplase in patients with acute posterior circulation strokes: A secondary analysis from the AcT randomized controlled trial

J Stroke Cerebrovasc Dis. 2024 Nov;33(11):107985. doi: 10.1016/j.jstrokecerebrovasdis.2024.107985. Epub 2024 Aug 31.

Authors

Petra Cimflova¹, Ibrahim Alhabli², Fouzi Bala³, MacKenzie Horn², Faysal Benali⁴, Brian H Buck⁵, Luciana Catanese⁶, Prof Shelagh B Coutts⁷, Houman Khosravani⁸, Ramana Appireddy⁹, Aleksander Tkach¹⁰, Dar Dowlatshahi¹¹, Federico Carpani¹², Thalia Field¹³, Gary Hunter¹⁴, Prof Michael D Hill⁷, Alexandre Y Poppe¹⁵, Ayoola Ademola², Michel Shamy¹¹, Tolulope T Sajobi⁸, Richard H Swartz⁸, Mohammed A Almekhlafi⁷, Prof Bijoy K Menon⁷, Nishita Singh¹⁶

Affiliations

¹ Department of Radiology, University of Calgary, Calgary, Canada; Universitätsinstitut für Diagnostische und Interventionelle Neuroradiologie, Universitätsspital Bern, Rosenbühlgasse 25, Bern 3010, Switzerland; Department of Clinical Neurosciences, University of Calgary, Calgary, Canada. Electronic address: [email protected].
² Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.
³ Department of Clinical Neurosciences, University of Calgary, Calgary, Canada; Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France.
⁴ Department of Clinical Neurosciences, University of Calgary, Calgary, Canada; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands.
⁵ Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
⁶ Hamilton Health Sciences Centre and McMaster University, Hamilton, ON, Canada.
⁷ Department of Radiology, University of Calgary, Calgary, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Canada; Cumming School of Medicine and Department of Community Health Sciences; University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, Calgary, Canada.
⁸ Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
⁹ Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada.
¹⁰ Kelowna General Hospital, Kelowna, BC, Canada.
¹¹ Department of Medicine, University of Ottawa and the Ottawa Heart Research Institute, Ottawa, ON, Canada.
¹² Toronto Western Hospital and the University of Toronto, Toronto, ON, Canada.
¹³ Vancouver Stroke Program and the Division of Neurology, University of British Columbia, Vancouver, BC, Canada.
¹⁴ University of Saskatchewan, Saskatoon, SK, Canada.
¹⁵ Division of Neurology, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada.
¹⁶ Department of Clinical Neurosciences, University of Calgary, Calgary, Canada; Department of Internal Medicine-Neurology Division, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.

PMID: 39222700
DOI: 10.1016/j.jstrokecerebrovasdis.2024.107985

Abstract

Objectives: There are limited data available demonstrating the safety and efficacy of intravenous tenecteplase versus alteplase in patients with acute ischemic stroke in the posterior circulation.

Materials and methods: This is a post-hoc analysis of the Alteplase compared to Tenecteplase (AcT) pragmatic, phase 3, registry-linked randomized controlled trial. Patients with any posterior circulation vessel occlusion on baseline imaging were included. Study outcomes included 90-day modified Rankin Scale (mRS) 0-1, mRS 0-2, ordinal mRS, death within 90 days, 24 h symptomatic intracerebral haemorrhage (sICH) and successful reperfusion/recanalization. Mixed effects regression adjusting for age, sex and stroke severity was used to analyze differences in outcomes between patients administered tenecteplase vs. alteplase. Further, sensitivity analysis was conducted for basilar artery occlusion (BAO) alone.

Results: Of 1577 patients, 136 (8.6 %, 77:alteplase, 59:tenecteplase) had posterior circulation stroke. Baseline characteristics were similar[median age 71 (IQR 60-81) vs. 72 (IQR 65-82) years, 57.1 % vs. 67.8 % males, median baseline NIHSS 7 (IQR 4-12) vs. 7 (IQR 4-16) in alteplase vs. tenecteplase arms, respectively]. 28 patients (20.6 %, 16:alteplase, 12:tenecteplase arm) underwent EVT. The median 90-120 days mRS was 2 (IQR 1-4). There were no differences between alteplase and tenecteplase for 90-d mRS 0-1 (adjRR 0.93;95 %CI 0.63-1.36), 90-day mRS 0-2 (adjRR 0.95; 95 %CI 0.72-1.26), sICH (RR 0.65; 95 %CI 0.06-7.02) and mortality (RR 1.21; 95 %CI 0.61-2.38). Successful reperfusion eTICI 2b-3 and successful recanalization rAOL 2b-3 was achieved in 23/28 (82 %, 12:alteplase, 11:tenecteplase) and in 16/28 (57 %, 14:alteplase, 12:tenecteplase), respectively. Similar results were seen in 31 patients (22.8 %) with BAO.

Conclusion: Intravenous tenecteplase has a similar effect on outcome as alteplase, without increased safety concerns in patients with acute posterior circulation strokes.

Keywords: Basilar artery occlusion; Intravenous thrombolysis; Posterior circulation stroke; Tenecteplase.

Publication types

Comparative Study
Randomized Controlled Trial
Multicenter Study
Clinical Trial, Phase III

MeSH terms

Administration, Intravenous
Aged
Aged, 80 and over
Disability Evaluation
Female
Fibrinolytic Agents* / administration & dosage
Fibrinolytic Agents* / adverse effects
Functional Status
Humans
Infusions, Intravenous
Ischemic Stroke* / diagnosis
Ischemic Stroke* / drug therapy
Ischemic Stroke* / mortality
Ischemic Stroke* / physiopathology
Male
Middle Aged
Recovery of Function
Registries
Risk Factors
Tenecteplase* / administration & dosage
Tenecteplase* / adverse effects
Thrombolytic Therapy* / adverse effects
Time Factors
Tissue Plasminogen Activator* / administration & dosage
Tissue Plasminogen Activator* / adverse effects
Treatment Outcome

Substances

Fibrinolytic Agents
Tenecteplase
Tissue Plasminogen Activator