Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke - EXTEND-IA TNK

May 02, 2018
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Author/Summarized by Author:
Anthony A. Bavry, MD, MPH, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
National Health and Medical Research Council of Australia and others.
Date Published:
04/25/2018
Date Updated:
05/02/2018
Original Posted Date:
05/02/2018
References

Contribution To Literature:

The EXTEND-IA TNK trial showed that tenecteplase was superior to alteplase at improving reperfusion and functional outcomes.

Description:

The goal of the trial was to evaluate intravenous tenecteplase compared with alteplase before endovascular thrombectomy for ischemic stroke.

Study Design

  • Randomized
  • Parallel
  • Stratified

Patients within 4.5 hours from symptom onset of ischemic stroke and undergoing endovascular therapy were randomized to tenecteplase 0.25 mg/kg (n = 101) versus alteplase 0.9 mg/kg (n = 101).

  • Total number of enrollees: 202
  • Duration of follow-up: median 90 days
  • Mean patient age: 70 years
  • Percentage female: 33%

Inclusion criteria:

  • Ischemic stroke due to occlusion of the internal carotid, basilar, or middle cerebral artery
  • Within 4.5 hours of symptom onset

Exclusion criteria:

  • Pre-existing disability

Principal Findings:

The primary outcome, reperfusion of >50% of the involved ischemic territory or an absence of retrievable thrombus at the time of the initial angiographic assessment, occurred in 22% of the tenecteplase group compared with 10% of the alteplase group (p for noninferiority = 0.002, p for superiority = 0.03).

Secondary outcomes:

  • Symptomatic intracerebral hemorrhage: 1% in the tenecteplase group vs. 1% in the alteplase group
  • Death: 10% in the tenecteplase group vs. 18% in the alteplase group (p = 0.049)

Interpretation:

Among patients with acute ischemic stroke undergoing endovascular therapy, tenecteplase was associated with a higher incidence of reperfusion and better functional outcome compared with alteplase. Intracranial hemorrhage was similar between groups. The bolus infusion of tenecteplase is practically easier to administer than a 1-hour infusion of alteplase.

References:

Campbell BC, Mitchell PJ, Churilov L, et al. Tenecteplase Versus Alteplase Before Thrombectomy for Ischemic Stroke. N Engl J Med 2018;378:1573-82.

Editorial: Paving the Way for Improved Treatment of Acute Stroke with Tenecteplase. N Engl J Med 2018;378:1635-6.

Keywords: Angiography, Brain Ischemia, Cerebral Hemorrhage, Endovascular Procedures, Intracranial Hemorrhages, Secondary Prevention, Reperfusion, Stroke, Thrombectomy, Thrombosis, Tissue Plasminogen Activator


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