Tenecteplase: A Better tPA for Acute Ischemic Stroke?

Naresh Mullaguri MDVascular Neurology Fellow

Cerebrovascular center

Cleveland Clinic Foundation

STROKE JOURNAL CLUB 08/2017

MECHANISM OF ACTION OF FIBRINOLYTICS

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DIFFERENT OPTIONS

ATTEST

Australian TNKase Study3

DIFFERENCES BETWEEN TNK AND ALT

1. Newer generation. It is not an infusion.

2. Less cost. $5000 Vs $8300.

3. Less disturbances in the fibrinolytic system compared to Alteplase in the first

24hrs.

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HYPOTHESIS

Patients with Complete vessel occlusion show greater recanalization at 24hrs and

have improved outcomes at 24hrs and 90 days when treated with TNKase Vs

Alteplase.

Methods: pooled analysis of patients in 2 RCTs ATTEST and Australian TNKase

study. 146 patients (96+50)

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Baseline clinical and

Imaging

characteristics

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RESULTS

1. Differences in Rx responses between complete occlusion group and partial

occlusion group.

2. TNK seems to have better recanalization rates @ 24hrs and 24hr NIHSS and

90 day outcome mRS with less sICH. Recan rates with TNK approaching

some thrombectomy trials. Higher mismatch in perfusion imaging in the TNK

group.

3. No difference btw TNK and ALT in the 24hr or 90 day clinical outcomes in the

partial vessel occlusion group likely due to low power.

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LIMITATIONS

1. Small data set of 146 patients in 2 pooled studies. Studies not designed for

clinical benefit with significant differences in design, imaging and outcome

measurements.

2. Open-label design can potentially introduce post-treatment biases in decision

making and clinical assessment despite the follow up assessments are

blinded to treatment.

3. Open-label study might also influenced patient motivation, compliance and

subjective reporting for the mRS.

4. Just to generate hypotheses from the limited data sets to help design future

phase III trials. 12

“Non-superiority of Tenecteplase over Alteplase in clinical benefit and safety

profile but underpowered and included patients with low NIH stroke scale and TIA

patients. Might have stroke mimics.”

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FUTURE TENECTEPLASE TRIALS

ATTEST 2

TASTE

EXTEND - 1A - TNK

TEMPO - 2

TWIST

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EVERY FELLOW DESERVES WORLD CLASS TRAINING

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