Tenecteplase use in the management of acute ischemic stroke: Literature review and clinical considerations

2022 ◽  
Author(s):  
Kirubel Hailu ◽  
Chad Cannon ◽  
Sarah Hayes
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Tissue Type ◽  
St Segment Elevation ◽  
Neurological Outcomes ◽  
Randomized Controlled Studies ◽  
Type Plasminogen Activator ◽  
St Segment ◽  
Clinical Considerations ◽  
Label Indication

Abstract Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Several research articles have been published within the last decade comparing the use of tenecteplase to alteplase in ischemic stroke management. Prior reporting on the comparative therapeutic efficacy and safety profiles of tenecteplase and alteplase is reviewed. Summary Tenecteplase is a variant of native tissue-type plasminogen activator, which rapidly promotes thrombolysis by catalyzing formation of the serine protease plasmin. Tenecteplase has theoretical advantages over alteplase as it has greater fibrin specificity and has a longer half-life than alteplase. This allows the administration of a single bolus over 5 to 10 seconds, as opposed to a bolus followed by a 1-hour infusion with alteplase. While currently approved by the Food and Drug Administration for the treatment of ST-segment elevation myocardial infarction, tenecteplase has also been studied in the treatment of acute ischemic stroke and has extensive data for this off-label indication. The most comprehensive trials to date evaluating the use of tenecteplase in acute ischemic stroke include the TNK-S2B, Australian TNK, ATTEST, Nor-Test, and EXTEND-IA TNK trials. Findings from these randomized controlled studies suggest that tenecteplase is at least as efficacious as alteplase in terms of neurological outcomes. The majority of these studies also reported a trend toward improved safety profiles with the use of tenecteplase. Conclusion Current clinical evidence shows that tenecteplase is not inferior to alteplase for the treatment of ischemic stroke and suggests that tenecteplase may have a superior safety profile. Furthermore, tenecteplase also has practical advantages in terms of its administration. This can potentially lead to a decrease in medication errors and improvement in door to thrombolytic time.

Abstract TP281: Reducing Door-to-Needle Times in Acute Ischemic Stroke : Multidisciplinary Team-based Approach at a Single Center

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Nobuyuki Ohara ◽  
Junya Kobayashi ◽  
Toshiaki Goda ◽  
Takeshi Ikegami ◽  
Kotaro Watanabe ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Multidisciplinary Team ◽  
Treatment Time ◽  
Multivariable Analysis ◽  
Tissue Type ◽  
National Guidelines ◽  
Rapid Acquisition ◽  
Type Plasminogen Activator ◽  
Independent Ambulation

Background: The benefits of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke are time dependent, and national guidelines recommend door-to-needle (DTN) time within 60 minutes. Several strategies have been reported to be associated with reducing DTN times. However, effectiveness of such strategies has not been fully evaluated. Methods: In 2014, we assembled a multidisciplinary team called ‘Acute Stroke Team (AST)’ aiming for improving outcomes of patients with acute ischemic stroke, especially by reducing onset-to-treatment time. A new protocol was implemented to minimize delays: AST staff prenotification, parallel process workflow, and rapid acquisition of laboratory testing and brain imaging. AST reviewed all intravenous tPA cases and discussed the points of improvement. AST also organized both public and in-hospital lectures, and simulation training course. We compared patients received intravenous tPA within 4.5 hours from the symptom onset at our institute in the pre AST (April 2011 - August 2014) and post AST (September 2014 - July 2016) period. Using univariate methods and multivariable logistic regression, we assessed the associated factors with favorable outcomes. Results: In the pre and post AST period, 46 and 36 patients were treated with intravenous tPA, respectively. Compared with pre AST period, the median (interquartile range) DTN times was reduced from 71 (63-95) minutes to 55 (49-71) minutes (p<0.01), and the percentage of patients with DTN times within 60 minutes were improved from 22% to 64% (P<0.001) in the post AST period. By multivariable analysis, shorter DTN times (OR 0.98, 95% CI 0.95-0.99, p=0.025), lower age (OR 0.90, 95% CI 0.85-0.96, p=0.001) and lower NIHSS on admission (OR 0.88, 95% CI 0.82-0.95, p=0.001) were independently associated with independent ambulation at hospital discharge. Conclusions: Multidisciplinary team-based approach reduced DTN times. Reducing DTN times was associated with improving patient outcomes. Future efforts should focus on sustainability and safety of this approach.

Abstract TMP19: Intravenous Recombinant Tissue-type Plasminogen Activator Use in Young Adults With Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jodi A Dodds ◽  
Ying Xian ◽  
Shubin Sheng ◽  
Gregg Fonarow ◽  
Ronald A Matsouaka ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Older Patients ◽  
Young Patients ◽  
Tissue Type ◽  
Stroke Patients ◽  
Younger Patients ◽  
Tissue Type Plasminogen Activator ◽  
Type Plasminogen Activator

Background: Intravenous recombinant tissue-type plasminogen activator (rt-PA) administration improves outcomes in acute ischemic stroke. However, young patients (<40 years old) presenting with stroke symptoms may experience delays in treatment due to misdiagnosis or a reluctance to treat since they do not fit the profile of a typical stroke patient. Methods: We analyzed data from the large national Get With The Guidelines–Stroke registry for acute ischemic stroke patients hospitalized between January 2009 and September 2015. Multivariable models with generalized estimating equations (GEE) were used to test for differences between younger (age 18-40) and older (age > 40) acute ischemic stroke patients, controlling for patient and hospital characteristics including stroke severity. Results: Of 1,320,965 AIS patients admitted to participating hospitals, 2.3% (30,448) were aged 18-40. Among these patients, 12.5% received rt-PA versus 8.8% of those aged >40 (p<0.001). Of patients arriving within 3.5 hours of symptom onset without contraindications, 68.7% of younger patients received IV rt-PA versus 63.3% of older patients (adjusted OR [aOR] 1.30, 95% CI 1.21 to 1.40), without evidence that age-related differences varied by sex (interaction p-value 0.25). Odds ratios of achieving target door-to-CT times and door-to-needle (DTN) times, and outcomes of rtPA-treated patients, are shown in the Table. Conclusions: Young acute ischemic stroke patients did not receive rt-PA treatment at lower rates than older patients. Outcomes were better and the rate of symptomatic intracranial hemorrhage was lower in the young patients. However, younger patients had significantly longer door-to-CT and DTN times, providing an opportunity to improve the care of these patients.

scholarly journals Strategies Used by Hospitals to Improve Speed of Tissue-Type Plasminogen Activator Treatment in Acute Ischemic Stroke

Stroke ◽  
2014 ◽  
Vol 45 (5) ◽  
pp. 1387-1395 ◽  
Author(s):  
Ying Xian ◽  
Eric E. Smith ◽  
Xin Zhao ◽  
Eric D. Peterson ◽  
DaiWai M. Olson ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Type ◽  
Tissue Type Plasminogen Activator ◽  
Type Plasminogen Activator

scholarly journals Intravenous Tissue-Type Plasminogen Activator in Acute Ischemic Stroke Patients With History of Stroke Plus Diabetes Mellitus

Stroke ◽  
2019 ◽  
Vol 50 (6) ◽  
pp. 1497-1503 ◽  
Author(s):  
Matthew E. Ehrlich ◽  
Li Liang ◽  
Haolin Xu ◽  
Andrzej S. Kosinski ◽  
Adrian F. Hernandez ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Type ◽  
Stroke Patients ◽  
Tissue Type Plasminogen Activator ◽  
Type Plasminogen Activator ◽  
History Of

scholarly journals Intravenous thrombolysis in acute ischemic stroke patients with negative CT perfusion: a case series

2014 ◽  
Vol 3 (7) ◽  
pp. 204798161454321
Author(s):  
Ratnesh Mehra ◽  
Chiu Yuen To ◽  
Omar Qahwash ◽  
Boyd Richards ◽  
Richard D Fessler
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Ct Perfusion ◽  
Case Series ◽  
Intravenous Thrombolysis ◽  
Hemorrhagic Transformation ◽  
Tissue Type ◽  
Stroke Patients ◽  
Radiographic Findings ◽  
Type Plasminogen Activator

Background Computed tomography perfusion (CTP) is a commonly used modality of neurophysiologic imaging to aid the selection of acute ischemic stroke patients for neuroendovascular intervention by identifying the presence of penumbra versus infarcted brain tissue. However many patients present with evidence of cerebral ischemia with normal CTP, and in that case, should intravenous thrombolytics be given? Purpose To demonstrate if tissue-type plasminogen activator (tPA)-eligible stroke patients without perfusion defects demonstrated on CTP would benefit from administration of intravenous thrombolytics. Material and Methods We retrospectively identified patients presenting with acute ischemic symptoms who received intravenous tPA (IV-tPA) from January to June 2012 without a perfusion defect on CTP. Clinical and radiographic findings including the NIHSS at presentation, 24 h, and at discharge, symptomatic and asymptomatic hemorrhagic transformation, and the modified Rankin score at 30 days were collected. A reduction of NIHSS of greater than 4 points or resolution of symptoms was considered significant. Results Seventeen patients were identified with a mean NIHSS of 8.2 prior to administration of intravenous thrombolytics, 3.5 after 24 h, and 2.5 at discharge. Among them, 13 patients had significant improvement of NIHSS with a mean reduction of 6.15 points at 24 h. One patient initially improved but had delayed hemorrhagic transformation and died. Two patients had improvement in NIHSS but were not significant and two patients had increased in NIHSS at 24 h, although one eventually improved at discharge. There was no asymptomatic hemorrhagic transformation. Mean mRS at 3 months is 1.76. Conclusion The failure to identify a perfusion deficit by CTP should not be used as a contraindication for intravenous thrombolytics. Criteria for administration of intravenous thrombolytics should still be based on time from symptom onset as previously published by NINDS.

Influence of Obesity on Effectiveness of Intravenous Tissue-Type Plasminogen Activator in Acute Ischemic Stroke (P04.056)

Neurology ◽  
2012 ◽  
Vol 78 (Meeting Abstracts 1) ◽  
pp. P04.056-P04.056
Author(s):  
K. Schlick ◽  
R. Raman ◽  
T. Hemmen ◽  
B. Meyer ◽  
D. Meyer ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Type ◽  
Tissue Type Plasminogen Activator ◽  
Type Plasminogen Activator

scholarly journals Update on therapies for acute ischemic stroke

2000 ◽  
Vol 8 (5) ◽  
pp. 1-5 ◽  
Author(s):  
Dean D. Kindler ◽  
George A. Lopez ◽  
Bradford B. Worrall ◽  
Karen C. Johnston
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Ischemia ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Type ◽  
Tissue Type Plasminogen Activator ◽  
Emerging Therapies ◽  
Type Plasminogen Activator ◽  
Acute Cerebral Ischemia ◽  
Promising Treatment

Acute ischemic stroke is now considered a neurological emergency for which there are new therapies. Neurosurgeons and neurologists need to remain apprised of advances in this field. The authors discuss approved and emerging therapies for patients suffering from acute ischemic stroke, based on a review of recent publications. Currently, intravenous tissue-type plasminogen activator is the only Food and Drug Administration–approved therapy for acute ischemic stroke. Intraarterial delivery of thrombolytics is a promising treatment and may be effective in selected patients. Other therapies for acute cerebral ischemia are intriguing but still in the investigational stages.

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