Safety and Efficacy of Tenecteplase Versus Alteplase in Stroke Patients with Carotid Tandem Lesions: Results from the AcT Trial

Overview

Journal Int J Stroke

Publisher Sage Publications

Specialty Cardiology & Vascular Diseases

Date 2023 Sep 21

PMID 37731173

Authors

Fouzi Bala

Mohammed Almekhlafi

Nishita Singh

Ibrahim Alhabli

Ayoola Ademola

Shelagh B Coutts

Yan Deschaintre

Houman Khosravani

Ramana Appireddy

Francois Moreau

Stephen Phillips

Gord Gubitz

Aleksander Tkach

Luciana Catanese

Dar Dowlatshahi

George Medvedev

Jennifer Mandzia

Aleksandra Pikula

Jay Shankar

Heather Williams

Thalia S Field

Alejandro Manosalva

Muzaffar Siddiqui

Atif Zafar

Oje Imoukhoude

Gary Hunter

Faysal Benali

MacKenzie Horn

Michael D Hill

Michel Shamy

Tolulope T Sajobi

Brian H Buck

Richard H Swartz

Bijoy K Menon

Alexandre Y Poppe

Affiliations

Soon will be listed here.

Abstract

Background: Carotid tandem lesions ((TL) ⩾70% stenosis or occlusion) account for 15-20% of acute stroke with large vessel occlusion.

Aims: We investigated the safety and efficacy of intravenous tenecteplase (0.25 mg/kg) versus intravenous alteplase (0.9 mg/kg) in patients with carotid TL.

Methods: This is a substudy of the alteplase compared with the tenecteplase trial. Patients with ⩾70% stenosis of the extracranial internal carotid artery (ICA) and concomitant occlusion of the intracranial ICA, M1 or M2 segments of the middle cerebral artery on baseline computed tomography angiography (CTA) were included. Primary outcome was 90-day-modified Rankin Scale (mRS) 0-1. Secondary outcomes were mRS 0-2, mortality, and symptomatic ICH (sICH). Angiographic outcomes were successful recanalization (revised Arterial Occlusive Lesion (rAOL) 2b-3) on first and successful reperfusion (eTICI 2b-3) on final angiographic acquisitions. Multivariable mixed-effects logistic regression was performed.

Results: Among 1577 alteplase versus tenecteplase randomized controlled trial (AcT) patients, 128 (18.8%) had carotid TL. Of these, 93 (72.7%) underwent intravenous thrombolysis plus endovascular thrombectomy (IVT + EVT), while 35 (27.3%) were treated with IVT alone. In the IVT + EVT group, tenecteplase was associated with higher odds of 90-day-mRS 0-1 (46.0% vs. 32.6%, adjusted OR (aOR) 3.21; 95% CI = 1.06-9.71) compared with alteplase. No statistically significant differences in rates of mRS 0-2 (aOR 1.53; 95% CI = 0.51-4.55), initial rAOL 2b-3 (16.3% vs. 28.6%), final eTICI 2b-3 (83.7% vs. 85.7%), and mortality (18.0% vs. 16.3%) were found. SICH only occurred in one patient. There were no differences in outcomes between thrombolytic agents in the IVT-only group.

Conclusion: In patients with carotid TL treated with EVT, intravenous tenecteplase may be associated with similar or better clinical outcomes, similar angiographic reperfusion rates, and safety outcomes as compared with alteplase.

Citing Articles

Intravenous thrombolysis with tenecteplase versus alteplase in acute ischemic stroke tandem occlusions: a systematic review and meta-analysis of current available literature.

Goncalves O, Ferreira M, de Almeida Monteiro G, Soares V, Schmitt L, Batista S J Thromb Thrombolysis. 2025; .

PMID: 40082388 DOI: 10.1007/s11239-025-03084-4.

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