Objective:

To compare large vessel occlusion stroke (LVOS) time-to-treatment metrics between patients receiving thrombolysis with alteplase (TPA) and tenecteplase (TNK) prior to endovascular treatment (EVT).

Background:

Tenecteplase has been adopted by many centers across the United States as an alternative to alteplase. Limited data exist comparing the time-to-treatment metrics between these agents in LVOS patients. 

Design/Methods:

Consecutive LVOS patients who received intravenous thrombolysis (either TPA or TNK) and EVT 01/2020 to 05/2024 were reviewed. The stroke system transition from TPA to TNK as primary thrombolytic in May 2021. Patients were stratified based on whether they presented to a comprehensive stroke center (CSC) or a primary stroke center (PSC). Door-to-needle time (DTN) and needle-to-groin puncture time (NTGP) were compared between TNK and TPA groups. A multivariable analysis was performed to identify factors associated with shorter DTN.

Results:

Of the 280 patients, 123 (43.9%) presented to a CSC, with 74.0% receiving TNK and 26.0% receiving TPA. Among the 157 (56.1%) patients presenting to a PSC, 57.3% received TNK and 42.7% received TPA. At CSCs, DTN was 32 minutes (IQR 25-54) for TNK and 39 minutes (IQR 29-50) for TPA (p = 0.225), while NTGP was 51 minutes (IQR 41-68) for TNK and 50 minutes (IQR 34-70) for TPA (p = 0.627). At PSCs, DTN were 50 minutes (IQR 33-65) for TNK and 44 minutes (IQR 33-60) for TPA (p = 0.476), with NTGP (including transfer) of 126 minutes (IQR 98-160) for TNK and 113 minutes (IQR 88-155) for TPA (p = 0.268). Multivariable analysis identified presentation to CSC and lower INR as independent factors associated with shorter DTN. 

Conclusions:

The transition from TPA to TNK did not significantly improve time-to-treatment metrics, suggesting that workflows with both agents were optimized. Efforts to improve DTNs at PSCs may enhance outcomes of stroke patients.