Intravenous Thrombolysis with Tenecteplase Versus Alteplase in Acute Ischemic Stroke Tandem Lesions: a Systematic Review and Meta-Analysis of Current Available Literature
Anthony Hong1, Ocilio Ribeiro Gonçalves2, Ana Santos1, Marcio Yuri Ferreira3, Gabriel de Almeida Monteiro4, Victor Gonçalves Soares4, Luiza G. Schmitt5, Savio Batista6, Luis O. S. Nogueira7, Christian Ken Fukunaga8, Marina Vilardo9, João Victor Araújo de Oliveira2, João de Deus Costa Alves10, Kelson James Almeida2
1University of Costa Rica, 2Federal University of Piaui, 3Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, 4Federal University of Ceará, 5Federal University of the Jequitinhonha and Mucuri Valleys, 6UFRJ, 7Federal University of Rio de Janeiro, 8Amazonas State University, 9Catholic University of Brasilia, 10FMABC University Center
Objective:
To synthesize available data comparing the efficacy and safety profiles of alteplase and tenecteplase in patients with tandem occlusions.
Background:
Tandem infarct is characterized by simultaneous extracranial and ipsilateral intracranial arterial occlusions. Currently, treatment involves intravenous thrombolysis (IVT) followed by endovascular thrombectomy. Direct comparisons between Alteplase and Tenecteplase for IVT in patients with tandem occlusions remain limited.
Design/Methods:
We systematically searched PubMed, Embase and Cochrane from inception to June 2024 for studies enrolling patients with tandem lesions in acute ischemic stroke treated with IVT involving Tenecteplase or Alteplase. Outcomes of interest included (1) modified Rankin Scale (mRS) 0-1, (2) mRS 0-2, (4) successful recanalization (TICI 2b-3), (4) symptomatic intracranial hemorrhage (sICH), and (5) overall mortality. We compared results using Risk Ratio (RR) with 95% Confidence Intervals (CI).
Results:
Three studies published between 2023 and 2024 were included: two randomized controlled trials and one observational study, comprising 917 patients. Tenecteplase was administered to 230 (25,1%) patients. Age ranged from 57 to 82 years, with baseline NIHSS from 10 to 24 points, and there were 314 (34.2%) female patients. No statistically significant difference between groups were observed for mRS 0-1 (RR 0.80; 95% CI 0.35-1.83; p = 0.597; I² = 86%), mRS 0-2 (RR 1.04; 95% CI 0.88-1.23; p = 0.630; I² = 0%), TICI 2b-3 (RR 1.00; 95% CI 0.93-1.09; p = 0.909; I² = 0%), sICH (RR 1.09; 95% CI 0.64-1.84; p = 0.756; I² = 0%), and overall mortality (RR 0.68; 95% CI 0.45-1.05; p = 0.081; I² = 17%).
Conclusions:
This meta-analysis found that tenecteplase achieved similar outcomes to alteplase in improving functional outcomes and recanalization rates. No significant difference was noted between tenecteplase and alteplase in sICH and mortality rates. Further large-scale randomized studies are needed to provide a definitive conclusion on the comparative efficacy and safety of tenecteplase versus alteplase.
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