Tenecteplase may be a better fibrinolytic than alteplase for treating acute ischemic stroke with complete vessel occlusion. A pooled analysis of 146 patients from two studies found that patients receiving tenecteplase had higher recanalization rates at 24 hours, better 24-hour NIHSS scores, and improved 90-day outcomes as measured by the mRS scale compared to alteplase, with less symptomatic intracerebral hemorrhage. However, the studies were small and open-label, so larger randomized controlled trials are still needed to definitively determine if tenecteplase provides superior clinical benefits over alteplase.

1. Tenecteplase: A Better tPA for Acute Ischemic Stroke?
Naresh Mullaguri MD
Vascular Neurology Fellow
Cerebrovascular center
Cleveland Clinic Foundation
STROKE JOURNAL CLUB 08/2017

2. MECHANISM OF ACTION OF FIBRINOLYTICS
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3. DIFFERENT OPTIONS
ATTEST
Australian TNKase Study
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4. 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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5. 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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6. Baseline clinical and
Imaging
characteristics
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11. 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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12. 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

13. “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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14. FUTURE TENECTEPLASE TRIALS
ATTEST 2
TASTE
EXTEND - 1A - TNK
TEMPO - 2
TWIST
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15. EVERY FELLOW DESERVES WORLD CLASS TRAINING
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