By Matthew E. Fink, MD

Louis and Gertrude Feil Professor and Chair, Department of Neurology, Associate Dean for Clinical Affairs, New York Presbyterian/Weill Cornell Medical College

SOURCE: Alemseged F, Ng FC, Williams C, et al. Tenecteplase vs alteplase before endovascular therapy in basilar artery occlusion. Neurology 2021;96:e1272-e1277.

Basilar artery occlusion is a dangerous clinical syndrome of large artery occlusion that carries a high morbidity and mortality with severe disability in survivors. In multiple trials, alteplase has shown minimal benefit in achieving reperfusion in patients with large artery occlusion, including the basilar artery. Tenecteplase is a modified variant of alteplase that has greater specificity in binding to fibrin, a longer half-life, and can be administered in a single bolus. This makes it operationally easier to use and theoretically more effective.

In the head-to-head trial of tenecteplase vs. alteplase before endovascular therapy in ischemic stroke (EXTEND-IA-TNK), tenecteplase led to a higher rate of reperfusion and improved clinical outcomes compared with alteplase.¹ To assess the benefit in patients with basilar artery occlusion, the authors retrospectively analyzed all of the cases of basilar artery occlusion reported in several studies that compared the use of tenecteplase with alteplase. A total of 110 patients with basilar artery occlusion were included and were treated with either alteplase or tenecteplase for intravenous thrombolysis prior to endovascular therapy. Nineteen patients were treated with tenecteplase and 91 with alteplase. Reperfusion > 50% was successful in 26% of patients treated with tenecteplase vs. 7% of patients treated with alteplase, despite shorter thrombolysis-to-arterial puncture times in the tenecteplase-treated group. The groups were not matched and they were unequal, but the risk ratio for alteplase was 4.0, P = 0.02. There was no difference in symptomatic intracranial hemorrhage between the groups. This observational study suggests benefits with tenecteplase above alteplase, and it warrants additional randomized trials of this agent in basilar artery occlusion, as well as other types of large vessel occlusions.

REFERENCE

1. Campbell BC, Mitchell PJ, Churilov L, et al. Tenecteplase versus alteplase before thrombectomy for ischemic stroke. N Engl J Med 2018;378:1573-1582.