Neurovascular Nuggets_ Tenecteplase vs. Alteplase and the Thrombus Length Mystery

The study included 1865 patients treated with either tenecteplase (n=787) or alteplase (n=1078) before mechanical thrombectomy. - Overall, early recanalization (modified TICI 2b-3) occurred in 19.8% with tenecteplase and 18.5% with alteplase (OR 1.09, 95% CI 0.83-1.44, p=0.52). - There was no significant difference in early recanalization rates between tenecteplase and alteplase based on time from IVT to angiography (Figure 2) or occlusion site (ICA, proximal M1, distal M1, M2) (Figure 3). - However, there was an interaction between treatment and thrombus length (Figure 4). Tenecteplase was associated with higher early recanalization compared to alteplase for thrombi ≥10mm in length (OR 2.43, 95% CI 1.02-5.81, p=0.04). - The authors conclude that overall recanalization rates were similar between tenecteplase and alteplase, but tenecteplase may be more effective than alteplase for early recanalization of larger thrombi before thrombectomy. Compared to previous studies, the results are mixed: The overall early recanalization rates are similar to those reported for both tenecteplase (around 20%) and alteplase (around 20% with longer IVT-to-angiography times) in prior studies. However, some previous studies like EXTEND-IA TNK found higher recanalization with tenecteplase (22%) compared to alteplase (10%). The current study did not replicate this difference. The finding that tenecteplase leads to higher recanalization for larger thrombi is consistent with recent in vitro data, but inconsistent with one prior study using the clot burden score that suggested tenecteplase was more effective for smaller clots. So the results add to conflicting data on whether tenecteplase provides superior early recanalization compared to alteplase before thrombectomy. The interaction with thrombus length is a novel finding and suggests tenecteplase could have particular benefits for larger clots if confirmed. Overall, the study supports current guidelines which recommend tenecteplase over alteplase based on the totality of evidence, but does not definitively demonstrate superior recanalization, especially for smaller distal occlusions. Further randomized controlled trials may be needed to clarify if tenecteplase should be first-line over alteplase. Read more at hashtag#neurovascularnuggets