2025 Southeastern Residency Conference

Title: Evaluating the Safety and Efficacy of Alteplase versus Tenecteplase in the Management of Acute Ischemic Stroke
Authors: Brooke Landry, Matthew McAllister, Shae Tirado, McKenzie Hodges
Background: Acute ischemic stroke (AIS) is a medical emergency caused by a sudden blockage or reduction in blood flow within the brain. Early medical treatment is crucial for reducing morbidity and mortality following AIS. Thrombolytics are the mainstay pharmacologic agent utilized in patients presenting within 4.5 hours of symptom onset. Alteplase and tenecteplase are two thrombytics FDA-approved for the management of AIS. This study aimed to compare outcomes of alteplase versus tenecteplase for AIS, focusing on time to administration, functional outcomes, and incidence of adverse events. The findings of this study may provide additional comparative evidence between these two thrombolytic agents, adding to the growing body of evidence in the treatment of AIS.
Methods: A multi-center, retrospective chart review was performed of individuals who received alteplase from September 1, 2023 to November 30, 2023 and tenecteplase from January 1, 2024 to March 31, 2024 for acute ischemic stroke within Piedmont Health System. We compared door-to-needle times, incidence of symptomatic intracranial hemorrhage, rate of successful reperfusion, mRS at 90-days, and incidence of angioedema between study arms. A subgroup analysis was conducted on patients who underwent mechanical thrombectomy following thrombolytic administration. Door-to-needle times and mRS at discharge/90 days were evaluated utilizing an independent t-test. A chi-squared test was used to assess incidence of symptomatic intracranial hemorrhage, incidence of angioedema, and rate of successful reperfusion.
Results: There were a total of 314 patients included in the study, 159 patients who received alteplase and 155 who received tenecteplase. Baseline characteristics were similar between groups. For the primary outcome of door-to-needle time, average time for the alteplase and tenecteplase arms were 50 minutes and 49 minutes, respectively. This difference was not statistically significant. For secondary outcomes, symptomatic hemorrhagic conversion was identified in 7 alteplase recipients and 5 tenecteplase recipients, average discharge/90-day mRS was 2.6 in the alteplase arm and 2.5 in the tenecteplase arm, and angioedema occurred in 1 alteplase recipient and 2 tenecteplase recipients. None of the secondary outcomes were statistically significant. In the subgroup analysis of patients who underwent mechanical thrombectomy, symptomatic hemorrhagic conversion was identified in 4 alteplase recipients and 1 tenecteplase recipient, average discharge/90-day mRS was 3.3 in the alteplase arm and 4.0 in the tenecteplase arm, and successful reperfusion was achieved in 14 alteplase recipients and 13 tenecteplase recipients. None of the subgroup outcomes were statistically significant.
Conclusion: This study found no difference in door-to-needle times between alteplase and tenecteplase. Additionally, no differences were seen in secondary safety and efficacy outcomes including incidence of angioedema, rate of symptomatic hemorrhagic conversion, mRS at discharge/90 days, or rate of successful reperfusion. These results suggest that tenecteplase is a safe and effective alternative thrombolytic to alteplase for the management of acute ischemic stroke.