2025 Southeastern Residency Conference

Authors: Raja Munthe, Lisa Sagardia Shapiro, Raphaelle Lombardo, Fadi Nahab, Deborah Westover

Objective: To assess the door-to-needle times (DTN) of patients who meet eligibility criteria for thrombolytic administration prior to and post implementation of the use of tenecteplase in ischemic strokes.

Self Assessment Question: What is the recommended door-to-needle times for patients with an acute ischemic stroke receiving a thrombolytic?

Background: Acute ischemic strokes (AIS) is commonly treated with thrombolytics like Alteplase (ALT) and Tenecteplase (TNK). ALT has a long history of research supportive improved outcomes, but TNK, with advantages such as longer half-life, higher fibrin specificity, and simpler admnistration as a single bolus, is emerging as a promising alternative. While previous studies show comparable safety and effiacy between TNK and ALT, including similar rates of mortality and adverse events, TNK’s favorable pharmacokinetic profile & administration technique may improve key time intervals like door-to-needle (DTN) and door-to- puncture (DTP). Not all studies have shown uniform improvements, nor have they looked at the impact of TNK implementation across types of stroke centers. With TNK now the preferred thrombolytic within Emory Healthcare, as of April 2024, this study aims to evaluate TNK’s impact on stroke care process times, outcomes, and potential obstacles to implementation.

Methods: This is a multicenter retrospective, observational cohort study of consecutive patients selected from Emory’s Stroke Get-With-The-Guidelines Registry, which includes all patients who were suspected of having a stroke, between October 2023 to October 2024. Patients who were 18 years or older, suspected of ischemic stroke, and received thrombolytic therapy with either ALT or TNK within an Emory healthcare facility were included. Patients who were pregnant or received thrombolytics while already admitted inpatient were excluded from the study. The primary endpoint studied was DTN. Secondary outcomes included DTP times, door-in-door-out (DIDO) times, rates of serious adverse effects, such as serious bleeding events or hypersensitivity reactions (e.g. angioedema); hospital length of stay (LOS) and successful thrombectomy defined as TICI scores 2B or greater. DTN and DIDO times, rates of serious adverse events, and hospital LOS were analyzed with Mann-Whitney U tests.Categorical data will be analyzed using a Chi-square test with quantity-limited variables assessed using Fisher's exact tests.


Results: Of 3,511 patients recorded in Emory’s Stroke Get-With-the-Guidelines registry during the study period, 188 (5.2%) received thrombolytics, and 154 patients that met inclusion criteria were included in the study. Our results showed no significant difference in DTN times (56 vs. 53 minutes, p = 0.14), DIDO times (106 vs. 121 minutes, p = 0.45), DTP times (123 vs 104 minutes, p = 0.51) or serious adverse bleeding effects (p = 0.11, OR 1.1 [95% CI 0.4,3.2]) between the pre- and post-implementation cohorts. DTN times did not differ significant based on stroke center classification (p = 0.07) or between thrombolytics at each site and type of stroke center. Hospital LOS and rate of successful thrombectomy were also not significantly different.

Conclusion: There was no statistically significant difference in DTN or DIDO times between cohorts treated with ALT or TNK. These results suggest that the change in thrombolytics did not make significant impact on our ability to promptly administer thrombolytics or transfer patients to thrombectomy-capable centers. Additionally, there were no significant differences in serious adverse effects between cohorts suggesting similar safety profiles between ALT and TNK. Due to the lack of significant difference in stroke response, outcomes, or rate of serious adverse events, transitioning from ALT to TNK should focus on the ease of administration.