Oral Presentation Asia Pacific Stroke Conference 2024

Bridging thrombolysis with tenecteplase versus mechanical thrombectomy alone for large vessel anterior circulation stroke - a target trial (107435)

Valerian L Altersberger 1 , Johannes Kaesmacher 2 , Vignan Yogendrakumar 1 , Leonid Churilov 1 , Peter J Mitchell 1 , Timothy Kleinig 3 , Jan Gralla 2 , Urs Fischer 4 , Bruce CV Campbell 1
  1. Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Victoria, Australia
  2. University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
  3. Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
  4. Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland

Background: Multiple trials have investigated the effect of mechanical thrombectomy (MT) alone compared to intravenous thrombolysis (IVT) before MT. As alteplase was used almost exclusively as thrombolytic agent, the effect of IVT with tenecteplase before MT remains unclear.

Methods: This is a causal inference study of data from the trials SWIFT DIRECT and EXTEND-IA TNK Part 1&2 applying target trial emulation. We compared patients receiving MT alone to patients receiving tenecteplase 0.25mg/kg or 0.40mg/kg before MT. The primary outcome was functional independence (mRS of 0-2) at 90 days. Secondary outcomes included improvement over the full mRS scale, freedom of disability (mRS 0-1), mortality and occurrence of symptomatic intracranial hemorrhage (sICH). The average causal treatment effect was estimated via inverse probability of treatment weighting (IPTW) and G-Computation.

Results: 377 patients (187 with MT alone and 190 with tenecteplase before MT) were included in the target trial. Tenecteplase before MT did not increase probability for functional independence (SRD 0.04[-0.06-0.13]) but resulted in a significant improvement of the mRS overall (OR 1.56[1.07-2.23]) and in a higher proportion for freedom of disability (SRD 0.10[0.01-0.20]) compared to MT alone. The probability for improvement of functional outcomes further increased in patients treated within 140 minutes after onset. No significant differences in safety outcomes were observed.

Conclusion: Tenecteplase before MT compared to MT alone did not increase the probability of functional independence but resulted in significant improvement over the full ordinal mRS scale. The improvement in outcomes was most evident in patients treated early.