Tenecteplase Compared to Alteplase in a Larger Wake-up Stroke Cohort

Tenecteplase is a newer thrombolytic agent with possible clinical and pharmacological advantages compared to alteplase. In NOR-TEST, a randomized-controlled study, both thrombolytics had a similar safety profile as well in Wake-up stroke (WUPS) patients. In order, to assess both thrombolytics in a bigger WUPS cohort, we merged WUPS patients treated in NOR-TEST with WUPS patients treated after the trial and reanalyzed the patient outcome. Methods: WUPS patients were included in Nor-Test based on DWI/FLAIR mismatch and randomly assigned (1:1) to receive intravenous tenecteplase 0·4 mg/kg or alteplase 0·9 mg/kg. The clinical outcome was measured by the National Institutes of Health Stroke Scale (NIHSS), functional outcome by the modified Rankin Scale (mRS). After the termination of the trial one center continued treating the patients with tenecteplase while another center switched back to alteplase. Patients with a pre-stroke mRS>1 were excluded from the analysis. Results: Total 114 patients were included in this study. Clinical outcome was measured in 97 patients with prestroke mRS≤1. Of them, 38 (39%) were treated with tenecteplase. There was neither a difference in neurological improvement 24h after admission, (alteplase: 41 (69.5%), tenecteplase: 21 (55.3%); (p=0.154) nor any difference in mRS at day 90; (alteplase: 39 (66.1%), tenecteplase: 22 (57.9%); p=0.414). Symptomatic intracranial hemorrhage was detected on control MRI/CT in one tenecteplase patient (n=1; 2.6%, p=0.392). Conclusion: Compared to alteplase, tenecteplase appears to have similar efficacy and safety profile in WUPS patients selected by DWI-FLAIR mismatch at admission MRI, also in a bigger WUPS patient cohort.