AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.).
STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.).
Stroke. 2023 Oct;54(10):2491-2499. doi: 10.1161/STROKEAHA.123.042691. Epub 2023 Aug 25.
Intravenous thrombolysis (IVT) with alteplase or tenecteplase before mechanical thrombectomy is the recommended treatment for large-vessel occlusion acute ischemic stroke. There are divergent data on whether these agents differ in terms of early recanalization (ER) rates before mechanical thrombectomy, and little data on their potential differences stratified by ER predictors such as IVT to ER evaluation (IVT-to-ER) time, occlusion site and thrombus length.
We retrospectively compared the likelihood of ER after IVT with tenecteplase or alteplase in anterior circulation large-vessel occlusion acute ischemic stroke patients from the PREDICT-RECANAL (alteplase) and Tenecteplase Treatment in Ischemic Stroke (tenecteplase) French multicenter registries. ER was defined as a modified Thrombolysis in Cerebral Infarction score 2b-3 on the first angiographic run, or noninvasive vascular imaging in patients with early neurological improvement. Analyses were based on propensity score overlap weighting (leading to exact balance in patient history, stroke characteristics, and initial management between groups) and confirmed with adjusted logistic regression (sensitivity analysis). A stratified analysis based on pre-established ER predictors (IVT-to-ER time, occlusion site, and thrombus length) was conducted.
Overall, 1865 patients were included. ER occurred in 156/787 (19.8%) and 199/1078 (18.5%) patients treated with tenecteplase or alteplase, respectively (odds ratio, 1.09 [95% CI, 0.83-1.44]; =0.52). A differential effect of tenecteplase versus alteplase on the probability of ER according to thrombus length was observed (=0.003), with tenecteplase being associated with higher odds of ER in thrombi >10 mm (odds ratio, 2.43 [95% CI, 1.02-5.81]; =0.04). There was no differential effect of tenecteplase versus alteplase on the likelihood of ER according to the IVT-to-ER time (=0.40) or occlusion site (=0.80).
Both thrombolytics achieved ER in one-fifth of patients with large-vessel occlusion acute ischemic stroke without significant interaction with IVT-to-ER time and occlusion site. Compared with alteplase, tenecteplase was associated with a 2-fold higher likelihood of ER in larger thrombi.
阿替普酶或替奈普酶静脉溶栓联合机械取栓是治疗大血管闭塞性急性缺血性脑卒中的推荐治疗方法。关于这些药物在机械取栓前早期再通（ER）率方面是否存在差异，存在不同的数据，而关于其潜在差异的信息很少，如根据 IVT 至 ER 评估（IVT-to-ER）时间、闭塞部位和血栓长度进行分层。
我们回顾性比较了来自 PREDICT-RECANAL（阿替普酶）和 Tenecteplase 治疗缺血性卒中（替奈普酶）法国多中心登记处的前循环大血管闭塞性急性缺血性卒中患者中，阿替普酶或替奈普酶静脉溶栓后 ER 的可能性。ER 定义为首次血管造影时改良的脑梗死溶栓评分 2b-3，或在早期神经功能改善的患者中进行无创血管成像。分析基于倾向评分重叠加权（导致组间患者病史、卒中特征和初始管理完全平衡），并通过调整后的逻辑回归（敏感性分析）进行确认。基于预先确定的 ER 预测因素（IVT-to-ER 时间、闭塞部位和血栓长度）进行了分层分析。
总体而言，纳入了 1865 名患者。替奈普酶组和阿替普酶组中 ER 分别发生在 156/787（19.8%）和 199/1078（18.5%）名患者中（比值比，1.09[95%CI，0.83-1.44]；=0.52）。替奈普酶与阿替普酶对 ER 概率的影响存在差异（=0.003），在血栓长度>10mm的患者中，替奈普酶与 ER 发生的更高几率相关（比值比，2.43[95%CI，1.02-5.81]；=0.04）。替奈普酶与阿替普酶对 ER 可能性的影响，在 IVT-to-ER 时间（=0.40）或闭塞部位（=0.80）方面没有差异。
两种溶栓药物都能使五分之一的大血管闭塞性急性缺血性卒中患者实现 ER，且与 IVT-to-ER 时间和闭塞部位无显著相互作用。与阿替普酶相比，替奈普酶在较大的血栓中更有可能实现 ER，其几率增加了两倍。
