Guo Sitong, Qin Shiran, Tan Sitao, Su Henghai, Chen Xiaoyu
Department of Pharmacy, Guangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China.
Front Neurol. 2024 Jan 29;15:1344961. doi: 10.3389/fneur.2024.1344961. eCollection 2024.
The current guideline recommended the use of intravenous thrombolysis (IVT) before Endovascular thrombectomy (EVT), but the effectiveness and safety of tenecteplase compare to alteplase in patients before EVT remain uncertain.
We searched PubMed, Embase, Web of Science, and the Cochrane Library to identify eligible articles from inception until September 16, 2023. The primary outcome was functional independence (mRS 0-2) at 90 days. Secondary outcomes included excellent outcome (mRS 0-1) at 90 days, all-cause mortality at follow-up, successful reperfusion (TICI 2b-3) after the end of EVT, symptomatic intracranial hemorrhage (sICH) or any intracranial hemorrhage (aICH). The PROSPERO registration number is CRD42023470419.
Eight randomized controlled trials (RCTs) were included involving 2,836 acute ischemic stroke (AIS) patients. Compared to EVT alone, tenecteplase (0.25 mg/kg and 0.4 mg/kg) + EVT and 0.9 mg/kg alteplase + EVT were significant difference associated with higher successful reperfusion (TICI 2b-3) after the end of EVT (RR = 2.31; 95% CI 1.15-4.63; RR = 2.31; 95% CI 1.00-5.33; RR = 1.05; 95% CI 1.01-1.09). And compared to 0.25 mg/kg tenecteplase + EVT, alteplase (0.6 mg/kg and 0.9 mg/kg) + EVT were significant difference associated with lower successful reperfusion (TICI 2b-3) after the end of EVT (RR = 0.45; 95% CI 0.22-0.90; RR = 0.45; 95% CI 0.23-0.91). The risk of aICH (RR = 1.50; 95% CI 1.07-2.09) was significantly higher for 0.6 mg/kg alteplase + EVT than EVT alone. There was no significant difference in functional independence (mRS 0-2), excellent outcome (mRS 0-1), all-cause mortality or sICH among the different IVT strategies (0.25 mg/kg or 0.4 mg/kg tenecteplase and 0.6 mg/kg or 0.9 mg/kg alteplase) before EVT.
The use of alteplase before EVT may potentially improve the successful reperfusion after EVT compared to tenecteplase. Due to the insufficient sample size, more high-quality RCTs are needed to confirm effectiveness and safety of tenecteplase compare to alteplase in patients before EVT.
https://www.crd.york.ac.uk/prospero/, identifier: CRD42023470419.
当前指南推荐在血管内血栓切除术（EVT）前使用静脉溶栓（IVT），但在接受EVT治疗的患者中，与阿替普酶相比，替奈普酶的有效性和安全性仍不确定。
我们检索了PubMed、Embase、Web of Science和Cochrane图书馆，以确定从创刊至2023年9月16日的符合条件的文章。主要结局是90天时的功能独立性（改良Rankin量表评分0 - 2分）。次要结局包括90天时的良好结局（改良Rankin量表评分0 - 1分）、随访期间的全因死亡率、EVT结束后的成功再灌注（脑梗死溶栓分级2b - 3级）、症状性颅内出血（sICH）或任何颅内出血（aICH）。PROSPERO注册号为CRD42023470419。
纳入了八项随机对照试验（RCT），涉及2836例急性缺血性卒中（AIS）患者。与单纯EVT相比，替奈普酶（0.25mg/kg和0.4mg/kg）+ EVT以及0.9mg/kg阿替普酶+ EVT与EVT结束后更高的成功再灌注（脑梗死溶栓分级2b - 3级）显著相关（RR = 2.31；95%CI 1.15 - 4.63；RR = 2.31；95%CI 1.00 - 5.33；RR = 1.05；95%CI 1.01 - 1.09）。与0.25mg/kg替奈普酶+ EVT相比，阿替普酶（0.6mg/kg和0.9mg/kg）+ EVT与EVT结束后较低的成功再灌注（脑梗死溶栓分级2b - 3级）显著相关（RR = 0.45；95%CI 0.22 - 0.90；RR = 0.45；95%CI 0.23 - 0.91）。0.6mg/kg阿替普酶+ EVT的aICH风险（RR = 1.50；95%CI 1.07 - 2.09）显著高于单纯EVT。在EVT前不同的IVT策略（0.25mg/kg或0.4mg/kg替奈普酶以及0.6mg/kg或0.9mg/kg阿替普酶）之间，功能独立性（改良Rankin量表评分0 - 2分）、良好结局（改良Rankin量表评分0 - 1分）、全因死亡率或sICH方面无显著差异。
与替奈普酶相比，在EVT前使用阿替普酶可能会潜在地改善EVT后的成功再灌注。由于样本量不足，需要更多高质量的RCT来证实与阿替普酶相比，替奈普酶在接受EVT治疗的患者中的有效性和安全性。
