Tenecteplase matched alteplase in posterior circulation stroke, with a possible functional edge

Design

Systematic review and meta-analysis of 5 comparative studies

Population

997 adults with posterior circulation ischaemic stroke given IV thrombolysis

Primary outcome

Functional independence (mRS 0–2) at 90 days

Effect

RR 1.10 (95% CI 0.89–1.37); mRS 0–3 RR 1.29 (1.03–1.60); sICH RR 0.89 (0.36–2.22)

This meta-analysis pooled five studies with 997 adults treated with intravenous thrombolysis for posterior circulation ischaemic stroke, comparing tenecteplase with alteplase. Posterior strokes are under-represented in the large tenecteplase trials, which is why the subgroup has been uncertain.

Functional independence at 90 days (mRS 0–2), the primary outcome, did not differ (RR 1.10, 95% CI 0.89–1.37). Tenecteplase was associated with more patients walking independently (mRS 0–3: RR 1.29, 1.03–1.60) and with better reperfusion before thrombectomy (RR 2.18). Symptomatic intracranial haemorrhage (RR 0.89, 0.36–2.22) and 90-day mortality (RR 0.88) were similar.

For stroke services that have moved to tenecteplase for its single bolus, this is reassurance that posterior strokes need not be treated differently. The secondary benefits are hypothesis-generating: the primary outcome was neutral, the studies were mixed in design and the haemorrhage estimates are imprecise.

• Tenecteplase can be used for eligible posterior circulation strokes as for anterior ones; the primary outcome was no different from alteplase.
• Its single bolus helps in drip-and-ship transfers to thrombectomy centres.
• Do not delay thrombectomy referral for basilar occlusion after thrombolysis.
• Symptomatic haemorrhage was similar, but the estimate was wide; apply standard contraindications unchanged.
• Tenecteplase is used for stroke in India; follow local protocol for the stroke-specific dose, which differs from the cardiac dose.

Why it matters

It removes a common hesitation about using tenecteplase in the stroke subtype the major trials under-sampled.

Don't overread it

The functional gain appeared only on a secondary outcome; the primary outcome was neutral.

The statistics, in plain English

A risk ratio of 1.10 with a 95% interval of 0.89 to 1.37 crosses 1.0, so tenecteplase was not shown to be better or worse for independence. The mRS 0–3 result (1.29, 1.03–1.60) only just clears 1.0, and when many secondary outcomes are tested one is likely to be 'significant' by chance.

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