BACKGROUND: Whether TNK (tenecteplase) benefits patients with acute ischemic stroke treated within 4.5 to 24 hours remains uncertain, and no previous meta-analysis has differentiated between clinical settings where endovascular thrombectomy (EVT) is unavailable or permitted, leading to pooled distinct clinical contexts and obscuring a clear estimation of TNK's net effect.

METHODS: We searched for randomized controlled trials comparing intravenous TNK of 0.25 mg/kg with standard care or placebo in adults within 4.5 to 24 hours after acute ischemic stroke onset. The primary outcome was excellent functional outcome (modified Rankin Scale score, 0-1) at 90 days, with additional efficacy and safety end points. A random-effects meta-analysis was performed both overall and within predefined subgroups, stratified by whether EVT was permitted in individual studies (non-EVT versus EVT-permitted).

RESULTS: Four multicenter randomized controlled trials enrolling 1278 patients were included. TNK significantly increased excellent functional outcome (odds ratio [OR], 1.34 [95% CI, 1.06-1.71]; P=0.02) at 90 days and recanalization (OR, 3.30 [95% CI, 1.59-6.84]; P=0.001) compared with the control group, whereas good functional outcome (modified Rankin Scale score, 0-2), reperfusion, and early neurological improvement did not differ significantly. Subgroup analyses of 596 patients in the non-EVT subgroup showed that TNK significantly improved excellent functional outcome (OR, 1.46 [95% CI, 1.02-2.08]; P=0.04), good functional outcome (OR, 1.50 [95% CI, 1.07-2.09]; P=0.02), recanalization (OR, 6.17 [95% CI, 3.36-11.33]; P<0.00001), and early neurological improvement (OR, 3.21 [95% CI, 1.82-5.66]; P<0.0001). However, in the EVT-permitted subgroup of 682 patients, TNK only improved recanalization (OR, 2.36 [95% CI, 1.34-4.17]; P=0.003). No significant differences were observed between TNK and control in the risks of symptomatic intracerebral hemorrhage or 90-day mortality, either in the overall or subgroup analyses.

CONCLUSIONS: TNK improves excellent functional outcomes and recanalization in patients with acute ischemic stroke treated within 4.5 to 24 hours, without increasing the risks of symptomatic intracerebral hemorrhage or mortality. Notably, extended-window TNK provides greater additional benefits when EVT is inaccessible, establishing its role as an alternative reperfusion strategy in resource-limited settings.

Emergency Medicine rater

The analysis comparing subgroups where endovascular thrombectomy (EVT) is unavailable or permitted provides some modest additional infection beyond previous meta-analyses and indicates a potential role for TNK in strokes presenting 4.5 to 24h after onset in settings where EVT is inaccessible.

Hospital Doctor/Hospitalists rater

I believe the authors overstated the strength of these findings, as the non-EVT data were driven by one study of ~500 patients and multiple other SRs found contradictory results (albeit with different studies included). It seems this work best provides justification for larger studies of extended window TNK where EVT is not available.