Abstract Details

Title Reciprocal Relationship Between Early Reperfusion and First-pass Effect in Tenecteplase versus Alteplase before Stroke Thrombectomy

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P5 - Poster Session 5 (11:45 AM-12:45 PM)

Poster/Presentation
Number 4-001

Objective To investigate the interplay of early reperfusion (ER) and first-pass effect (FPE) between patients receiving thrombolysis with tenecteplase (TNK) and alteplase (TPA) prior to endovascular treatment (EVT).

Background In large vessel occlusion stroke (LVOS) thrombectomy, ER and FPE are key procedural endpoints. TNK’s greater fibrin specificity may allow for higher ER than TPA, but the impact on FPE is unclear. We hypothesized that higher ER with TNK may preferentially eliminate thrombi that are easily retrievable on the first pass, leaving behind a greater proportion of EVT-resistant clots and thereby reducing FPE. Conversely, because TPA achieves less early lysis, more of these easily retrievable clots remain available for mechanical extraction, resulting in higher FPE despite lower ER.

Design/Methods Patients from two U.S. stroke centers with consecutive anterior circulation LVOS treated with intravenous thrombolysis prior to EVT were reviewed. ER was defined as eTICI 2b-3 on initial angiography. FPE was defined as eTICI 2c-3 after a single pass without rescue maneuvers. Predictors of ER and FPE were identified using multivariable logistic regression. Ordinal logistic regression assessed associations of thrombolytic agent, ER, and FPE with 90-day modified Rankin Scale (mRS) shift.

Results Among 299 patients (TNK 201, TPA 98), 60 (20.1%) experienced ER with increased rates in TNK (24.4%) than TPA (11.2%, aOR 2.54, 95% CI 1.19-5.42). Of the 239 that proceeded to EVT, FPE was less frequent with TNK (30.3%) than TPA (40.2%, aOR 0.50. 95% CI 0.27-0.91). ER and FPE each independently predicted better functional outcome, but functional outcomes were similar between TNK and TPA overall.

Conclusions The benefit of higher ER rates with TNK may be offset by greater FPE with TPA, resulting in comparable outcomes. This ER-FPE trade-off supports a selective depletion hypothesis, which, if confirmed in prospective studies, may have important implications for endpoint selection and interpretation in future bridging thrombolysis trials.

Authors/Disclosures
Kelsey Kline, BS PRESENTER	Miss Kline has nothing to disclose.
Tyler M. Bielinski	Mr. Bielinski has nothing to disclose.
Grant N. Badger	Mr. Badger has nothing to disclose.
Veronica Bohl	Ms. Bohl has nothing to disclose.
Sina Hemmer, MD	Dr. Hemmer has nothing to disclose.
Wysteria Stedman, RN	Miss Stedman has nothing to disclose.
Oded Goren, MD	Dr. Goren has nothing to disclose.
Min Li, Sr., NA	Ms. Li has received personal compensation for serving as an employee of Daiichi Sankyo (China) Holding Co., Ltd.
Clemens M. Schirmer, MD, PhD	Dr. Schirmer has received personal compensation for serving as an employee of Geisinger. Dr. Schirmer has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Balt. Dr. Schirmer has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Medtronic. Dr. Schirmer has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Stryker. Dr. Schirmer has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Viz.ai. Dr. Schirmer has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Microvention. Dr. Schirmer has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Werfen. Dr. Schirmer has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for NIH. Dr. Schirmer has stock in NTI. Dr. Schirmer has stock in REIST. The institution of Dr. Schirmer has received research support from NIH. The institution of Dr. Schirmer has received research support from Medtronic. The institution of Dr. Schirmer has received research support from Cerenovus. The institution of Dr. Schirmer has received research support from MIVI. The institution of Dr. Schirmer has received research support from Balt. The institution of Dr. Schirmer has received research support from Microvention. The institution of Dr. Schirmer has received research support from Stryker. The institution of Dr. Schirmer has received research support from Penumbra. The institution of Dr. Schirmer has received research support from NICO. The institution of Dr. Schirmer has received research support from Route 92.
Philipp Hendrix, MD, PhD	Dr. Hendrix has nothing to disclose.

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