Comparative Analysis of Time-to-treatment Metrics for Tenecteplase vs. Alteplase in Large Vessel Occlusion Stroke

Introduction: Tenecteplase (TNK) has been adopted by many centers across the United States as the primary thrombolytic in acute ischemic stroke treatment. Limited data exist whether the transition from alteplase (TPA) to the new agent TNK affected time-to-treatment metrics in large vessel occlusion stroke (LVOS) patients. Here we compared benchmark time-to-treatment stroke metrics between the TPA and TNK treatment eras.

Methods: Adult LVOS patients who received intravenous thrombolysis and EVT 01/2020 to 05/2024 were reviewed. Our health care system transitioned to TNK in 05/2021. Patients were stratified based on presentation to a comprehensive stroke center (CSC) or a primary stroke center (PSC). Door-to-needle time (DTN) and needle-to-groin puncture time (NTGP) were compared between thrombolytic groups. A multivariable analysis was performed to identify factors associated with shorter DTN.

Results: Of 280 patients, 123 (43.9%) presented to a CSC, with 74.0% receiving TNK and 26.0% receiving TPA. At CSCs, DTN was 32 minutes (IQR 25-54) for TNK and 39 minutes (IQR 29-50) for TPA (p = 0.225), while NTGP was 51 minutes (IQR 41-68) for TNK and 50 minutes (IQR 34-70) for TPA (p = 0.627). Among the 157/280 patients (56.1%) presenting to a PSC, 57.3% received TNK and 42.7% received TPA. Comparatively, PSCs’ DTN were 50 minutes (IQR 33-65) for TNK and 44 minutes (IQR 33-60) for TPA (p = 0.476), with NTGP of 126 minutes (IQR 98-160) for TNK and 113 minutes (IQR 88-155) for TPA (p = 0.268). Multivariable analysis identified presentation to CSC and lower INR as independent factors associated with shorter DTN.

Conclusion : Time-to-treatment metrics were similar between the TPA and TNK groups. The usage of TPA vs TNK did not significantly change time-to-treatment metrics, suggesting optimized workflows with both agents. Efforts to improve DTNs at PSCs may enhance outcomes of stroke patients.