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Urdu“Early Experience with Tenecteplase at a Comprehensive Stroke Center” 1explores how the intravenous prescription medication tenecteplase (TNKase®), a tissue Plasminogen Activator (tPA) that dissolves blood clots, can be used to treat certain patients with acute ischemic stroke. This new agent is a form of tPA and an improvement of existing clot busting medication, alteplase.
“We constantly strive to offer new treatment options for our stroke patients based on the latest clinical practice guidelines, so that they may have shorter recovery times and better health outcomes,” said the article’s lead author, Spozhmy Panezai, M.D., vascular neurologist at JFK University Medical Center’s Neuroscience Institute and associate professor at Hackensack Meridian Health School of Medicine. “Because the medication tenecteplase has been studied and recommended as an alternative clot-dissolving agent in acute stroke, our team wanted to write a review of the clinical trials and guidelines and provide our clinical decision process for the drug’s use, to share with other clinicians and institutions.”
After review of the 2019 American Stroke Association’s updated treatment guidelines, the JFK University Medical Center’s Stroke and Neurovascular team created a standardized care plan, or clinical pathway, in which tenecteplase could be offered to select patients who came to the hospital with acute ischemic stroke. This pathway was created with the joint efforts of the stroke and neurovascular team of physicians and advanced practice nurses, clinical pharmacy specialists, emergency medicine and nursing staff.
“Our multidisciplinary stroke committee determined that, based on the published clinical data and current American Stroke Association treatment guidelines, and reviews by other authorities in the field, tenecteplase in patients with and without large vessel blockages, within 4.5 hours, showed a trend toward increased early neurological improvement and lower risk of brain hemorrhage when compared to alteplase, an FDA-approved treatment for stroke.” said Dr. Panezai.
Tenecteplase as a Treatment Option
Tenecteplase is FDA-approved to treat blood clots in heart attacks, and several Phase 2 clinical studies of tenecteplase in patients with acute stroke have been conducted, showing some advantages over alteplase, the standard of care to treat clots in stroke patients. These potential benefits include better restoration of blood to the brain and clinical improvement with no significant between-group differences in bleeding inside the brain or other serious adverse events. One study that compared tenecteplase to alteplase in patients who came to the hospital within 4.5 hours of experiencing stroke, and who were eligible to undergo a minimally invasive procedure to remove their blood clots, found that tenecteplace was superior to alteplase.2 Additionally, the latest update to the American Stroke Association (ASA) guidelines on Emergency Management of Acute Ischemic Stroke and TIA includes recommendations on the use of tenecteplase as an alternative to alteplase.3
A Case Report
The new Neurology Clinical Practice article by the JFK Neuroscience Institute team includes a case report of an 89-year-old woman with a history of hypertension who was brought to the emergency room with sudden onset of weakness on the right side of her body and loss of speech. She was found to be in atrial fibrillation, a heart rhythm problem that was new for her. A brain computed tomography (CT) scan and CT angiogram showed signs of a clot in a large blood vessel. After discussion with the family consent was obtained to administer tenecteplase instead of alteplase. The medication was administered in less than 45 minutes of the patient’s stroke symptom onset.
“The Stroke and Neurovascular Center at JFK University Medical Center works like clockwork where early response at the ED and ready availability of a multidisplinary patient-centric approach assures rapid assembly and expeditious care of the patients,” said Jawad Kirmani, M.D., director, Stroke and Neurovascular Center at JFK University Medical Center and vice chair of the Neuroscience Institute.
The patient was taken to the neuroangiography suite for an emergent mechanical thrombectomy, but during the cerebral angiogram it was found that the blood clot had dissolved.
Siddhart Mehta, M.D., neurointerventionalist explained what he discovered during the procedure, “With traditional alteplase we only see the clot dissolving extremely rarely without the approach that involves mechanically removing the clot with the surgical intervention. It was really a ‘wow moment’ when we saw this large clot completely disappear in front of our eyes with this new agent”.
Due to improvements in the flow of blood to her brain, the patient did not require mechanical removal of the blood clot. On examination during the procedure the patient was found to have minimal deficits and the following day was back to normal. Repeat CT scans after 24 hours did not show any evidence of bleeding. The patient was started on an oral anticoagulant for secondary stroke prevention and transferred to rehabilitation therapy.
Ongoing Safety Assessment
Under Dr. Panezai’s direction, the stroke team is carefully assessing ongoing safety outcomes with the use of tenecteplase, the results of which may further augment the use of the medication in clinical practice.
“The future for treating acute ischemic stroke is exciting as we continue to introduce new agents, improve processes, enhance safety and expand treatment eligibility,” said Dr. Panezai.
“Tenecteplase may prove to be a future successful agent which safely and effectively treats an even larger number of patients with acute ischemic stroke.”
For more information about the Stroke and Neurovascular Center at JFK University Medical Center visit: Stroke and Neurovascular Center – JFK University Medical Center (jfkmc.org).
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About JFK University Medical Center
Serving residents of central New Jersey for more than 50 years, JFK Medical Center offers a complete array of advanced services in its 498-bed facility located in Edison, N.J. With more than 1,000 affiliated physicians, this academic medical center offers a complete spectrum of advanced services including general and specialized surgery, cardiac care, maternity and pediatrics, oncology, imaging, breast center, sleep center, wound care, robotic surgery, emergency medicine, weight loss surgery, radiology, long term care and assisted living. It is home to the world-renowned Neuroscience Institute that diagnoses and treats brain, spine and nervous system disorders. To learn more, visit JFKMC.org.
References
- Spozhmy Panezai, MD; Ilya Dubinsky, PharmD; Sindhu Sahito MD; Nancy Gadallah, DO; Sindhu Sahito, MD; Nancy Gadallah, DO; Laura Suhan, APN; Siddhart Mehta, MD; Jawad Kirmani, MD “Early Experience with Tenecteplase at a Comprehensive Stroke Center”; Neurology® Clinical Practice, 2021
- Bruce C.V. Campbell, PhD; Peter J. Mitchell, M.Med; Leonid Churilov, PhD, et al. Tenecteplase Versus Alteplase Before Thrombectomy for Ischemic Stroke, NEMJ. 2018. 378: 1573-1582.
- Powers WJ, Rabinstein AA, Ackerson T et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association / American Stroke Association. Stroke 2019;50:e344-e418.
