Tenecteplase Prior to Mechanical Thrombectomy: Ready for Prime Time?

Although a proven therapy for acute ischemic stroke within 4.5 hours of symptom onset for >20 years, IV tissue plasminogen activator has a less-than-ideal effect on large vessel occlusion (LVO). For instance, IV alteplase alone resulted in 25% reocclusion rate, leading to higher hemorrhagic transformation risk and worse functional outcome.1 Five positive endovascular thrombectomy (EVT) trials in 2015 and the 2 subsequent extended-window trials in 2018 have demonstrated a major benefit of EVT in the treatment of LVO up to 24 hours after symptom onset with a number needed to treat of 2.6. Professional society practice guidelines have since incorporated EVT as standard of care for LVO. The benefit of IV alteplase before EVT for LVO, however, remains debated and is an active area of research.

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