Tenecteplase Improves Door-to-Needle Time in Real-World Acute Stroke Treatment

Background: We report the interim results of a process improvement initiative at a comprehensive stroke center in which all tPA (tissue-type plasminogen activator)-eligible patients were given tenecteplase for acute ischemic stroke. Methods: We retrospectively analyzed a prospectively maintained single-center registry of consecutive patients with acute ischemic stroke treated at our comprehensive stroke center emergency department or transferred for further care. Patients treated with alteplase (tPA) before the process improvement initiative (October 2019-April 2020) were compared with those treated with tenecteplase (May 2020-July 2021). The primary efficacy outcome was the Target: Stroke Phase II recommendation of door-to-needle (DTN) time <= 45 minutes. Backward stepwise logistic regression was used to estimate an independent effect of tenecteplase against DTN time <= 45 minutes. Two contemporaneous, negative controls (time to first emergency department antibiotic for patients who presented with infectious symptoms and door-to-groin puncture for thrombectomy) were evaluated to confirm DTN time was unrelated to emergency department and other stroke treatment throughput. Results: Of the 113 included patients, 53 (47%) received tenecteplase. DTN time was significantly faster in patients treated with tenecteplase (median, 41 [interquartile range, 34-62] minutes versus 58 [interquartile range, 45-70] minutes; P<0.01), with no significant difference in symptomatic intracranial hemorrhage (2% versus 7%; P=0.37). Despite the higher proportion of tPA patients being transferred for care (with slower DTN time), tenecteplase remained independently predictive of DTN time <= 45 minutes (adjusted odds ratio, 3.96; 95% CI, 1.58-9.91). There was no difference in time to first emergency department antibiotic (P>0.05) or door-to-puncture (P>0.05) when similar periods were compared. Conclusions: Tenecteplase was associated with faster DTN time when compared with tPA in those with acute ischemic stroke. This can likely be attributed to the ease of single bolus administration of tenecteplase.