Intravenous tenecteplase is associated with a higher incidence of thrombus movement before endovascular treatment for acute ischemic stroke: a secondary analysis of the AcT randomized controlled trial

BACKGROUND: Thrombus migration can occur in patients receiving IV thrombolysis for acute stroke. This study compared the effects of IV tenecteplase (0.25 mg/kg) versus alteplase (0.9 mg/kg) on thrombus movement in patients undergoing endovascular treatment (EVT) in the AcT trial. METHODS: Patients with intracranial occlusion on baseline CT angiography (CTA) who underwent EVT were included. Thrombus movement from baseline CTA to first angiographic EVT run was classified as no thrombus movement, thrombus extension (TE, movement to a proximal location on DSA compared with CTA), thrombus migration (TM, movement to a more distal location), or recanalization. Outcomes were 90-day modified Rankin Scale (mRS) score 0-2 and final extended Thrombolysis in Cerebral Infarction score 2b-3. Mixed-effects logistic regression was performed. RESULTS: Of the 1577 patients in the AcT trial, 496 patients with intracranial occlusions underwent EVT (median age 73 years, 50.8% female). No thrombus movement was seen in 398 patients (80.2%), TE in six (1.2%), TM in 77 (15.5%), and complete recanalization in 15 (3.0%). Tenecteplase recipients (n=252) had higher TM rates than alteplase recipients (19.4% vs 11.5%, adjusted OR (aOR) 1.83, 95% CI 1.10 to 3.07). TM did not impact final successful reperfusion (aOR 0.76, 95% CI 0.40 to 1.38) but was associated with increased odds of 90-day mRS 0-2 (aOR 1.77, 95% CI 1.05 to 3.06). Thrombolytic type did not affect the relationship between thrombus movement and study outcomes (P>0.05). CONCLUSION: IV tenecteplase is associated with higher thrombus migration rates before EVT compared with alteplase, which is linked to better functional outcomes. However, the type of thrombolytic agent did not affect final reperfusion and functional outcomes.