Two Strategies to Improve Stroke Outcome

Two recent trials from China evaluated strategies to improve outcomes in patients with acute ischemic stroke treated within 4.5 hours of symptom onset. In the first open-label trial, 550 patients with large-vessel occlusion were randomized to receive either intravenous tenecteplase followed by endovascular thrombectomy or thrombectomy alone. Functional independence at 90 days was achieved in 52.9% of patients in the tenecteplase group compared to 44.1% in the thrombectomy-only group (risk ratio 1.20), suggesting a modest benefit with tenecteplase pretreatment. Rates of successful reperfusion and symptomatic intracranial hemorrhage were similar between groups, though slightly higher in the tenecteplase arm. In a separate double-blind, placebo-controlled trial, 832 patients with noncardioembolic stroke who were not eligible for thrombectomy received either a 24-hour infusion of tirofiban or placebo within 60 minutes after thrombolysis. An excellent functional outcome (modified Rankin Scale score 0–1) at 90 days was more frequent in the tirofiban group (65.9% vs. 54.9%; risk ratio 1.20). While symptomatic intracranial hemorrhage was rare, it occurred slightly more often with tirofiban (1.7% vs. 0%), with similar mortality in both groups. These findings suggest that both intravenous tenecteplase before thrombectomy and early tirofiban post-thrombolysis may enhance recovery in selected stroke patients, though with some increased bleeding risk. Source: https://www.nejm.org/