title: A new therapeutic strategy for acute ischemic stroke: sequential combined intravenous tPA-tenecteplase for proximal middle cerebral artery occlusion based on first results in 13 consecutive patients.
abstract: OBJECTIVE
  Intravenous tissue-type plasminogen activator (IV tPA) frequently fails to recanalize proximal middle cerebral artery (MCA-M1) obstructions, preventing favorable outcomes. Only neurointerventional procedures prevail in these cases, but well-equipped centers remain scarce. A new therapeutic strategy consisting of a second IV thrombolysis with low-dose tenecteplase was applied.
  
  
  METHODS
  Consecutive patients with an MCA-M1 occlusion that did not reopen at the end of IV tPA perfusion received IV tenecteplase (0.1 mg/kg). Partial or complete thrombolysis in myocardial infarction recanalization (Thrombolysis In Myocardial Infarction grade 2/3) and intracerebral hemorrhage were assessed by magnetic resonance aging approximately 24 hours later. Clinical outcomes at 3 months were evaluated with the modified Rankin score.
  
  
  RESULTS
  Among 40 patients with MCA-M1 occlusions who received IV tPA, 13 were treated according to the protocol of sequential combined IV thrombolytics. Baseline National Institutes of Health Stroke Scale score was 15. At a mean of 16.8 hours after IV thrombolysis, the recanalization rate was 100% (2 with Thrombolysis In Myocardial Infarction grade 2, 11 with Thrombolysis In Myocardial Infarction grade 3). Intracerebral hemorrhage occurred in 4 of 13 (31%) patients, with no symptomatic hemorrhage. Good clinical outcomes (modified Rankin score = 0/1) were achieved in 9 of 13 (69%) patients. Functional outcomes were very similar to those of 13 patients with early IV-tPA recanalization. Among 4 patients treated as protocol violations, 1 presented with a lack of recanalization and a parenchymal hematoma type 2.
  
  
  CONCLUSIONS
  For patients with MCA-M1 occlusions treated with IV tPA but without early recanalization, a second bolus of IV tenecteplase (0.1 mg/kg) may be a relatively safe, effective, and easy option in carefully selected cases, but additional studies are needed to confirm these findings.
authors.affiliation: Department of Neurology and Stroke Center, University Hospital of Fort-de-France, BP 632, 97261 Fort-de-France Cedex, Martinique, French West Indies. didier.smadja@chu-fortdefrance.fr
authors.forename: Didier
authors.initials: D
authors.lastname: Smadja
authors.forename: Nicolas
authors.initials: N
authors.lastname: Chausson
authors.forename: Julien
authors.initials: J
authors.lastname: Joux
authors.forename: Martine
authors.initials: M
authors.lastname: Saint-Vil
authors.forename: Aïssatou
authors.initials: A
authors.lastname: Signaté
authors.forename: Mireille
authors.initials: M
authors.lastname: Edimonana
authors.forename: Séverine
authors.initials: S
authors.lastname: Jeannin
authors.forename: Blaise
authors.initials: B
authors.lastname: Bartoli
authors.forename: Mathieu
authors.initials: M
authors.lastname: Aveillan
authors.forename: Philippe
authors.initials: P
authors.lastname: Cabre
authors.forename: Stéphane
authors.initials: S
authors.lastname: Olindo
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000188:drug therapy*; D004359:Drug Therapy, Combination; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000188:drug therapy* / Q000473:pathology; D007275:Injections, Intravenous; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000188:drug therapy*; D000077785:Tenecteplase; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator; D000077785:Tenecteplase