The New England Journal of MedicineSmall Step or Giant Leap? Expanding the Acute Stroke Thrombolysis Window to 24 Hours

Expanding Acute Stroke Treatment: Tenecteplase Shows Promise in Extended Time Window

A recent study published in the New England Journal of Medicine presents compelling evidence for expanding the treatment window for acute ischemic stroke. The TRACE-III trial demonstrates that tenecteplase, administered up to 24 hours after stroke onset in patients with large-vessel occlusion and salvageable brain tissue, can improve functional outcomes compared to standard medical treatment. This finding has significant implications for stroke care, particularly in regions without immediate access to thrombectomy.

Key Points:

• Tenecteplase is replacing alteplase as the preferred thrombolytic agent for acute stroke treatment
• Current thrombolysis window is generally limited to 4.5 hours after stroke onset
• Large-vessel occlusion strokes have poor outcomes without intervention
• Endovascular thrombectomy within 24 hours of stroke onset shows substantial benefit
• Less than 3% of patients with large-vessel occlusion worldwide undergo thrombectomy
• The TIMELESS trial showed tenecteplase is safe in the 4.5-24 hour window but did not demonstrate benefit in centers with immediate thrombectomy access
• TRACE-III trial enrolled 516 Chinese patients with large-vessel occlusion 4.5-24 hours after last known well time
• Patients in TRACE-III had NIHSS scores of 6-25 and evidence of salvageable tissue on perfusion imaging
• TRACE-III excluded patients with planned immediate thrombectomy
• Tenecteplase group showed higher rates of good outcomes (mRS 0-1) at 90 days: 33.0% vs 24.2% (p=0.03)
• Tenecteplase group had higher recanalization rates
• Mortality was similar between groups
• Symptomatic intracranial hemorrhage was numerically higher in the tenecteplase group
• Less than 2% of TRACE-III patients underwent rescue thrombectomy
• Results need replication in other populations
• Hospitals would need perfusion-imaging capability for clinical implementation
• The study does not address tenecteplase use in conjunction with planned transfer for thrombectomy

HCN Medical Memo
The TRACE-III trial results suggest that tenecteplase may be a viable treatment option for acute ischemic stroke due to large-vessel occlusion up to 24 hours after onset, particularly in settings where thrombectomy is not immediately available. This finding could significantly impact stroke care strategies, especially in resource-limited areas.

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