Ericka Samantha Teleg, MD
Accessibility to stroke services, timely treatment and management differ in regions and locations throughout the world. Each geographic location is different in terms of barriers to stroke treatment. Evidence translated to real-world findings is an important key element in this article by Mahawish et al. The New Zealand Central Region Hyper-Acute Stroke Network switched to tenecteplase driven by data supporting probable improvement of large vessel occlusion (LVO) recanalization in areas wherein, first, endovascular accessibility is a challenge due to geographical limitations, and second, the ease of tenecteplase administration. This model can contribute to other regions that have similar landscape in terms of medical resources and accessibility to tertiary or regional centers with endovascular administration infrastructure.
The implementation approach and evaluation provided by the authors included the identification of the several barriers. One, it takes about five hours for more than 50% of thrombectomy patients to be dripped and shipped to a thrombectomy hub hospital. In these transfers, the 1-hour alteplase infusion delays and complicates transfers, as the authors mentioned. The evidence for tenecteplase as having pharmacological and practical advantages over alteplase was discussed in this article. It carries a greater fibrin specificity, faster onset of action, longer half-life and requires a single bolus injection. There exist completed trials, as well as ongoing clinical trials, that further validate the safety profile of tenecteplase as an alternative for LVO and improvement recanalization post thrombectomy. In New Zealand, tenecteplase is licensed only for acute myocardial infarction as an indication for its use. The working group in this study derived an agreement based on a consensus that routine tenecteplase use for all eligible stroke patients was acceptable using the thrombolysis consent. However, confusion can arise as alteplase is maintained for use at the thrombectomy center for non-LVO cases as well. Tenecteplase is used for acute myocardial infarction, and dosages differ in stroke treatments. Pathways were initiated in labeling stroke and thrombolysis kits. This is important as education and communication on drug indications and administrations and training of staff are crucial to this implementation for it to be carried out while minimizing treatment errors. Thus, a universal switch in all hospitals was done on March 2, 2020. Regional safety monitoring was conducted monthly.
In the carrying out of this implementation, anonymous surveys were carried out to provide support and highlight concerns. Nineteen stroke specialists across eight hospitals (90% respondents) supported switching to tenecteplase. The following concern was raised: possible administration errors brought about by different dosing in acute myocardial infarction. After 12 months, 100% respondents affirmed that errors and the complexity of its use can be reduced, and therefore, no concerns were subsequently reported.
Results included important points and conclusions from the switch of alteplase to tenecteplase. Namely, onset-to-door times, thrombectomy rates, and baseline mRS were higher. Patients treated with tenecteplase had greater odds of favorable mRS and shorter median door-to-needle times. There were no significant differences in the rate of sICH between treatment groups. Needle-to-groin time for the 42 transferred regional patients was lower but did not have any significant difference.
In summary, the evidence for tenecteplase can ease out several barriers to the drip-and-ship models in various regions around the world. Each region has a different stroke landscape and set of barriers to overcome. How to fit in the best evidence out there for stroke treatment is important for implementation. It is essential that education, training, and the presence of stroke champions in these regions play an important role to minimize errors and provide good communication across stroke teams from transferring and receiving hospitals. The authors of this study acknowledged that further implementation evidence is necessary for the universal acceptance of the benefits of tenecteplase to health care settings.