Ischemic Stroke
Conditions
Keywords
thrombolytic, stroke, distal emboli
Brief summary
Prospective, single center, non-randomized, pilot study to assess the feasibility of IA TNK following standard of care mechanical thrombectomy (MT) in patients with AIS. Participants will receive IA TNK after achieving mTICI 2b or 2c reperfusion with standard of care MT. Patients enrolled into the study will be followed for 3 months after treatment with IA TNK.
Detailed description
As current MT technology is not amenable to retrieval of distal occlusions (M3/M4, etc), we hypothesize that IA lytic may play an important role as an adjunctive therapy to open up distal vessels (after the primary LVO has been removed) to achieve complete or near complete reperfusion. In this pilot trial, our goal is to assess the feasibility and safety of IA Tenecteplase (TNK) as an adjunctive therapy following standard of care mechanical thrombectomy (MT) in patients with AIS. A total of 20 patients will be enrolled into the ALLY pilot study.
Interventions
intra-arterial drug administered after mechanical thrombectomy
Sponsors
Genentech, Inc.
ProMedica Health System
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Intervention model description
Participants will receive intra-arterial Tenecteplase after achieving mTICI 2b or 2c reperfusion with standard of care mechanical thrombectomy.
Eligibility
Sex/Gender
ALL
Age
18 Years to 85 Years
Healthy volunteers
No
Inclusion criteria
* 1\. Age 18-85 * 2\. Anterior circulation ischemic stroke symptoms with confirmed occlusion (ICA, M1, or M2) on angiogram and mechanical thrombectomy initiated within 24 hours since last known well * 3\. a. Patients treated less than 6 hours since last known well with ASPECTS \>6. b. Patients treated beyond 6 hours since last known well, CT or MRI perfusion scan showing favorable mismatch profile (Target mismatch profile on CT perfusion or MRI (ischemic core volume is \<70ml, mismatch ratio is \>1.8 and mismatch volume is \>15ml) * 4\. Post-mechanical thrombectomy with ≤5 device passes and mTICI grade 2b or 2c with persistent occlusion(s) in terminal branches not amenable to MT. * 5\. Signed informed consent
Exclusion criteria
* 1\. Premorbid modified Rankin scale (mRS) score of 4 or greater * 2\. Presence of any hemorrhage and/or ASPECT score ≤6 on baseline head CT * 3\. Platelet count \<100,000 * 4\. Known bleeding diathesis * 5\. Known hereditary or acquired hemorrhagic diathesis, coagulation factor deficiency * 6\. Active anticoagulation treatment with novel oral anticoagulant (NOACs) taken within the last 48 hours, or INR \>1.8 * 7\. Patients requiring active treatment with dual antiplatelet agents (e.g. proximal cervical carotid artery stenting) * 8\. Pregnant or lactating * 9\. Previous known allergy to TNK * 10\. Major surgery in past 30 days * 11\. Patient is on or requires dialysis * 12\. History of intracranial hemorrhage or serious head trauma at any time * 13\. Any condition in the opinion of the enrolling physician that would preclude the patient from participating * 14\. Pre-existing medical, neurological, or psychiatric disease that would confound the neurological or functional evaluation * 15\. Severe, uncontrolled hypertension (systolic blood pressure \>180 mmHg or diastolic blood pressure \>110 mmHg) that is refractory to treatment * 16\. History of acute ischemic stroke in the last 60 days * 17\. Presumed septic embolus; suspicion of bacterial endocarditis * 18\. Suspicion of aortic dissection * 19\. Intracranial neoplasm * 20\. Any mass effect * 21\. Any terminal medical condition with life expectancy less than 6 months * 22\. Concurrent enrollment in another trial that could confound the results of this study
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Incidence of any intracranial hemorrhage and neurologic worsening | 24 hours post-treatment with intra-arterial Tenecteplase | Incidence of any intracranial hemorrhage and neurologic worsening of at least 4 points on the National Institute of Health Stroke Scale (NIHSS), according to the European Cooperative Acute Stroke Study II (ECASS-II) criteria, within 24 hours of treatment with IA TNK |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Ordinal modified Rankin Scale Score | 90 days post-treatment | Ordinal modified Rankin Scale Score at 90 days. The mRS is the standard tool to assess neurological outcome in trials with acute severe brain disease. The scale runs from 0-6, running from perfect health without symptoms (= 0) to death (= 6). |
| Functional Independence | 90 days post-treatment | Proportion of patients with functional independence, defined as a mRS of 0-2 at 90 days |
| Final revascularization grade | immediate post-treatment | Final revascularization grade at end of IA treatment using the modified Thrombolysis in Cerebral Infarction (mTICI) grading scale. |
| Improved reperfusion | immediate post-treatment | Proportion of patients with improved reperfusion (mTICI 2c/3) at end of IA treatment |
| Asymptomatic intracranial hemorrhage | 24 hours post-treatment | Incidence of any asymptomatic intracranial hemorrhage |
| Mean number of boluses | Immediate post-procedure | Mean number of boluses to achieve improvement in reperfusion to mTICI 2c and mTICI 3 |
| Mortality | Hospital Discharge (Day 6 post-randomization (+/- 1 day)) | Mortality rate at discharge |
Countries
United States
Outcome results
None listed