Tenecteplase real-world data: A three phase sequential comparison.

INTRODUCTION: The New Zealand (NZ) Central Region Stroke Network, serving 1.17 million catchment population, changed to tenecteplase for stroke thrombolysis in 2020 but was forced to revert to Alteplase in 2021 due to a sudden cessation of drug supply. We used this unique opportunity to assess for potential before and after temporal trend confounding. PATIENTS AND METHODS: In NZ all reperfused patients are entered prospectively into a national database for safety monitoring. We assessed Central Region patient outcomes and treatment metrics over three time periods: alteplase use (January 2018-January 2020); during switch to tenecteplase (February 2020-February 2021) and after reverting to alteplase (February 2021-December 2022) adjusting regression analyses for hospital, age, onset-to-needle, NIHSS, pre-morbid mRS and thrombectomy. RESULTS: Between January 2018 and December 2022, we treated 1121 patients with Alteplase and 286 with tenecteplase. Overall, patients treated with tenecteplase had greater odds of favorable outcome ordinal mRS [aOR = 1.43 (95% CI = 1.11-1.85)]; shorter door-to-needle (DTN) time [median 52 (IQR 47-83) vs 61 (45-84) minutes, p < 0.0001] and needle to groin (NTG) times [118 (74.5-218.5) vs 185 (118-255); p = 0.02)]. Symptomatic intracerebral hemorrhage (sICH) rate was lower in tenecteplase group [aOR 0.29 (0.09-0.95)]. Findings similarly favored tenecteplase when comparing tenecteplase to only the second alteplase phase. There was no inter-group difference when comparing the two alteplase phases. CONCLUSIONS: Our results suggest that previously reported benefits from tenecteplase in a real-world setting were not likely attributable to a temporal confounding.

Stroke clot retrieval from Taranaki, New Zealand: a real-world regional experience.

AIM: Stroke clot retrieval (SCR) is now considered a standard of care for select stroke patients with proximal large vessel occlusion (LVO) of the anterior circulation. Here we present the experience of regional Taranaki patients transferred by air for SCR and compare this to metropolitan Auckland patients who were transferred by road. The aim is to present and compare process metrics and outcomes between the regional and metropolitan centres. METHODS: This is a retrospective analysis of consecutive patients with anterior LVO transferred to Auckland City Hospital (ACH) for SCR from Taranaki, Waitemata and Counties Manukau district health boards (DHBs) between November 2017 and December 2020. RESULTS: Thirty Taranaki patients were transferred for SCR, compared to 244 patients from Waitemata and Counties Manukau DHBs. Taranaki patients were seven years older and less ethnically diverse but similar in other characteristics. The proportion of patients with an independent Modified Rankin Scale (mRS) score between 0 and 2 at three months was the same as for the regional and metropolitan centres. CONCLUSIONS: In this real-world study, regional stroke patients can achieve similar SCR outcomes to metropolitan patients. Overcoming the post-code lottery for hyperacute stroke care can be achieved in a New Zealand setting.

Case report: marantic endocarditis in renal cell carcinoma: nephrectomy a treatment.

BACKGROUND: Marantic endocarditis (non-bacterial thrombotic endocarditis) is a rare condition that involves non-infectious thrombotic lesions typically of the aortic and mitral valves. It is predominantly associated with malignancy and less commonly systemic lupus erythematosus. In this case, we report a patient with marantic endocarditis secondary to a renal cell carcinoma that was successfully treated with nephrectomy and anticoagulation. CASE SUMMARY: A 65-year-old male patient with embolic signs and symptoms was found to have non-infective thrombotic vegetations on three cardiac valves through transoesophageal echocardiography. Computed tomography revealed a 70 mm renal mass that confirmed to be a grade two clear-cell renal cell carcinoma. Nephrectomy and anticoagulation led to resolution of the embolic symptoms and of the valvular vegetations. DISCUSSION: The diagnosis of marantic endocarditis requires high clinical suspicion in a patient who presents with features of embolization. Incidence is highest in patients with an underlying malignancy, particularly adenocarcinoma. This case highlights the importance of echocardiography in diagnosis, removal of the source of thrombus, and prompt treatment with anticoagulation.

Switching to Tenecteplase for Stroke Thrombolysis: Real-World Experience and Outcomes in a Regional Stroke Network.

Background and Purpose: Due to practical advantages, increasing trial safety data, recent Australian Guideline endorsement and local population needs we switched to tenecteplase for stroke thrombolysis from alteplase. We describe our change process and real-world outcome data. Methods: Mixed-methods including stakeholder engagement, preimplementation and postimplementation surveys, and assessment of patient treatment rates, metrics, and clinical outcomes preimplementation and postimplementation adjusting regression analyses for age, sex, National Institutes of Health Stroke Scale, premorbid modified Rankin Scale score, and thrombectomy using New Zealand National Stroke Registry data. Results: Preswitch consultation involved stroke and emergency clinicians, pharmacists, national regulatory bodies, and hospital legal teams. All survey responders (90% response rate) supported the proposed change and remained satisfied 12 months postimplementation. Between January 2018 and February 2021, we treated 555 patients with alteplase and 283 with tenecteplase. Patients treated with tenecteplase had greater odds of a favorable modified Rankin Scale using both shift (adjusted odds ratio, 1.60 [95% CI, 1.15­2.22]) and dichotomous analyses (modified Rankin Scale score, 0­2; adjusted odds ratio, 2.17 [95% CI, 1.31­3.59]) and shorter median (interquartile range) door-to-needle time (median, 53 [38­73.5] versus 61 minutes [45­85], P=0.0002). Symptomatic intracranial hemorrhage rates (tenecteplase 1.8% versus 3.4%; adjusted odds ratio, 0.46 [95% CI, 0.13­1.64]), death by day 7 (tenecteplase 7.5% versus 11.8%; adjusted odds ratio, 0.46 [95% CI, 0.21­0.99]), and median (interquartile range) needle to groin time for the 42 transferred regional patients (tenecteplase 155 [113­248] versus 200 [158­266]; P=0.27) did not significantly differ. Conclusions: Following stakeholder endorsement, a region-wide switch from alteplase to tenecteplase was successfully implemented. We found evidence of benefit and no evidence of harm.

Visual snow: Not so benign.

Visual snow is the perception of flickering dots throughout the entire visual field and occurs with other symptoms of dysfunctional central sensory processing. We describe a patient who presented with visual snow, illusory visual motion, photopsia, and reduced night vision. He subsequently developed progressive cognitive impairment, myoclonus and ataxia. A diagnosis of sporadic Creutzfeldt-Jakob Disease was confirmed on post-mortem examination more than 49 months after symptom onset. The visual snow syndrome is typically benign, but our patient illustrates that occasionally it is the first manifestation of a serious brain disease. Careful application of the diagnostic criteria for the visual snow syndrome is important, particularly with the use of neuroimaging to exclude pathology in the occipital cortex.