Stroke research changes clinical practice

A new clot-busting drug is being used to treat stroke patients following years of research.

Tenecteplase has been recommended as a treatment option for stroke in adults.

The latest results from ATTEST-2, newly published in The Lancet Neurology, suggest it works as well as alteplase. This is the current standard treatment.

Dozens of patients at University Hospital Southampton (UHS) took part in this research.

Preliminary results from the trial helped inform guidance published by the National Institute for Health and Care Excellence (NICE) this summer. They highlighted that tenecteplase’s lower cost could save the NHS millions.

Finding an alternative

About four out of every five strokes are due to a blockage in the brain. These are called ischaemic strokes.

The standard clot-busting drug used in the UK to treat these strokes is alteplase.

However, alteplase is not always successful in breaking down clots. It can also have dangerous side effects.

Researchers saw tenecteplase as a promising alternative. It is already used to treat heart attacks caused by blood clots.

Compared to alteplase, tenecteplase is better at sticking to and breaking down fibrin, one of the proteins that makes up blood clots. This means it's likely to be more effective at dissolving clots and less likely to have side effects.

It is also easier to administer as it is a single dose injection.

Promising results

ATTEST-2 investigated tenecteplase as a stroke treatment option. Professor Keith Muir at the University of Glasgow led the trial.

Around 1,800 people took part at hospitals across the UK. This included 38 patients at UHS.

They were randomly allocated to two groups. Half received alteplase, while the other half received tenecteplase.

The results showed that tenecteplase was as effective as alteplase – but not superior.

However, tenecteplase was found to be easier to administer, especially when patients needed to be transferred to another hospital. This led the researchers to conclude that tenecteplase is preferable to alteplase.

“When all the evidence from recent trials is combined, tenecteplase improves the chances of recovery with minimal symptoms”, Prof Muir explained.

“Other countries have seen faster treatment as a result of introducing tenecteplase.

“The drug has particular advantages for treatment in people who need to move between hospitals for mechanical thrombectomy. It is currently complicated to supervise and deliver clot-busting treatment while being transferred by ambulance."

The Stroke Association and the British Heart Foundation co-funded the trial.

Stroke treatment in Southampton

UHS operates a regional thrombectomy (blood clot removal) service seven days a week. The team recently performed their 250th mechanical thrombectomy of the year.

The hospital has now begun receiving its first shipments of tenecteplase. It will soon become the main drug used here for thrombolysis treatment.

Dr Richard Marigold, a Consultant in Stroke Medicine at UHS, was the local lead for the ATTEST-2 trial. He is supported by the UHS Research Leaders Programme. Dr Marigold said:

“It's fantastic that we have been involved in such an important trial. What's even more fantastic is that it is rapidly transforming clinical practice.

“Delivered as a single injection, tenecteplase significantly speeds up treatment. Every 30-minute delay reduces a patient’s chance of returning home to independent living by 10%, so this change will undoubtedly improve neurological outcomes.”

Stroke patients are transferred to UHS from across the Wessex region.

Dr Marigold added: “An infusion of alteplase takes around an hour and has often led to delays in transferring patients to UHS for treatment. With tenecteplase, patients will receive faster treatment with better outcomes.”