Thrombolysis With Tenecteplase Is as Safe as Alteplase in Stroke Mimics

IV injection
IV injection
The most frequent stroke mimic diagnoses included migraine and peripheral vertigo.

Tenecteplase demonstrated similar safety outcomes as alteplase for thrombolysis in patients with stroke mimics (SMs), according to the results of a retrospective analysis of a phase 3 trial published in the International Journal of Stroke. Independent predictors of SMs in this patient population included older age, female sex, and having a systolic blood pressure of 150 mmHg.

Patients with clinically suspected acute ischemic stroke who were admitted within a 4.5-hour period of stroke onset with quantifiable deficits were included in the retrospective analysis (N=1091). Researchers from the original phase 3 Norwegian Tenecteplase Stroke Trial randomly assigned patients to receive either 0.4 mg/kg tenecteplase or 0.9 mg/kg alteplase.

At baseline, the investigators collected data on pre-stroke risk factors, including the presence of diabetes mellitus, hypertension, atrial fibrillation, hyperlipidemia, and history of ischemic stroke, transient ischemic attack (TIA), or myocardial infarction (MI). Based on diagnosis at discharge, patients were categorized as belonging in either the SMs or acute cerebral ischemia group.

A total of 181 (16.6%) patients were categorized as having SMs. The most frequent SM diagnoses included migraine (22.2%) and peripheral vertigo (11.4%). In the SM group, there were no cases of symptomatic intracerebral hemorrhage. Patients age 60 were significantly more likely to be in the SM group than younger patients (odds ratio [OR] 2.75, P <.001).

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Additional independent predictors of SMs included female sex (OR 1.48, P =.026), no prior MI (OR 2.03, P =.045), systolic blood pressure of 150 mmHg (OR 2.33, P <.001), National Institutes of Health Stroke Scale score of 6 points (OR 1.83, P =.011), sensory loss (OR 1.55, P =.015), and no facial paresis (OR 2.41, P <.001) on hospital admission.

Study limitations include its retrospective design and the lack of standardization in the diagnosis of SMs.

The predictors of SMs identified in the trial “may be helpful in differentiating SMs from acute cerebral ischemia in future randomized stroke trials,” the researchers concluded.


Kvistad CE, Novotny V, Næss H, et al. Safety and predictors of stroke mimics in The Norwegian Tenecteplase Stroke Trial (NOR-TEST) [published online January 1, 2018]. Int J Stroke. doi:10.1177/1747493018790015