Tenecteplase Versus Alteplase in Ischemic Stroke Management (TALISMAN)

Patients presenting with symptoms of acute ischemic stroke (AIS) who present within 3 to 4.5
hours of symptom onset and who meet the inclusion criteria for intravenous (IV) thrombolysis
will receive, in a randomized, double-blind fashion, either IV Alteplase at 0.9 mg/kg per
standard protocol or IV Tenecteplase at 0.25 mg/kg with saline infusion over one hour.
Patients must also have no exclusion criteria for IV thrombolysis within the 3 to 4.5 hour
window. The only required imaging is non-contrasted CT of the head. Patients will be
monitored according to standard post-thrombolytic care. A CT of the head will be performed
at 24 hours based on standard protocol or if there is any neurological change. Neurological
function at 24 hours using NIHSS and at 3 months based on modified mRS and the NIHSS.

Inclusion Criteria:

1. Age 18 to 80 years

2. Acute neurologic deficit with an NIHSS ≥ 4

3. Non-enhanced computed tomography (NECT) of the head showing no hemorrhage

4. Acute ischemic stroke symptoms with onset, or time last known well, clearly defined
between 3 and 4.5 hours

5. Treatment can be initiated within 3 to 4.5 hours from symptom onset

Exclusion Criteria:

1. Evidence of intracranial hemorrhage on NECT

2. Clinical suspicion of subarachnoid hemorrhage even with normal NECT

3. NECT shows hypo-density greater than 1/3 cerebral hemisphere)

4. History of intracranial hemorrhage/stroke

5. Uncontrolled HTN: At time treatment begins SBP remains >185 mmHg or DBP remains >110
mmHg despite repeated measurements

6. Known arteriovenous malformation, neoplasm, or aneurysm

7. Witnessed seizure at stroke onset

8. Acute bleeding tendencies

9. Platelet count <100,000/mm3

10. Heparin received in prior 48 hours with elevated aPTT

11. Current use of an anticoagulant (Coumadin/Warfarin) irrespective of INR

12. Prior use (within 48 hours) of direct thrombin inhibitors (dabigatran) or direct
factor Xa inhibitors (rivaroxaban, apixaban)

13. Within prior 3 months: intracranial or spinal surgery, head trauma, or previous
stroke

14. Arterial puncture at non-compressible site within last 7 days

15. Woman of child bearing age who has a positive pregnancy test

16. NIH stroke scale >25 (severe deficit) or <4 and no dysphasia (mild deficit) or
rapidly improving

17. Symptoms spontaneously clearing

18. 14 days post-operative or post major trauma

19. Recent gastrointestinal or urinary tract hemorrhage within the past 21 days

20. Recent acute MI within the past 3 months

21. Serum glucose <50 mg/dl or >400 mg/dL

22. Age >80 or less than 18

23. History of ischemic stroke AND diabetes mellitus

24. Unable to obtain consent from patient or power of attorney

25. Baseline mRS > 2

26. Consent not obtained by 20 minutes prior to closure of the therapeutic window.

27. The subject has been treated with a thrombolytic agent within the past 72 hours

28. The subject is a pregnant woman (positive serum βHCG pregnancy test, positive urine
pregnancy test or clinically evident pregnancy)

29. The subject is, in the opinion of the investigator, unlikely to comply with the
clinical study protocol or is unsuitable for any other reason