TENecteplase in Central Retinal Artery Occlusion Stuy (TenCRAOS)

Central retinal artery occlusion (CRAO) is an ophthalmologic emergency that, without prompt revascularization, bears high risk of permanent blindness. The condition is typically the result of an artery-to-artery embolism from a carotid plaque or cardio embolism. A recent meta-analysis of observational data indicates that prompt revascularization with systemic thrombolysis might improve outcome. A randomized controlled trial of early systemic thrombolysis for CRAO is therefore warranted. The aim of this project is to assess the effect of systemic tissue plasminogen activator tenecteplase versus placebo administered within 4.5 hours of CRAO onset in patients admitted to the participating hospitals in Europe. The main endpoint is the proportion of patients with ≤ 0.7 logMAR visual acuity 30 (±5) days after treatment, representing an improvement in visual acuity of at least 0.3 logMAR, equal to at least 15 letters/three lines on a visual acuity chart. In addition, we will access differences in visual field parameters and patient reported outcome measures between the groups. This study is based on a broad collaboration and interaction between leading ophthalmologists and neurologists in European centres.

Inclusion criteria

• Non-arteritic central retinal artery occlusion with ≥ 1.0 logMAR visual acuitiy and symptoms lasting less than 4.5 hours.
• Ability to administer the Investigator Medicinal Product (IMP) within 4.5 hours of symptom onset.
• Age ≥18 years.
• Informed written consent of the patient.
• A woman of childbearing potential (WOCBP) must confirm that in her opinion, she cannot be pregnant, OR if there is a possibility that she is pregnant, a negative pregnancy test must be confirmed before any IMP is given.

Exclusion criteria

• Other active intervention targeting CRAO.
• Branch retinal artery occlusion, cilioretinal artery supplying the macula, combined arterial-venous occlusion, proliferative diabetic retinopathy, elevated intraocular pressure (> 30 mmHg) or clinical suspicion of ophthalmic artery occlusion occlusion (e.g. choroidal nonperfusion, absence of cherry red spot, no light perception).
• Systemic diseases; severe general diseases, systemic arterial hypertension (blood pressure >185/110 mmHg), despite medical therapy, or clinical suspicion of acute systemic inflammation.
• Presence of intracranial haemorrhage on brain MRI/CT.
• Medical history: heart attack within the last 6 weeks, intracerebral bleeding or neurosurgical operation within the last 4 weeks, therapy with anticoagulation, allergic reaction to contrast agent, hemorrhagic diathesis, aneurysms, inflammatory vascular diseases (eg, giant cell arteritis, granulomatosis with polyangitis), endocarditis, or gastric ulcer.
• No willingness and ability of the patient to participate in all follow-up examinations.
• Pregnancy (if suspicion of pregnancy s-hCG or u-hCG must be negative).
• Allergy or intolerance to any ingredients of IMP or placebo or gentamicin.
• Other conditions / circumstances likely to lead to poor treatment adherence (eg, history of poor compliance, alcohol or drug dependency, no fixed abode).
• Significant bleeding disorder either at present or within the past 6 months.
• Effective oral anticoagulant treatment, eg, warfarin sodium (INR >1.3).
• Effective anticoagulant treatment with heparin or low molecular weight heparin the last 48 hours.
• Any history of central nervous system damage (ie, neoplasm, aneurysm, intracranial or spinal surgery).
• Known hemorrhagic diathesis.
• Major surgery, biopsy of a parenchymal organ, or significant trauma within the past 2 months (this includes any trauma associated with acute myocardial infarction).
• Recent non-compressible vessel puncture within 2 weeks.
• Recent trauma to the head or cranium.
• Prolonged cardiopulmonary resuscitation (>2 minutes) within the past 2 weeks.
• Acute pericarditis and/or subacute bacterial endocarditis.
• Acute pancreatitis.
• Severe hepatic dysfunction, including hepatic failure, cirrhosis, portal hypertension (oesophageal varices) and active hepatitis.
• Active peptic ulceration.
• Arterial aneurysm and known arterial/venous malformation.
• Neoplasm with increased bleeding risk.
• Any known history of hemorrhagic stroke or stroke of unknown origin.
• Known history of ischemic stroke or transient ischemic attack in the preceding 3 months.
• Dementia.