Clinical question: Does IV Tenecteplase administered before endovascular thrombectomy lead to a higher likelihood of functional independence at 90 days compared to endovascular thrombectomy alone?
Background: IV thrombolysis prior to endovascular thrombectomy has the potential benefit of enhancing reperfusion and the potential risk of increasing intracranial hemorrhage (ICH). This study aimed to define the safety and efficacy of treatment with IV Tenecteplase before endovascular thrombectomy in patients with acute ischemic stroke due to large-vessel occlusion who presented within 4.5 hours after symptom onset and were eligible for thrombolysis. Tenecteplase offers pharmacokinetic advantages over alteplase, suggesting potential for superior efficacy with respect to reperfusion.
Study design: BRIDGE-TNK is an investigator-initiated, multicenter, randomized, open-label trial with blinded assessment of outcomes. Patients were randomly assigned in a 1:1 ratio to one of two groups: IV Tenecteplase followed by endovascular thrombectomy or endovascular thrombectomy alone.
Setting: The trial was conducted at 39 hospitals in China
Synopsis: The primary outcome of functional independence at 90 days was observed in 52.9% of patients in the Tenecteplase-thrombectomy group compared to 44.1% in the thrombectomy alone group (unadjusted risk ratio, 1.20 [1.01-1.43], p = 0.04). Successful reperfusion before thrombectomy occurred in 6.1% of the Tenecteplase-thrombectomy group versus 1.1% in the thrombectomy-alone group, indicating earlier reperfusion with Tenecteplase. Successful reperfusion after thrombectomy was comparable between groups (91.4% versus 94.1%). Safety outcomes, including symptomatic ICH within 48 hours and mortality at 90 days, showed no statistically significant differences between the two groups.
Bottom line: Among patients with acute ischemic stroke due to large-vessel occlusion presenting within 4.5 hours of symptom onset, the combination of IV Tenecteplase plus endovascular thrombectomy led to a higher percentage of functional independence at 90 days compared to endovascular thrombectomy alone, without significantly increasing hemorrhagic risk.
Citation: QiuZ, et al. Intravenous Tenecteplase before Thrombectomy in Stroke. N Engl J Med. 2025. doi:10.1056/NEJMoa2503867.
Dr. Brooks is a hospitalist in the South Texas Veterans Health Care System and an adjoint associate professor in the division of internal medicine at UT Health San Antonio.