Written by Clay Smith
Spoon Feed
Tenecteplase before thrombectomy in adults with large vessel occlusion (LVO) stroke resulted in better 90-day functional outcomes than thrombectomy alone.
Who you gonna call? Clotbusters!
Six RCTs, which largely used alteplase before thrombectomy, failed to show clear benefit in the IRIS meta-analysis, though earlier lytics are likely better. However, head-to-head – tenecteplase beat alteplase when given before thrombectomy.
This RCT in China randomized adult patients––with LVO, within 4.5 hours, and no contraindications––to receive tenecteplase before thrombectomy (N=278) or thrombectomy alone (N=272). Blinded assessments for good 90-day functional outcomes (modified Rankin score 0-2) were better in the lytic group (52.9%) vs. no-lytic patients (44.1%): unadjusted RR 1.20 (95%CI 1.01 to 1.43; P=0.04; NNT=12). Symptomatic hemorrhage was higher in the lytic vs. no-lytic group: 8.5% vs 6.7%, NNH=55.
There were a few issues. The primary outcome barely met statistical significance (fragility index = 1). This was not done in a U.S. population; it did not use a placebo; and lytic patients had greater risk of groin hematoma and pseudoaneurysm.
How will this change my practice?
Big picture––I think the best possible outcomes are most likely with tenecteplase over alteplase pre-thrombectomy and by giving it as early as possible after symptom onset. Patients should be informed of the very real NNT and NNH.
Source
BRIDGE-TNK Trial Investigators. Intravenous Tenecteplase before Thrombectomy in Stroke. N Engl J Med. 2025 Jul 10;393(2):139-150. doi: 10.1056/NEJMoa2503867. Epub 2025 May 21. PMID: 40396577.
