Written by Rebecca DiFabio
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Tenecteplase administration up to 24 hours after onset of ischemic basilar artery stroke showed improved disability scores compared to standard medical treatment without an increase in adverse events.
Busting through clots and treatment windows
Basilar artery occlusions are rare but devastating, with 80–90% morbidity and mortality without reperfusion. Thrombectomy within 24 hours of stroke onset is beneficial, although the utility of IV thrombolytics beyond the accepted 4.5-hour treatment window requires further research.
The Tenecteplase Reperfusion Therapy in Acute Ischaemic Cerebrovascular Events-5 (TRACE-5) trial was a prospective, randomised, superiority phase-3 trial conducted at 66 stroke centers in China, investigating IV tenecteplase within 24 hours of ischemic basilar artery occlusion stroke compared with standard medical management.
At 90 days, of the 221 patients in the tenecteplase group, 38% had no disability (modified Rankin Score 0-1 [mRS]) or returned to baseline mRS, versus 29% of the 231 patients in the standard medical treatment group (aRR 1.50, 95%CI 1.09-2.08; p=0.014). Rates of adverse events were similar between tenecteplase and standard medical treatment groups, including 2% and 3%, respectively, for symptomatic intracranial hemorrhage within 36 hours (aRR 0.58, 95%CI 0.17-1.99) and 29% and 31% for 90-day all-cause mortality (aRR 0.87, 95%CI 0.62-1.22). Importantly, patients in both groups were also still eligible for thrombectomy, which 51% of the tenecteplase group and 48% of the standard medical treatment group underwent.
Generalizability may be limited, as the Chinese population traditionally has a higher prevalence of intracranial atherosclerosis compared to other ethnicities.
How does this change my practice?
This is a really exciting study that could open additional treatment options for a population that usually has abysmal outcomes. While I won’t be making any changes to my practice now, I’m interested to see if further studies can replicate results. Especially with the new AHA recommendations of an extended thrombolytic window for select stroke patients, I could see them moving in this direction for basilar artery occlusion patients as well.
Source
Tenecteplase versus standard medical treatment for basilar artery occlusion within 24 h (TRACE-5): a multicentre, prospective, randomised, open-label, blinded-endpoint, superiority, phase 3 trial. Lancet. 2026 Feb 21;407(10530):763-772. doi: 10.1016/S0140-6736(25)02633-9. Epub 2026 Feb 5. PMID: 41655588.
