Intravenous tenecteplase before endovascular thrombectomy improves functional independence among patients with acute ischemic stroke due to large-vessel occlusion (LVO) presenting within 4.5 hours vs. thrombectomy alone, according to new results from the BRIDGE-TNK randomized trial, published in The New England Journal of Medicine.

In this open-label trial, Zhongming Qiu, MD, et al., randomly assigned 550 patients (median age 70 years; 42% women), who presented to 39 hospitals in China within 4.5 hours of onset of acute ischemic stroke due to LVO to the tenecteplase-thrombectomy group (n=278) or the thrombectomy-alone group (n=272).

Results showed that the median time from tenecteplase administration to arterial puncture was 16 minutes. Time from thrombectomy puncture to reperfusion was a median of 55 minutes in the tenecteplase-thrombectomy group vs. 64 minutes in the thrombectomy-alone group.

Looking at the primary outcome revealed that patients in the tenecteplase-thrombectomy group were 53% more likely to retain functional independence at 90 days vs. 44% in the thrombectomy-alone group (risk ratio, 1.20; p=0.04). The researchers suggest that the shorter time to reperfusion in the tenecteplase-thrombectomy group may contribute to this difference in functional outcomes.

Notably, successful reperfusion before thrombectomy occurred in 6% of those receiving Tenecteplase-thrombectomy compared with 1% of those receiving thrombectomy alone; no significant difference in successful reperfusion was seen in either group after thrombectomy.

Safety outcomes were similar in the two groups, with symptomatic intracranial hemorrhage within 48 hours occurring in 9% and 7% of the tenecteplase-thrombectomy and thrombectomy alone groups, and mortality at 90 days occurring in 22% and 20% respectively.

In an accompanying editorial comment, Thomas W. Leung, MD, writes that the "jury is still out for thrombolysis before thrombectomy." The ongoing RESILIENT DIRECT-TNK trial is testing the same hypothesis as BRIDGE-TNK and advancement in thrombectomy strategies may enhance the procedure's effectiveness, which could minimize bridging therapy's benefit. "But for now, the bridge has not fallen. The current findings reinforce the recommendation that intravenous thrombolysis should not be skipped in the treatment of LVO strokes."