This post hoc analysis of the randomized BRIDGE-TNK trial explored whether baseline ischemic extent, measured by the Alberta Stroke Program Early Computed Tomography Score (ASPECTS), modifies the efficacy and safety of intravenous tenecteplase administered prior to endovascular thrombectomy in acute large-vessel occlusion stroke patients treated within 4.5 hours of last known well.
The impact of baseline ischemic extent on the net benefit and safety of intravenous thrombolysis given before mechanical thrombectomy remains uncertain. The primary aim of this analysis was to evaluate whether the baseline ASPECTS score influences outcomes—specifically 90-day functional independence (modified Rankin Scale [mRS] 0–2)—when tenecteplase is given before thrombectomy compared with thrombectomy alone. Safety outcomes examined included 48-hour symptomatic intracranial hemorrhage (sICH) and 90-day mortality.
This was a post hoc analysis of the BRIDGE-TNK (thrombectomy with vs without rhTNK-tPA in stroke) randomized trial conducted in China from May 2022 to September 2024. The analysis compared tenecteplase plus thrombectomy versus thrombectomy alone in patients presenting within 4.5 hours of last known well. Patients were stratified by baseline ASPECTS into two groups: <8 and 8–10. Regression models including a treatment-by-ASPECTS interaction term were used to assess whether the effect of tenecteplase differed by baseline ischemic extent.
A total of 550 patients were included in this analysis. Of these, 241 patients (43.8%) had baseline ASPECTS <8 and 309 patients had ASPECTS 8–10. Reported median ages were similar across strata (ASPECTS <8 median 69 years, interquartile range [IQR] 61–77; ASPECTS 8–10 median 70 years, IQR 61–77). The proportion of male patients was approximately 56.4% in the ASPECTS <8 group and 59.5% in the ASPECTS 8–10 group. The abstract does not provide additional baseline clinical or imaging covariates in the available source text.
In the subgroup with baseline ASPECTS <8, treatment with intravenous tenecteplase plus thrombectomy was associated with a higher rate of 90-day functional independence (mRS 0–2) compared with thrombectomy alone. The reported adjusted risk ratio (aRR) was 1.67 with a 95% confidence interval (CI) of 1.18–2.35.
In contrast, among patients with ASPECTS 8–10, there was no observed benefit of tenecteplase on 90-day functional independence; the aRR was 0.99 (95% CI 0.84–1.17).
A statistically significant treatment-by-ASPECTS interaction was reported (p interaction = 0.007), indicating that baseline ischemic extent by ASPECTS modified the effect of pre-thrombectomy tenecteplase on functional outcome.
The abstract states that rates of 48-hour symptomatic intracranial hemorrhage (sICH) did not differ significantly between groups. The source text truncates before providing numeric sICH rates and the detailed 90-day mortality results. Therefore, exact event counts, comparative risk estimates, and confidence intervals for sICH and mortality are not reported in the available source material and cannot be inferred.
Regression models incorporating a treatment-by-ASPECTS interaction term were used to assess effect modification. The reported interaction p value of 0.007 supports a statistically significant difference in tenecteplase treatment effect on functional outcome across the ASPECTS strata presented. The abstract provides adjusted risk ratios for functional independence in each ASPECTS subgroup but does not detail the full set of covariates included in the adjusted models in the available text.
Within the limits of the reported data, this post hoc analysis suggests that patients with greater baseline ischemic injury (ASPECTS <8) experienced a relative benefit in achieving 90-day functional independence when treated with intravenous tenecteplase prior to thrombectomy, while those with ASPECTS 8–10 did not demonstrate such benefit. The significant treatment-by-ASPECTS interaction implies that baseline ischemic extent may be an important modifier when considering pre-thrombectomy thrombolysis with tenecteplase.
Clinicians interpreting these results should consider that this is a post hoc analysis and that details on safety outcomes, model covariates, and other secondary endpoints are incompletely reported in the available abstract. Decisions about using tenecteplase before thrombectomy should integrate full trial data, patient-specific factors, and guideline recommendations.
Key limitations of what can be concluded from the provided source text include:
Because the source text is incomplete with respect to safety and other outcome details, readers should consult the full published article for comprehensive results and methodological specifics.
In this post hoc BRIDGE-TNK analysis, baseline ASPECTS appeared to modify the effect of intravenous tenecteplase given before thrombectomy: patients with ASPECTS <8 showed higher adjusted rates of 90-day functional independence with tenecteplase plus thrombectomy versus thrombectomy alone, whereas no benefit was observed in patients with ASPECTS 8–10. Reported rates of 48-hour sICH were not significantly different between groups in the abstract, but complete safety and mortality data were not included in the available source text. Further evaluation of the full trial report is required to fully assess safety and to guide clinical application.