Intra-arterial tenecteplase after successful endovascular recanalisation in patients with acute posterior circulation arterial occlusion (ATTENTION-IA): multicentre randomised controlled trial
Authors: Hu Wei , Tao Chunrong , Wang Li , Chen Zhongjun , Li Di , Chen Wenhuo , Yi Tingyu , Xu Lihua , Yu Chuanqing , Wang Tao , Yao Xiaoxi , Cui Tao , Yuan Guangxiong , Su Junfeng , Chen Li , Zhou Zhiming , Ma Zhengfei , Wang Junjun , Wang Benxiao , Han Hongxing , Wang Hao , Chen Jie , Zhou Peiyang , Cao Zhihua , Ren Youquan , Cai Xueli , Shi Huaizhang , Zhang Guang , Yu Liping , Yuan Xingyun , Li Jinglun , Zeng Guoyong , Ni Chuyuan , Li Tong , Wu Yingchun , Li Yuwen , Li Kai , Liu Yong , Wang Yao , Jin Yu , Liu Hanwen , Wen Jianshang , Sun Jun , Zhu Yuyou , Li Rui , Zhang Chao , Liu Tianlong , Song Jianlong , Wang Li , Cheng Juan , Qureshi Adnan I , Nguyen Thanh N , Saver Jeffrey L , Nogueira Raul G , Liu Xinfeng 
Published: January 2025

Abstract

Objective
To assess whether intra-arterial tenecteplase administered after successful endovascular recanalisation improves outcomes in patients with acute arterial occlusion of the posterior circulation.

Design
Multicentre randomised controlled trial.

Setting
31 hospitals in China, 24 January 2023 to 24 August 2023.

Participants
208 patients with successful recanalisation (grade 2b50-3 on the extended thrombolysis in cerebral infarction scale) of an occlusion in the V4 segment of the vertebral artery; proximal, middle, or distal segment of the basilar artery; or P1 segment of the posterior cerebral artery: 104 were randomly allocated to receive tenecteplase and 104 to receive standard care.

Interventions
Intra-arterial tenecteplase (0.0625 mg/kg, maximum dose 6.25 mg) administered proximal to the residual thrombus (if still present) or distal to the origin of the main pontine perforator branches over 15 seconds, or endovascular treatment only (control group).

Main outcome measures
The primary outcome was freedom from disability (modified Rankin scale score 0 or 1) at 90 days after randomisation. Primary safety outcomes included symptomatic intracranial haemorrhage within 36 hours and all cause mortality at 90 days. All efficacy and safety analyses were conducted by intention to treat and adjusted for age, pre-stroke modified Rankin scale score, time from onset of moderate to severe stroke (National Institutes of Health stroke scale score ≥6) to randomisation, hypertension, and baseline stroke severity.

Results

At 90 days, 36 patients (34.6%) in the tenecteplase group and 27 (26.0%) in the control group had a modified Rankin scale score of 0 or 1 (adjusted risk ratio 1.36, 95% confidence interval 0.92 to 2.02; P=0.12). Mortality at 90 days was similar between the tenecteplase and control groups: 29 (27.9%)
v
28 (26.9%), adjusted risk ratio 1.13, 0.73 to 1.74. Symptomatic intracranial haemorrhage within 36 hours occurred in eight patients (8.3%) in the tenecteplase group and three (3.1%) in the control group (adjusted risk ratio 3.09, 0.78 to 12.20).

Conclusions
In patients with acute ischaemic stroke due to acute posterior large or proximal vessel occlusion, intra-arterial tenecteplase administered after successful recanalisation was not associated with a statistically significant reduction in combined disability and mortality at 90 days.

Trial registration

ClinicalTrials.gov
NCT05684172.