Clinical trial NCT06987305: Intravenous rhTNK-tPA Before Stroke Thrombectomy in the Extended Time Window
Official title: Intravenous rhTNK-tPA Versus Placebo Before Endovascular Thrombectomy For Stroke Patient With Large Vessel Occlusion In The Extended Time Window: the BRIDGE-TNK EXTEND Randomized, Placebo-controlled, Double-blind Trial
Study type: INTERVENTIONAL
Overall status: NOT_YET_RECRUITING
Phase: PHASE3
Conditions: Stroke, Acute Ischemic
Keywords: acute ischemic stroke
endovascular treatment
rhTNK-tPA
Lead sponsor: Xinqiao Hospital of Chongqing
Sponsor class: OTHER
Collaborators: name: China Shijiazhuang Pharmaceutical Company RECOMGEN PHARMACEUTICAL (GUANGZHOU) CO.,LTD
First posted: 2025-05-23
Enrollment: 820
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: This randomized, double-blind, placebo-controlled phase III clinical trial aims to evaluate the efficacy and safety of intravenous recombinant human tenecteplase (rhTNK-tPA) in acute ischemic stroke patients with large vessel occlusion presenting 4.5-24 hours after last known well. The study will address two primary questions: 1) Whether rhTNK-tPA enhances pre-thrombectomy reperfusion rates and improves 90-day functional outcomes compared to placebo; 2) Whether rhTNK-tPA increases the risk of symptomatic intracranial hemorrhage and mortality.

Participants will be randomized to receive either a single bolus of rhTNK-tPA (0.25 mg/kg, max 25 mg) or matching placebo administered intravenously over 5 seconds. Key assessments include repeat neuroimaging (CT/CTA or MRI/MRA) at 24 hours post-treatment to evaluate reperfusion, NIH Stroke Scale score at day 5-7, and modified Rankin Scale score assessment at 90 days. Safety monitoring will focus on hemorrhagic transformation and mortality events throughout the study period.

Detailed description: This multicenter, phase III trial employs a randomized, double-blind, placebo-controlled design to investigate the therapeutic window extension for rhTNK-tPA in large vessel occlusion stroke. Eligible participants are adults with large vessel occlusion confirmed by vascular imaging (CTA/MRA), and salvageable brain tissue demonstrated by perfusion imaging (CTP/MRP) mismatch. Exclusion criteria include contraindications to thrombolysis, and large core infarction (\>70 mL on CTP).

Patients will be randomized 1:1 to receive either weight-adjusted rhTNK-tPA (0.25 mg/kg) or placebo. All participants will undergo endovascular thrombectomy.

The primary outcome is functional independence (mRS 0-2) at 90 days. Secondary outcomes include substantial reperfusion at initial angiogram, first-pass reperfusion, final infarct volume on day 1.5 MRI/CT, etc. Safety outcomes include symptomatic intracranial hemorrhage per Heidelberg Bleeding Classification criteria within 36 hours, and 90-day mortality.

Safety monitoring includes independent adjudication of hemorrhagic events and all-cause mortality. A sample size of 820 participants provides 80% power to detect a 10% absolute difference in functional independence (α=0.05).

The trial incorporates centralized blinded outcome assessment and intention-to-treat analysis, with data oversight by an independent clinical events committee and data safety monitoring board.

Eligibility criteria: Inclusion Criteria:

1. Age ≥18 years;
2. Acute ischemic stroke presenting within 4.5-24 hours of last known well;
3. No significant pre-stroke functional disability: for age \<80 years, pre-stroke modified Rankin scale (mRS) ≤2; for age ≥80 years, prestroke mRS ≤1;
4. Baseline NIHSS score ≥5;
5. Imaging criteria of BOTH:

   1. Occlusion on CTA/MRA in one of the following vessels: M1/M2 segment of middle cerebral artery, A1 segment of anterior cerebral artery, V4 segment of vertebral artery, basilar artery, or P1 segment of posterior cerebral artery. For A1, or P1 occlusions, vessel diameter must be ≥0.75 mm;
   2. For anterior circulation occlusion: CTP/MRP demonstrating mismatch ratio ≥1.8, absolute mismatch volume ≥15 mL, and ischemic core volume \<70 mL; OR have a mismatch between the presence of an abnormal signal on MRI diffusion-weighted imaging and no visible signal change on FLAIR. For posterior circulation occlusion: pc-ASPECTS score ≥6.
6. Plan to received endovascular thrombectomy;
7. The patient or their legal representative provides written informed consent.

Exclusion Criteria:

1. Intracranial hemorrhage confirmed by CT/MRI;
2. Already received intravenous thrombolytic after index stroke.;
3. Pregnancy or lactation;
4. Concurrent participation in other investigation drug clinical trials;
5. Arterial tortuosity or other vascular anomalies precluding endovascular access to target vessel;
6. Pre-existing neurological/psychiatric disorders interfering with neurological assessment;
7. Space-occupying intracranial tumors (except small meningiomas ≤3 cm);
8. Intracranial aneurysm or arteriovenous malformation;
9. Terminal illness with life expectancy \<6 months;
10. Anticipated inability to complete follow-up assessments.

Primary outcomes:
measure: Proportion of patients functionally independent (mRS score 0 to 2) at 90 days
timeFrame: 90 days post-randomization
Secondary outcomes:
measure: Substantial reperfusion (defined as an eTICI grade of 2b, 2c, or 3) at initial angiogram
timeFrame: within 5 minutes at initial angiogram
measure: Successful reperfusion (defined as an eTICI grade of 2b, 2c, or 3) at end-of-procedure angiography
timeFrame: 15 minutes after initial angiogram
measure: Modified first-pass reperfusion
timeFrame: Perioperative (After artery puncture, but the start of procedure)
measure: First-pass reperfusion
timeFrame: Perioperative (After artery puncture, but the start of procedure)
measure: Final infarct volume on day 1.5 MRI/CT
timeFrame: 1.5 days post-randomization
measure: Symptomatic intracranial hemorrhage within 48 hours
timeFrame: within 48 hours after endovascular treatment
measure: Mortality within 90 days
timeFrame: 90 days post-randomization
measure: Procedural-related complications
timeFrame: within 90 days
measure: Severe adverse events
timeFrame: within 90 days
Other outcomes:
Locations:
Study officials:
affiliation: Department of Neurology, Xinqiao Hospital of the Army Medical University
name: Qingwu Yang, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: Department of Neurology Jingdezhen First People's Hospital
name: Shunfu Jiang, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: Hangzhou First Hospital of Westlake University
name: Congguo Yin, MD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Albers GW, Jumaa M, Purdon B, Zaidi SF, Streib C, Shuaib A, Sangha N, Kim M, Froehler MT, Schwartz NE, Clark WM, Kircher CE, Yang M, Massaro L, Lu XY, Rippon GA, Broderick JP, Butcher K, Lansberg MG, Liebeskind DS, Nouh A, Schwamm LH, Campbell BCV; TIMELESS Investigators. Tenecteplase for Stroke at 4.5 to 24 Hours with Perfusion-Imaging Selection. N Engl J Med. 2024 Feb 22;390(8):701-711. doi: 10.1056/NEJMoa2310392. Epub 2024 Feb 8.
citation: Yogendrakumar V, Campbell BC, Churilov L, Garcia-Esperon C, Choi PM, Cordato DJ, Guha P, Sharma G, Chen C, McDonald A, Thijs V, Mamun A, Dos Santos A, Balabanski AH, Kleinig TJ, Butcher KS, Devlin MJ, O'Rourke F, Donnan GA, Davis SM, Levi CR, Ma H, Parsons MW. Extending the time window for tenecteplase by effective reperfusion of penumbral tissue in patients with large vessel occlusion: Rationale and design of a multicenter, prospective, randomized, open-label, blinded-endpoint, controlled phase 3 trial. Int J Stroke. 2025 Mar;20(3):367-372. doi: 10.1177/17474930241308660. Epub 2024 Dec 31.