Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Observational Study
. 2025 Jul 16;96(8):775-783.
doi: 10.1136/jnnp-2024-335325.

Bridging thrombolysis with tenecteplase versus endovascular thrombectomy alone for large-vessel anterior circulation stroke: a target trial emulation analysis

Valerian L Altersberger  1   2 , Johannes Kaesmacher  3 , Leonid Churilov  4 , Vignan Yogendrakumar  4   5 , Jan Gralla  3 , Daniel Strbian  6 , David J Seiffge  7 , Peter J Mitchell  8 , Timothy J Kleinig  9 , Bruce Cv Campbell  4 , Urs Fischer  2   7
Affiliations
Observational Study

Bridging thrombolysis with tenecteplase versus endovascular thrombectomy alone for large-vessel anterior circulation stroke: a target trial emulation analysis

Valerian L Altersberger et al. J Neurol Neurosurg Psychiatry. .

Abstract

Background: Whether bridging thrombolysis with tenecteplase is beneficial compared with thrombectomy alone in patients who had a stroke with large-vessel occlusion remains unclear.

Methods: This is a causal inference study of observational data from the trials SWIFT DIRECT and EXTEND-IA TNK Parts 1 and 2 applying target trial emulation. We compared patients receiving thrombectomy alone to patients receiving tenecteplase 0.25 mg/kg or 0.40 mg/kg before thrombectomy. The primary outcome was functional independence (modified Rankin Scale (mRS) of 0-2) at 90 days. Secondary outcomes included improvement over the full ordinal mRS scale, freedom of disability (mRS 0-1), mortality and occurrence of symptomatic intracranial haemorrhage. The average causal treatment effect was estimated via inverse probability of treatment weighting and G-Computation. We calculated standardised risk differences (SRDs) and adjusted (common) ORs (a(c)ORs).

Results: Of 377 patients included in the target trial, 187 received thrombectomy alone and 190 tenecteplase before thrombectomy. Tenecteplase before thrombectomy did not increase the probability of patients achieving functional independence (SRD 0.04 (95% CI -0.06 to 0.13)) but resulted in a significant improvement in the mRS overall (acOR 1.56 (95% CI 1.07 to 2.23)) and in a higher probability of freedom from disability (SRD 0.10 (95% CI 0.01 to 0.20)). The probability for improvement of functional outcomes was further increased in patients treated within 140 min after onset (ordinal mRS acOR 1.63 (95% CI 1.04 to 2.56)). No significant differences in safety outcomes were observed between the two groups.

Conclusion: Tenecteplase before thrombectomy compared with thrombectomy alone did not increase the probability of functional independence but resulted in significant improvement over the full mRS scale. This improvement was most evident in patients treated early.

Keywords: CEREBROVASCULAR DISEASE; STROKE.

PubMed Disclaimer

Conflict of interest statement

Competing interests: VLA, LC, VY, DS, TK and BCVC have no relevant disclosures. JK reports research grants from Medtronic, which sponsored the SWIFT DIRECT trial. JG is the global PI of the SWIFT DIRECT trial (NCT03192332) (sponsored by Medtronic). DS reports Unrestricted Research or Educational Grants of Boehringer-Ingelheim, which produces and sells Metalyse. PM received institutional research support from Medtronic, which sponsored the SWIFT DIRECT trial. UF reports research grants from Medtronic, which sponsored the SWIFT DIRECT trial, and from Boehringer Ingelheim, which produces and sells Metalyse. He participated in an advisory board for Boehringer Ingelheim.

Figures

Figure 1
Figure 1. Study flow chart.
Figure 2
Figure 2. Distribution of the mRS at 90 days. ASPECTS, Alberta Stroke Programme Early CT Score; ICA, internal carotid artery; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; SWIFT DIRECT, Solitaire With the Intention for Thrombectomy Plus Intravenous t-PA vs DIRECT Solitaire StentRetriever Thrombectomy in Acute Anterior Circulation Stroke Trial.
See this image and copyright information in PMC

References

    1. Berge E, Whiteley W, Audebert H, et al. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J . 2021;6:I–LXII. doi: 10.1177/2396987321989865. - DOI - PMC - PubMed
    1. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–418. doi: 10.1161/STR.0000000000000211. - DOI - PubMed
    1. Turc G, Tsivgoulis G, Audebert HJ, et al. European Stroke Organisation (ESO)-European Society for Minimally Invasive Neurological Therapy (ESMINT) expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischemic stroke and anterior circulation large vessel occlusion. J Neurointerv Surg. 2022;14:209. doi: 10.1136/neurintsurg-2021-018589. - DOI - PubMed
    1. Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723–31. doi: 10.1016/S0140-6736(16)00163-X. - DOI - PubMed
    1. Majoie CB, Cavalcante F, Gralla J, et al. Value of intravenous thrombolysis in endovascular treatment for large-vessel anterior circulation stroke: individual participant data meta-analysis of six randomised trials. Lancet. 2023;402:965–74. doi: 10.1016/S0140-6736(23)01142-X. - DOI - PubMed

Publication types