Tenecteplase, alteplase, and endovascular thrombectomy in extended-window acute ischemic stroke with intracranial large-vessel occlusion: a Bayesian network meta-analysis.
Wenkui Li, Chuyue Wu, Rong Deng et al.
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In 30 seconds
This Bayesian network meta-analysis compared reperfusion strategies in imaging-selected patients with acute ischemic stroke treated 4.5 to 24 hours after onset or last known well. It included 15 randomized trials; 8 contributed to the primary network of confirmed intracranial large-vessel or basilar artery occlusion. Compared with placebo or best medical care, endovascular thrombectomy (EVT) improved 90-day functional independence (OR, 2.93 [95% CrI, 1.40-6.53]) and reduced mortality, while increasing symptomatic intracranial haemorrhage. Tenecteplase plus EVT had favorable but inconclusive estimates versus EVT alone; the incremental benefit of bridging tenecteplase remains uncertain.
Key findings
- Compared with placebo or best medical care, EVT improved 90-day functional independence (OR, 2.93 [95% CrI, 1.40-6.53]).
- EVT was associated with lower 90-day mortality (OR, 0.71 [95% CrI, 0.50-0.98]) and more symptomatic intracranial haemorrhage (OR, 2.65 [95% CrI, 1.28-5.81]).
- Tenecteplase plus EVT did not establish superiority over EVT alone for functional independence (OR, 1.10 [95% CrI, 0.34-3.52]).
- Tenecteplase alone showed no clear differences from placebo or best medical care.
Why it matters
For imaging-selected patients with confirmed intracranial large-vessel or basilar artery occlusion presenting in the extended window, the analysis identifies EVT as the strategy with the most consistent evidence of benefit. It also highlights a trade-off: improved functional outcomes and lower mortality were accompanied by increased symptomatic intracranial haemorrhage. Whether adding tenecteplase provides further benefit remains unresolved.
What to keep in mind
The primary network included only 8 of the 15 trials, and estimates for tenecteplase plus EVT versus EVT alone were imprecise; direct pairwise evidence came from 2 trials.