BACKGROUND: The efficacy and safety of intravenous thrombolysis with tenecteplase within 24 h after stroke onset due to basilar artery occlusion are not well studied. We aimed to assess whether intravenous tenecteplase administered within 24 h after symptom onset improved functional outcome compared with standard medical treatment in patients with basilar artery occlusion.
METHODS: TRACE-5 was a prospective, randomised, open-label, blinded-endpoint, superiority, phase 3 trial conducted at 66 stroke centres in China. We included patients aged 18 years or older with stroke due to basilar artery occlusion who were eligible for intravenous thrombolytics within 24 h of stroke onset or the time they were last known to be well and had a pre-stroke modified Rankin scale (mRS) score of 3 or less (scores range from 0 to 6, with higher scores indicating greater disability). Patients were randomly assigned to receive a single intravenous bolus of tenecteplase (0·25 mg/kg; maximum 25 mg) within 24 h after symptom onset or standard medical treatment (which could include intravenous alteplase at 0·9 mg/kg, maximum 90 mg, within 4·5 h of symptom onset; anticoagulation; or antiplatelets), with or without endovascular thrombectomy. The primary outcome was a score of 0-1 on the mRS or return to the baseline mRS score (if the baseline pre-stroke mRS score was 2-3) at 90 days. Safety outcomes were symptomatic intracranial haemorrhage and death. The primary outcome and safety outcomes were assessed in all randomly assigned participants included in their originally assigned groups. This trial is registered with ClinicalTrials.gov, NCT06196320.
FINDINGS: Between Jan 24, 2024, and June 20, 2025, 452 patients were enrolled (mean age 66·4 years [SD 11·2], 321 [71%] males, and 131 [29%] females), of whom 222 (49%) subsequently underwent thrombectomy; 221 were randomly assigned to receive tenecteplase and 231 to receive standard medical treatment. Alteplase was used in 80 (35%) of the patients in the standard medical treatment group. An mRS score of 0-1 or return to the baseline mRS score occurred in 83 (38%) patients in the tenecteplase group and 66 (29%) patients in the standard medical treatment group (adjusted relative rate 1·50 [95% CI 1·09-2·08], p=0·014). Symptomatic intracranial haemorrhage within 36 h occurred in four (2%) patients in the tenecteplase group and seven (3%) patients in the standard medical treatment group (adjusted relative rate 0·58 [95% CI 0·17-1·99]). All-cause mortality at 90 days was similar between groups (65 [29%] patients in the tenecteplase group and 71 [31%] patients in the standard medical treatment group; adjusted relative rate 0·87 [95% CI 0·62-1·22]), as was the proportion of patients with an mRS score of 5-6 at 90 days (82 [37%] vs 89 [39%]; 0·87 [0·65-1·18]).
INTERPRETATION: In this trial involving Chinese patients with ischaemic stroke due to basilar artery occlusion, tenecteplase within 24 h after stroke onset improved functional outcome compared with standard medical treatment. The incidence of symptomatic intracranial haemorrhage and death was similar.
FUNDING: Noncommunicable Chronic Diseases-National Science and Technology Major Project, Beijing Municipal Science Fund for Distinguished Young Scholars, National Natural Science Foundation of China, and China Shijiazhuang Pharmaceutical Company Recomgen Pharmaceutical (Guangzhou).
| Discipline Area | Score |
|---|---|
| Neurology |  |
| Emergency Medicine |  |
| Internal Medicine | |
The current standard of care for patients with acute ischemic stroke (AIS) between 4.5 hours and 24 hours with a large vessel occlusion (LVO) and favorable perfusion imaging is thrombectomy (http://pmid.us/37479410). The American College of Emergency Physician's most recent Clinical Policy for acute ischemic stroke (http://pmid.us/39578010) provides a Level B recommendation in favor of thrombolytics within 4.5 hours in addition to thrombectomy, but basilar artery strokes are under-represented in the evidentiary basis for these recommendations. Furthermore, patients with AIS without LVO and beyond 4.5 hours are in a no-mans land for interventions. This trial provides promising results for thrombolytic therapy up to 24 hours in those without a brain hemorrhage or existing tumor.
Tenectplase was better than alteplase for patients with vertebral artery stroke in this Chinese open-label trial. Interesting!
We now have evidence of a benefit of TNK for basilar artery occlusion in a broader time window than previously assumed. This provides a treatment option for a group of patients that are generally assumed to have a poor prognosis. It also confirms the clinical impression of a lower bleeding risk in posterior circulation stroke.
Excellent study answering a very valid clinical question. In devastating BAO stroke in absence of MT availability beyond 4.5 hours with mainly limited resources,TNK is justifiable based on pcASPECT.