Basilar Artery Occlusion Stroke Managed With Tenecteplase Versus Alteplase Before Endovascular Treatment (BAO-TNK).

OBJECTIVE

To compare the effectiveness and safety of tenecteplase (TNK) versus alteplase (TPA) in patients with basilar artery occlusion prior to endovascular treatment (EVT).

METHODS

In this retrospective multicenter study (BAO-TNK), we analyzed consecutive BAO patients from 14 U.S. stroke systems who received TNK or TPA within 4.5 h of last known well and were referred for EVT (01/2020-08/2024). Multivariable logistic regression models were adjusted for age, sex, NIH Stroke Scale (NIHSS), posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS), last-known-well-to-door time, and stroke etiology. Outcomes included 90-day modified Rankin Scale (mRS), reperfusion rates, and intracranial hemorrhage (ICH) per Heidelberg classification.

RESULTS

Of 163 BAO patients, 75 (46.0%) received TNK and 88 (54.0%) received TPA. Rates of 90-day good functional outcome (mRS 0-3) were comparable between groups (TNK: 61.8% vs. TPA: 48.8%, adjusted odds ratio [aOR] 1.372, 95% CI 0.616-3.054, p = 0.439). No significant differences were observed in rates of pre-thrombectomy early reperfusion (18.7% vs. 14.8%, aOR 0.933, 95% CI 0.369-2.359, p = 0.884), post-thrombectomy final reperfusion (97.3% vs. 92.0%, aOR 2.133, 95% CI 0.376-12.116, p = 0.393), 90-day mortality (32.4% vs. 39.5%, aOR 0.989, 95% CI 0.436-2.244, p = 0.979), or symptomatic ICH (4.0% vs. 4.5%, aOR 1.319, 95% CI 0.245-7.114, p = 0.747). Predictors of favorable outcome included younger age, lower NIHSS, higher pc-ASPECTS, shorter LKW-to-puncture time, and non-atherothrombotic stroke etiology.

INTERPRETATION: In BAO stroke, TNK and TPA administered within 4.5 h pre-EVT were associated with similar functional outcomes, reperfusion success and hemorrhage rates.