In late-window large-vessel stroke, thrombectomy has the evidence; bridging tenecteplase is unproven

Design

Bayesian network meta-analysis of randomised trials

Population

15 trials; primary network of 8 trials with confirmed large-vessel or basilar occlusion, treated 4.5–24 h after onset

Primary outcome

Functional independence (mRS 0–2) at 90 days

Effect

Thrombectomy vs medical care OR 2.93 (1.40–6.53); tenecteplase plus thrombectomy vs thrombectomy OR 1.10 (0.34–3.52)

A Bayesian network meta-analysis pooled 15 randomised trials of reperfusion given 4.5 to 24 hours after stroke onset or last known well, in imaging-selected patients. The primary network used the 8 trials that required a confirmed intracranial large-vessel or basilar occlusion.

Against medical care, thrombectomy improved functional independence at 90 days (OR 2.93, 95% CrI 1.40–6.53), excellent outcome (OR 2.22) and reperfusion, and reduced mortality (OR 0.71, 0.50–0.98). Symptomatic intracranial haemorrhage rose (OR 2.65). Adding tenecteplase before thrombectomy gave a point estimate close to no difference with a very wide interval (OR 1.10, 0.34–3.52), and tenecteplase alone did not clearly differ from medical care. Sensitivity analyses pointed the same way.

For late presenters with a large-vessel occlusion, the priority is getting the patient to thrombectomy. Whether bridging tenecteplase adds anything in this window is unanswered, and the analysis does not show harm from it either. Guideline positions on late-window thrombolysis have not changed on the basis of this analysis, and local protocols should be followed.

In India, where many patients present late and thrombectomy access is uneven, this underlines the value of imaging-based triage and transfer pathways.

• Image late presenters to identify large-vessel occlusion and salvageable tissue, rather than excluding them on time alone.
• Prioritise rapid transfer for thrombectomy when a large-vessel occlusion is found in the 4.5 to 24 hour window.
• Do not delay thrombectomy to give tenecteplase; its added benefit in this window is unproven.
• Counsel families that thrombectomy improves recovery but raises the risk of symptomatic bleeding.
• Follow local protocols on late-window thrombolysis; guidelines have not changed on this analysis.

Why it matters

Time spent on a bridging drug of unproven late benefit is time not spent getting to the catheter laboratory.

Don't overread it

An inconclusive result for bridging tenecteplase is not evidence that it is ineffective or harmful.

The statistics, in plain English

A credible interval is the Bayesian equivalent of a confidence interval. For thrombectomy, 1.40 to 6.53 lies wholly above 1.0, so benefit is likely. For tenecteplase plus thrombectomy, 0.34 to 3.52 is so wide that the data cannot distinguish benefit from harm.

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