BRIDGE-TNK post hoc: benefit from tenecteplase before thrombectomy was seen only when ASPECTS was below 8

Design

Post hoc analysis of a randomised trial

Population

550 patients with large-vessel occlusion stroke within 4.5 h, China

Primary outcome

90-day functional independence (mRS 0–2)

Effect

ASPECTS <8: aRR 1.67 (95% CI 1.18 to 2.35); ASPECTS 8–10: aRR 0.99 (0.84 to 1.17)

BRIDGE-TNK randomised 550 Chinese patients with large-vessel occlusion within 4.5 hours to intravenous tenecteplase plus thrombectomy or thrombectomy alone. This post hoc analysis split them by baseline ASPECTS.

With ASPECTS below 8 (241 patients), tenecteplase was associated with more functional independence at 90 days (aRR 1.67, 95% CI 1.18 to 2.35). With ASPECTS 8–10 (309), there was no benefit (aRR 0.99) and 90-day mortality was numerically higher (aRR 1.89, 0.99 to 3.61). Symptomatic haemorrhage did not differ significantly in either group.

This runs against the intuition that thrombolysis is riskier in larger infarcts, and the authors call it exploratory. It should not yet change who gets bridging thrombolysis. What it does is make the ASPECTS in the report more consequential.

• Report ASPECTS on every non-contrast CT for suspected large-vessel occlusion.
• Score it consistently — use a structured template or validated software as a second read.
• Do not withhold thrombolysis on ASPECTS alone on the strength of this analysis.
• Expect ASPECTS-based selection to be tested prospectively.

Why it matters

It suggests the score radiologists already produce may help decide who gains from thrombolysis before thrombectomy.

Don't overread it

A post hoc subgroup analysis of one Chinese trial; it generates a hypothesis and does not change eligibility.

The statistics, in plain English

The interaction P value of 0.007 says the effect differed between subgroups, but subgroups defined after a trial are prone to chance findings. The mortality interval (0.99 to 3.61) touches 1, so harm in high-ASPECTS patients is not established.

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