For patients with acute ischaemic stroke due to large-vessel occlusion (LVO), the role of bridging thrombolysis with intravenous tenecteplase before endovascular thrombectomy has been a subject of ongoing debate. The BRIDGE-TNK trial provides new evidence, demonstrating that this combination therapy leads to better functional outcomes compared to thrombectomy alone.¹ The findings, published in the New England Journal of Medicine, suggest a clear benefit for administering tenecteplase in eligible patients within the 4.5-hour window.

The BRIDGE-TNK trial was an open-label, randomised trial conducted across multiple centres in China. The study enrolled patients with acute ischaemic stroke secondary to LVO who presented within 4.5 hours of symptom onset and were eligible for thrombolysis. A total of 550 patients were randomised into two groups. The intervention group (n=278) received intravenous tenecteplase followed by endovascular thrombectomy, while the control group (n=272) proceeded directly to endovascular thrombectomy alone.

The primary outcome was functional independence at 90 days, defined as a score of 0 to 2 on the modified Rankin Scale (mRS). Key secondary outcomes included the rate of successful reperfusion both before and after thrombectomy. Safety endpoints were symptomatic intracranial haemorrhage (sICH) within 48 hours and mortality at 90 days.

The trial met its primary endpoint, showing a significantly higher percentage of patients achieving functional independence in the combination therapy group. At 90 days, 52.9% of patients in the tenecteplase–thrombectomy group had an mRS score of 0–2, compared with 44.1% in the thrombectomy-alone group (unadjusted risk ratio, 1.20; 95% CI, 1.01 to 1.43; P=0.04).¹

Tenecteplase administration led to successful reperfusion before thrombectomy in 6.1% of patients, versus just 1.1% in the control group. Successful reperfusion rates after thrombectomy were high and comparable between the groups (91.4% vs 94.1%, respectively).

Regarding safety, the incidence of sICH within 48 hours was slightly higher in the tenecteplase group (8.5%) than in the thrombectomy-alone group (6.7%), though this difference was not statistically significant. Mortality at 90 days was also similar, at 22.3% and 19.9%, respectively.

These findings support the use of bridging tenecteplase in patients with LVO stroke who are eligible for both thrombolysis and thrombectomy. The improvement in functional independence suggests that the benefits of early chemical thrombolysis outweigh the small, non-significant increase in bleeding risk in this population. As an accompanying editorial notes, these results reinforce that thrombolysis before thrombectomy is a 'bridge not fallen'.² The study investigators concluded that "among patients with acute ischemic stroke due to large-vessel occlusion who had presented within 4.5 hours after onset, the percentage of patients with functional independence at 90 days was higher with intravenous tenecteplase plus endovascular thrombectomy than with endovascular thrombectomy alone."¹ This evidence may influence clinical guidelines for the hyperacute management of stroke.

References

1. Qiu Z, Li F, Sang H, et al. Intravenous Tenecteplase before Thrombectomy in Stroke. N Engl J Med 2025;393:139-150. https://doi.org/10.1056/NEJMoa2503867

2. Leung TW. Thrombolysis before Thrombectomy in Stroke — A Bridge Not Fallen. N Engl J Med 2025;393(2):189-191. https://doi.org/10.1056/NEJMe2506729

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