Large Core Stroke Thrombectomy Is Safe and Effective Regardless of Prior Antithrombotic or Thrombolytic Treatment: A Secondary Analysis of the Randomized TENSION Trial

BACKGROUND: The relevance of prior antithrombotic and thrombolytic treatment for decision-making regarding endovascular thrombectomy (EVT) for acute ischemic stroke due to large vessel occlusion with established large infarcts is uncertain. This study investigates associations of prior antithrombotic medication and thrombolysis with the efficacy and safety of EVT for acute ischemic stroke due to large vessel occlusion with established large infarct. METHODS: TENSION (Efficacy and Safety of Thrombectomy in Stroke With Extended Lesion and Extended Time Window) was a prospective randomized open-label blinded-end point clinical trial. Patients with acute ischemic stroke due to large vessel occlusion and established large infarct were randomized to EVT with medical therapy or medical therapy alone. Exposures were preadmission antithrombotic treatment with antiplatelet agents or anticoagulants and intravenous thrombolysis. The primary efficacy end point was functional outcome at 90 days. Safety outcomes included death and symptomatic intracranial hemorrhage. RESULTS: The study included 246 patients (median age, 74 years; interquartile range, 65 to 80 years; 49% women); 124 (50%) were assigned to EVT. Of 176 patients (72%) with prior antithrombotic therapy, 75 (31%) received antiplatelets, 56 (23%) anticoagulants, and 89 (36%) intravenous thrombolysis. EVT was associated with better functional outcome in patients with (common odds ratio [cOR], 2.40 [95% CI, 1.22-4.99]) and without (cOR, 2.29 [95% CI, 1.53-3.46]) antiplatelet therapy; with (cOR, 2.45 [95% CI, 1.17-5.28]) and without (cOR, 2.12 [95% CI, 1.44-3.15]) anticoagulation; as well as receiving (cOR, 1.46 [95% CI, 0.83-2.61]) and not receiving (cOR, 2.89 [95% CI, 1.87-4.51]) thrombolysis. Interaction analyses were consistent with similar treatment effects across subgroups. Mortality and rates of symptomatic intracranial hemorrhage were similar between groups. CONCLUSIONS: Benefit and safety of EVT were not modified by prior antithrombotic/thrombolytic therapy. Preadmission exposure to antiplatelets or anticoagulants or use of intravenous thrombolysis should not exclude eligible patients with stroke from EVT. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03094715.

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Journal
Journal of the American Heart Association
Published
2026-06-09
DOI
https://doi.org/10.1161/jaha.125.047192
Primary Topic
Acute Ischemic Stroke Management
Type
article
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article

Large Core Stroke Thrombectomy Is Safe and Effective Regardless of Prior Antithrombotic or Thrombolytic Treatment: A Secondary Analysis of the Randomized TENSION Trial

Alex Brehm, Franziska Dorn, Jan Raupach, Maximilian Bellut et al.
Journal of the American Heart Association
Acute Ischemic Stroke Management
article

Large Core Stroke Thrombectomy Is Safe and Effective Regardless of Prior Antithrombotic or Thrombolytic Treatment: A Secondary Analysis of the Randomized TENSION Trial

Alex Brehm, Franziska Dorn, Jan Raupach, Maximilian Bellut, Andreas Kastrup, Erendira Gabriela Boss, Vi Tuan Hua, Dominik F. Vollherbst, Elke R. Gizewski, Markus Alfred Möhlenbruch, Paolo Pagano, Joachim Berkefeld, Anne Hege Aamodt, Gernot Reimann, Silke Hopf-Jensen, Bastian Cheng, Maximilian Schell, Olaf Adamczewski, Jozef Haring, Jan Borggrefe, Fabian Flottmann, Märit Jensen, Nico Münnich, Egon Kurča, Rolf Ankerlund Blauenfeldt, Peter A. Ringleb, Quentin Alias, Susanne Bonekamp, Christian Herweh, Ronni Mikkelsen, Maria Boutchakova, Kateřina Vališ, Andrej Klepanec, Maria Barleben, Christian Brem, Stella Breuer, Christian Ulfert, Fabien Subtil, Anne Assmann, Eckhard Schlemm, Volker Puetz, Annemarie Brandhofe, Silvia Schönenberger, Kamil Zeleňák, Hannes Appelbohm, Hannes Deutschmann, Johannes Gerber, Mirko Pham, Petra Brodová, Christoph Brosinski, Kirill Alektoror, Fadha Elawi Al-Kuzae, Rolf AnkerlundBlaufeldt, Riedel Antje, Xénia Bavúzová, Rikke BayThomsen, März Alexander, Elfi Boxhammer, E Bach, Ramona Boese, Maximillian Bester, Eva Vítková, C Keil, Tobias Breyer, Michael Augustin, Flore Baronnet, Angélique Denis, Sylvia Beer, Casper Brekenfeld, Felix J. Bode, Maria Alexandrou, Michael Breckwoldt, M Hill, Ferdinand Bohmann, Maria Argren, Bjørn Tennøe, Rahman Al-Schameri, Andrés Barrios, Julien Allard, Lukas Meyer, Laurent Pierot, Grethe Andersen, Stefan Müller‐Hülsbeck, Gabriel Broocks, Antonín Krajina, Mayank Goyal, Susanne Gellißen, Wolfgang Wick, Claus Z. Simonsen, Christian Boehme, Daniel Behme, Blanca Fuentes, Sandra Becker, Panagiotis Papanagiotou, Götz Thomalla, Michal Bar, Martin Bendszus, Alberto Álvarez, Gabor C. Petzold, Jens Fiehler
article en

Abstract

BACKGROUND: The relevance of prior antithrombotic and thrombolytic treatment for decision-making regarding endovascular thrombectomy (EVT) for acute ischemic stroke due to large vessel occlusion with established large infarcts is uncertain. This study investigates associations of prior antithrombotic medication and thrombolysis with the efficacy and safety of EVT for acute ischemic stroke due to large vessel occlusion with established large infarct. METHODS: TENSION (Efficacy and Safety of Thrombectomy in Stroke With Extended Lesion and Extended Time Window) was a prospective randomized open-label blinded-end point clinical trial. Patients with acute ischemic stroke due to large vessel occlusion and established large infarct were randomized to EVT with medical therapy or medical therapy alone. Exposures were preadmission antithrombotic treatment with antiplatelet agents or anticoagulants and intravenous thrombolysis. The primary efficacy end point was functional outcome at 90 days. Safety outcomes included death and symptomatic intracranial hemorrhage. RESULTS: The study included 246 patients (median age, 74 years; interquartile range, 65 to 80 years; 49% women); 124 (50%) were assigned to EVT. Of 176 patients (72%) with prior antithrombotic therapy, 75 (31%) received antiplatelets, 56 (23%) anticoagulants, and 89 (36%) intravenous thrombolysis. EVT was associated with better functional outcome in patients with (common odds ratio [cOR], 2.40 [95% CI, 1.22-4.99]) and without (cOR, 2.29 [95% CI, 1.53-3.46]) antiplatelet therapy; with (cOR, 2.45 [95% CI, 1.17-5.28]) and without (cOR, 2.12 [95% CI, 1.44-3.15]) anticoagulation; as well as receiving (cOR, 1.46 [95% CI, 0.83-2.61]) and not receiving (cOR, 2.89 [95% CI, 1.87-4.51]) thrombolysis. Interaction analyses were consistent with similar treatment effects across subgroups. Mortality and rates of symptomatic intracranial hemorrhage were similar between groups. CONCLUSIONS: Benefit and safety of EVT were not modified by prior antithrombotic/thrombolytic therapy. Preadmission exposure to antiplatelets or anticoagulants or use of intravenous thrombolysis should not exclude eligible patients with stroke from EVT. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03094715.

Journal of the American Heart Association
Goethe University Frankfurt (DE), Oslo University Hospital (NO), Innsbruck Medical University (AT), University of Trnava (SK), Witten/Herdecke University (DE), University of Calgary (CA), National and Kapodistrian University of Athens (GR), Medical University of Graz (AT), Université de Lyon (FR), Charles University (CZ), Masaryk University (CZ), Heidelberg University (DE), University Hospital Bonn (DE), Hospital Universitario La Paz (ES), German Center for Neurodegenerative Diseases (DE), University Hospital Heidelberg (DE), Aarhus University Hospital (DK), Foothills Medical Centre (CA), European Neuroendocrine Tumor Society (DE), Hospices Civils de Lyon (FR), Hospital La Paz Institute for Health Research (ES), University Medical Center Hamburg-Eppendorf (DE), Environnement, ville, société (FR), Universitätsklinikum Würzburg (DE), University Hospital Frankfurt (DE), Paul Gerhardt Diakonie (DE), Klinikum Bremen-Mitte (DE), Electronic Product Services (Czechia) (CZ), University Hospital Carl Gustav Carus (DE), Klinik und Poliklinik für Psychotherapie und Psychosomatik (DE), Chirurgische Universitätsklinik Heidelberg (DE), Comenius University Bratislava (SK), Université de Reims Champagne-Ardenne (FR)
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Openalex Percentile: Top 7%
Acute Ischemic Stroke Management
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