Tenecteplase Efficacy in Patients With Distal Occlusions: Secondary Analysis of the TASTE Randomized Clinical Trial

BACKGROUND: Tenecteplase has been previously evaluated in large- and medium-sized vessel occlusion subgroups, but its effectiveness in more distal occlusions, particularly those involving the distal middle cerebral artery branches or the anterior cerebral artery and posterior cerebral artery territories, and across varying ischemic core and perfusion profiles, remains uncertain. METHODS: We performed a secondary analysis of TASTE (Tenecteplase Versus Alteplase for Stroke Thrombolysis Evaluation), a randomized clinical trial comparing tenecteplase and alteplase in patients presenting within 4.5 hours of symptom onset with perfusion imaging-confirmed stroke and evidence of target mismatch (penumbra/core ratio >1.8 and an absolute difference >15 mL). The primary outcome was the modified Rankin Scale (mRS) score of 0 to 1 at 90 days. We compared the effect of tenecteplase versus alteplase in subgroups based on occlusion site (proximal M2, distal M2, M3 and beyond, anterior cerebral artery, and posterior cerebral artery), ischemic core, core growth rate, and penumbra. The treatment effect of tenecteplase and alteplase was compared stratifying by the subgroup of interest, adjusting for age, baseline National Institutes of Health Stroke Scale score, and premorbid mRS score in modified Poisson regression models. RESULTS: Of the 680 patients enrolled, 492 were included in the primary analysis (median age, 73 [interquartile range, 63–82] years; male sex: 306/492 [62%]). Two hundred forty-two (49%) received tenecteplase, and 250 (51%) received alteplase. Tenecteplase was associated with a higher proportion of mRS score of 0 to 1 with distal (M3 and beyond) occlusions (tenecteplase: 62/81 [77%] versus alteplase: 59/93 [63%]; adjusted risk ratio, 1.23 [95% CI, 1.04–1.46]). Numerically higher rates of mRS score of 0 to 1 were observed with distal M2 (tenecteplase: 30/46 [65%] versus alteplase 28/48 [58%]; adjusted risk ratio, 1.14 [95% CI, 0.84–1.54]) and anterior cerebral artery occlusions (tenecteplase: 12/21 [57%] versus alteplase 5/13 [38%]; adjusted risk ratio, 1.46 [95% CI, 0.71–3.00]). No treatment differences were seen for proximal M2 or posterior cerebral artery occlusions ( P interaction across all occlusion sites: 0.89). Across ischemic core, penumbra, and core growth rate subgroups, no difference in treatment effect was observed. CONCLUSIONS: Patients with distal middle cerebral artery occlusions who are treated with tenecteplase are more likely to achieve an mRS score of 0 to 1 at 90 days than those treated with alteplase. REGISTRATION: URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx? ; Unique identifier: ACTRN12613000243718.

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Journal
Stroke
Published
2026-07-22
DOI
https://doi.org/10.1161/strokeaha.126.056290
Primary Topic
Acute Ischemic Stroke Management
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article
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article

Tenecteplase Efficacy in Patients With Distal Occlusions: Secondary Analysis of the TASTE Randomized Clinical Trial

Rohan Grimley, Andrew Bivard, Chon‐Haw Tsai, Chushuang Chen et al.
Stroke
Acute Ischemic Stroke Management
article

Tenecteplase Efficacy in Patients With Distal Occlusions: Secondary Analysis of the TASTE Randomized Clinical Trial

Rohan Grimley, Andrew Bivard, Chon‐Haw Tsai, Chushuang Chen, Vignan Yogendrakumar, Angelos Sharobeam, Leonid P. Churilov, Christopher Levi, Khaled Alanati, Fana Alemseged, Christine Selmes, Brian H Buck, Hannah Tabitha Johns, Timothy John Kleinig, Daniel Strbian, R C Starling, Geoffrey Alan Donnan, Fouke Ombelet, Jiann‐Shing Jeng, Stephen M. Davis, Regan Cooley, Akshay Deepak, Andre Loiselle, Dunkerton Sb, Malcolm Evans, Kennedy Lees, Philip Choi, Edward Callaly, Longting Lin, Ross Cody, Annalese Johnson, Ferdinand Miteff, Carlos García-Esperón, Nicole Lachapelle, García Royan A, Shyam Gangadharan, Michael Valente, Jiunn-Tay Lee, Felix Ng, Neil J. Spratt, Lara Kaauwai, Arman Sabet, Atte Meretoja, Bruce C.V. Campbell, Markku Kaste, Sally Ormond, Ferdi Miteff, Kenneth Butcher, Hossein Zareie, P. Park, Mark William Parsons, Juan F. Arenillas, Dennis Cordato, Teddy Y. Wu, Linda Belevski, Carlos A. Molina, John Fink, M. Devlin, Rachael MacISaac, M.F. Chung, Jo Lyn Ng, Tessa Busch, Beng Lim Chew, Helen Brown, Niruta Dhimal, Henry Zhao, Timothy Ang, Narelle Stuart, Peter Tan, Helen Dewey, Raka Datta, Cameron Williams, Anna Balabanski, James Beharry, Joseph Wong, Venkatesh Krishnamurthy, Justin YH Phung, Margaret Ma, Tissa Wijeratne, Chris Bladin, Tom Wellings, Billy O’Brien, Michelle L. Russell, Gagan Sharma, Davor Pavlin-Premrl, Angela Dos Santos, Elizabeth Pepper, John Williamson, Jiacheng He, Hugh S. Markus, Timmy Phan, Thanh G. Phan, Nawaf Yassi, Grace Thomas, Sunil K. Munshi, Erin Kerr, Jennifer Liu, Channa Senanayake, Henry Ma, Smriti Agarwal
article en

Abstract

BACKGROUND: Tenecteplase has been previously evaluated in large- and medium-sized vessel occlusion subgroups, but its effectiveness in more distal occlusions, particularly those involving the distal middle cerebral artery branches or the anterior cerebral artery and posterior cerebral artery territories, and across varying ischemic core and perfusion profiles, remains uncertain. METHODS: We performed a secondary analysis of TASTE (Tenecteplase Versus Alteplase for Stroke Thrombolysis Evaluation), a randomized clinical trial comparing tenecteplase and alteplase in patients presenting within 4.5 hours of symptom onset with perfusion imaging-confirmed stroke and evidence of target mismatch (penumbra/core ratio >1.8 and an absolute difference >15 mL). The primary outcome was the modified Rankin Scale (mRS) score of 0 to 1 at 90 days. We compared the effect of tenecteplase versus alteplase in subgroups based on occlusion site (proximal M2, distal M2, M3 and beyond, anterior cerebral artery, and posterior cerebral artery), ischemic core, core growth rate, and penumbra. The treatment effect of tenecteplase and alteplase was compared stratifying by the subgroup of interest, adjusting for age, baseline National Institutes of Health Stroke Scale score, and premorbid mRS score in modified Poisson regression models. RESULTS: Of the 680 patients enrolled, 492 were included in the primary analysis (median age, 73 [interquartile range, 63–82] years; male sex: 306/492 [62%]). Two hundred forty-two (49%) received tenecteplase, and 250 (51%) received alteplase. Tenecteplase was associated with a higher proportion of mRS score of 0 to 1 with distal (M3 and beyond) occlusions (tenecteplase: 62/81 [77%] versus alteplase: 59/93 [63%]; adjusted risk ratio, 1.23 [95% CI, 1.04–1.46]). Numerically higher rates of mRS score of 0 to 1 were observed with distal M2 (tenecteplase: 30/46 [65%] versus alteplase 28/48 [58%]; adjusted risk ratio, 1.14 [95% CI, 0.84–1.54]) and anterior cerebral artery occlusions (tenecteplase: 12/21 [57%] versus alteplase 5/13 [38%]; adjusted risk ratio, 1.46 [95% CI, 0.71–3.00]). No treatment differences were seen for proximal M2 or posterior cerebral artery occlusions ( P interaction across all occlusion sites: 0.89). Across ischemic core, penumbra, and core growth rate subgroups, no difference in treatment effect was observed. CONCLUSIONS: Patients with distal middle cerebral artery occlusions who are treated with tenecteplase are more likely to achieve an mRS score of 0 to 1 at 90 days than those treated with alteplase. REGISTRATION: URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx? ; Unique identifier: ACTRN12613000243718.

Stroke
Hebron University (PS), Royal Adelaide Hospital (AU), The Royal Melbourne Hospital (AU), University of Helsinki (FI), Box Hill Hospital (AU), University of Alberta (CA), The University of Melbourne (AU), China Medical University (TW), Helsinki University Hospital (FI), Ottawa Hospital (CA), Princess Alexandra Hospital (AU), Christchurch Hospital (NZ), University of Alberta Hospital (CA), UNSW Sydney (AU), Novita Healthcare (Australia) (AU), Eastern Health (AU), Monash Health (AU), China Medical University Hospital (TW), Vall d'Hebron Hospital Universitari (ES), National Taiwan University Hospital (TW), Ingham Institute (AU), Hunter New England Local Health District (AU), Hospital Clínico Universitario de Valladolid (ES), Austin Health (AU), Mercy Hospital (US), Monash University (AU), Western Sydney University (AU), National Defense Medical Center (TW), University of Newcastle Australia (AU)
Good health and well-being
Openalex Percentile: Top 8%
Acute Ischemic Stroke Management
DOISourceOpenAlex
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