Rescue treatment for medium vessel occlusion by intra-arterial tenecteplase: the RESCUE-TNK randomized clinical trial

In patients with acute ischemic stroke caused by medium vessel occlusion (MeVO), intra-arterial tenecteplase may offer a targeted strategy to improve recanalization; we hypothesized that intra-arterial tenecteplase would increase successful reperfusion compared with standard care with a comparable safety profile. This phase 2, prospective, randomised, open-label, blinded-endpoint, multicentre study aims to assess the efficacy and safety of intra-arterial tenecteplase for patients with acute ischemic stroke caused by MeVO. Patients with MeVO were randomly (1:1) assigned to receive intra-arterial tenecteplase or standard care. The primary outcome was successful reperfusion of medium vessel occlusion. A total of 80 patients were randomized to either the tenecteplase group (n = 41) or control group (n = 39). Successful reperfusion reached 61.0% (25/41) in the tenecteplase group versus 28.2% (11/39) in the control group (unadjusted odds ratio 3.98, 95% CI 1.56-10.16; P = 0.004). Symptomatic intracranial hemorrhage within 24 h was similar between the tenecteplase and control groups. This work suggests that intra-arterial tenecteplase significantly increased the probability of successful reperfusion compared with standard care, with a comparable safety profile in this stroke population. (Funded by Shenyang Science Tech Project and hospital-initiated grants; ClinicalTrials.gov registration: NCT05657470) Medium-vessel occlusion accounts for a substantial proportion of acute ischemic stroke cases, yet optimal reperfusion treatment strategies remain unclear for patients ineligible for mechanical endovascular thrombectomy. Here, the authors show that intra-arterial tenecteplase significantly increases reperfusion rates for medium-vessel occlusion with acceptable safety, although statistically-significant improvements in 90-day functional outcomes were not detected in this phase-2 randomized trial.