POST-TNK
Intra-Arterial Tenecteplase Following Endovascular Reperfusion for Large Vessel Occlusion Acute Ischemic Stroke: The POST-TNK Randomized Clinical Trial
Clinical Question
Does adjunct intra-arterial tenecteplase after successful thrombectomy improve functional outcome in acute LVO stroke?
Bottom Line
Intra-arterial tenecteplase after EVT did not significantly improve disability-free survival at 90 days and increased radiologic hemorrhage without increasing symptomatic ICH or mortality.
Major Points
- Largest trial of adjunct intra-arterial tenecteplase post-EVT (n=540)
- Included only patients with eTICI 2c–3 reperfusion and no prior IV tPA
- 49.1% vs 44.1% had mRS 0–1 at 90 days (not statistically significant)
- Symptomatic ICH rates similar (6.3% vs 4.4%), but radiologic ICH higher in tenecteplase group
- No significant mortality difference (16.0% vs 19.3%)
Design
Study Type: Randomized, open-label, blinded outcome trial
Randomization: 1
Blinding: Outcome assessors were blinded; treating physicians were not
Enrollment Period: October 26, 2022 – March 1, 2024
Follow-up Duration: 90 days
Centers: 34
Countries: China
Sample Size: 540
Analysis: Intention-to-treat using modified Poisson regression, Cox models, and adjusted generalized odds ratio
Inclusion Criteria
- Age ≥18 years
- NIHSS ≤25
- Anterior circulation LVO (ICA, M1, M2)
- eTICI 2c–3 post-EVT
- ASPECTS ≥6 within 6h or DEFUSE 3/DAWN eligible (6–24h window)
- No prior IV thrombolysis
Exclusion Criteria
- Prestroke mRS ≥2
- Prior IV tPA
- Hemorrhage on imaging
- Procedure time >90 min
- Life expectancy <90 days
- Recent GI bleeding
Arms
| Field | Intra-arterial tenecteplase | Control |
|---|---|---|
| Intervention | Tenecteplase 0.0625 mg/kg via catheter after EVT | No intra-arterial thrombolysis after EVT |
| Duration | Single dose post-reperfusion | Single EVT procedure |
Outcomes
| Outcome | Type | Control | Intervention | HR / OR / RR | P-value |
|---|---|---|---|---|---|
| mRS 0–1 at 90 days | Primary | 44.1% | 49.1% | 0.11 | |
| mRS 0–2 at 90 days | Secondary | 58.9% | 61.3% | 0.38 | |
| Death at 90 days | Secondary | 19.3% | 16.0% | 0.75 | 0.16 |
| Symptomatic Intracranial Hemorrhage | Adverse | 4.4% | 6.3% | 1.43 | 0.35 |
| Any Intracranial Hemorrhage | Adverse | 27.3% | 36.6% | 1.33 | 0.02 |
Subgroup Analysis
No interaction found across predefined subgroups (age, sex, NIHSS, ASPECTS, occlusion site, reperfusion grade)
Criticisms
- No benefit in primary or secondary outcomes
- Higher rate of radiologic hemorrhage
- Excludes patients who received IV tPA, limiting generalizability
- No post-procedure imaging to assess perfusion effects
- Study conducted only in Chinese population
Funding
National Natural Science Foundation of China; China Postdoctoral Science Foundation; study drug provided by Shijiazhuang Recomgen Pharmaceutical
Based on: POST-TNK (JAMA, 2025)
Authors: Jiacheng Huang, Jie Yang, Chang Liu, ..., Wenjie Zi
Citation: JAMA. 2025;333(7):579-588. doi:10.1001/jama.2024.23466
Content summarized and formatted by NeuroTrials.ai.