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ATTENTION-IA

Intra-arterial tenecteplase after successful endovascular recanalisation in patients with acute posterior circulation arterial occlusion (ATTENTION-IA): multicentre randomised controlled trial

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Year of Publication: 2025

Authors: Wei Hu, Chunrong Tao, Li Wang, ..., Xinfeng Liu

Journal: BMJ

Citation: BMJ 2025;388:e080489

Link: https://www.bmj.com/content/388/bmj-2024-080489

PDF: https://www.bmj.com/content/bmj/388/bmj-2024-080489.full.pdf

Clinical Question

Does intra-arterial tenecteplase administered after successful thrombectomy improve clinical outcomes in posterior circulation stroke?

Bottom Line

Intra-arterial tenecteplase after successful thrombectomy for posterior circulation stroke did not significantly improve functional outcomes at 90 days and was associated with a non-significant increase in symptomatic intracranial hemorrhage.

        Major Points
        Multicentre, randomized controlled trial of 208 patients with acute posterior circulation stroke and successful endovascular recanalization (eTICI ≥2b50).
Intra-arterial tenecteplase (0.025 mg/kg) did not significantly increase the proportion of patients with mRS 0–1 at 90 days compared with control (34.6% vs. 26.0%; P=0.12).
Symptomatic intracranial hemorrhage occurred more often in the tenecteplase group (8.3% vs. 3.1%; RR 2.70, 95% CI 0.76–9.60).
No significant difference in 90-day mortality (27.9% vs. 26.9%).
Subgroup analysis suggested a potential benefit in patients with NIHSS 10–19, but not NIHSS ≥20.

      

Design

Study Type: Multicentre randomized controlled trial

Randomization: 1

Blinding: Open-label with blinded outcome assessment

Enrollment Period: January 24 to August 24, 2023

Follow-up Duration: 90 days

Centers: 31

Countries: China

Sample Size: 208

Analysis: Intention-to-treat and modified intention-to-treat; Poisson regression and ordinal logistic regression (adjusted), using STATA 15.0

Inclusion Criteria

Age ≥18 years
NIHSS ≥10
Acute occlusion of vertebral artery (V4), basilar artery, or P1 segment of PCA
Successful endovascular recanalization (eTICI ≥2b50)
Onset-to-recanalization time ≤24 hours

Exclusion Criteria

Prestroke mRS >1
Intracranial hemorrhage on imaging before thrombectomy
pc-ASPECTS <6
Severe renal or hepatic dysfunction
Allergy to tenecteplase

Baseline Characteristics

Characteristic	Control	Active
Age	67.3 ± 10.8	65.0 ± 11.3
Male	70.2%	80.8%
NIHSS	20 (IQR 14–35)	19 (IQR 12–35)
Hypertension	84.6%	70.2%
Diabetes	27.9%	27.9%
Received IVT	24.0%	26.9%

Arms

Field	Tenecteplase	Control
Intervention	Intra-arterial tenecteplase 0.025 mg/kg (max 2.5 mg) infused over 10 seconds post-thrombectomy	Standard care without additional intra-arterial thrombolytic therapy after thrombectomy
Duration	Single administration after recanalization	Standard care

Outcomes

Outcome	Type	Control	Intervention	HR / OR / RR	P-value
Proportion of patients with modified Rankin Scale score 0–1 at 90 days	Primary	26.0%	34.6%	8.60%	0.12
Proportion with mRS 0–2 at 90 days	Secondary	40.4%	38.5%		0.76
Reperfusion (patency on CTA or MRA) at 24–72 hours	Secondary	91.4%	90.0%		0.70
Symptomatic ICH	Adverse	3.1%	8.3%	2.7	0.11
All-cause mortality (90d)	Adverse	26.9%	27.9%	1.04	0.85

Subgroup Analysis

Subgroup analysis showed a higher proportion of mRS 0–1 in the tenecteplase group among patients with baseline NIHSS 10–19 (RR 1.64, 95% CI 1.02–2.62), but not in those with NIHSS ≥20 (RR 0.75, 95% CI 0.38–1.50)

Criticisms

Open-label design may introduce bias despite blinded outcome adjudication
Sample size was relatively small and underpowered for definitive conclusions
Limited generalizability outside Chinese population
Numerical baseline imbalance in hypertension
Lack of perfusion imaging post-intervention to confirm sustained reperfusion

Funding

Funded by Fundamental Research Funds for the Central Universities; sponsor had no role in trial design, data collection, or manuscript writing

Based on: ATTENTION-IA (BMJ, 2025)

Authors: Wei Hu, Chunrong Tao, Li Wang, ..., Xinfeng Liu

Citation: BMJ 2025;388:e080489

Content summarized and formatted by NeuroTrials.ai.

ATTENTION-IA

(2025)

Objective

To assess whether intra-arterial tenecteplase improves functional outcomes in patients with posterior circulation stroke after successful thrombectomy.

Study Summary

• Intra-arterial tenecteplase did not significantly improve excellent outcome at 90 days
• No difference in 90-day mortality compared to control
• Symptomatic ICH was numerically higher with tenecteplase

Intervention

Patients with successful recanalization from posterior circulation stroke were randomized 1:1 to receive either intra-arterial tenecteplase (0.025 mg/kg, max 2.5 mg) or standard care alone, following endovascular thrombectomy.

Inclusion Criteria

Adults with NIHSS ≥10 and occlusion in basilar, vertebral (V4), or P1 PCA segments within 24h of onset and successful recanalization (eTICI 2b50 or higher)

Study Design

Arms: Intra-arterial Tenecteplase (0.025 mg/kg, max 2.5 mg) vs No adjunctive treatment (control)

Patients per Arm: 104 per arm

Outcome

• mRS 0–1 at 90 days: 34.6% (tenecteplase) vs 26.0% (control), RR 1.36, P=0.12
• Symptomatic ICH: 8.3% (tenecteplase) vs 3.1% (control), RR 3.09
• Mortality: 27.9% vs 26.9%, no significant difference

Bottom Line

Major Points

Multicentre, randomized controlled trial of 208 patients with acute posterior circulation stroke and successful endovascular recanalization (eTICI ≥2b50).
Intra-arterial tenecteplase (0.025 mg/kg) did not significantly increase the proportion of patients with mRS 0–1 at 90 days compared with control (34.6% vs. 26.0%; P=0.12).
Symptomatic intracranial hemorrhage occurred more often in the tenecteplase group (8.3% vs. 3.1%; RR 2.70, 95% CI 0.76–9.60).
No significant difference in 90-day mortality (27.9% vs. 26.9%).
Subgroup analysis suggested a potential benefit in patients with NIHSS 10–19, but not NIHSS ≥20.

Study Design

Study Type: Multicentre randomized controlled trial
Randomization: Yes
Blinding: Open-label with blinded outcome assessment
Sample Size: 208
Follow-up: 90 days
Centers: 31
Countries: China

Primary Outcome

Definition: Proportion of patients with modified Rankin Scale score 0–1 at 90 days

Control	Intervention	HR/OR	P-value
26.0%	34.6%	- (0.92 to 2.02)	0.12

Limitations & Criticisms

Open-label design may introduce bias despite blinded outcome adjudication
Sample size was relatively small and underpowered for definitive conclusions
Limited generalizability outside Chinese population
Numerical baseline imbalance in hypertension
Lack of perfusion imaging post-intervention to confirm sustained reperfusion

Citation

BMJ 2025;388:e080489

View Original Publication →

ATTENTION-IA

Intra-arterial tenecteplase after successful endovascular recanalisation in patients with acute posterior circulation arterial occlusion (ATTENTION-IA): multicentre randomised controlled trial

Clinical Question

Bottom Line

Major Points

Design

Inclusion Criteria

Exclusion Criteria

Baseline Characteristics

Arms

Outcomes

Subgroup Analysis

Criticisms

Funding

Ask about ATTENTION-IA