POST-TNK
(2025)Objective
POST-TNK evaluated whether adjunct intra-arterial tenecteplase following near-complete to complete reperfusion after thrombectomy could improve disability-free outcome in large vessel occlusion stroke.
Study Summary
• Slight increase in intracranial hemorrhage with tenecteplase
• No difference in mortality or symptomatic ICH
Intervention
Randomized, open-label, blinded outcome trial comparing intra-arterial tenecteplase (0.0625 mg/kg) vs. no thrombolysis after endovascular thrombectomy in 540 patients with LVO stroke across 34 hospitals in China.
Inclusion Criteria
LVO stroke with eTICI 2c–3 post-thrombectomy, no prior IV thrombolysis, age ≥18, NIHSS ≤25, ASPECTS ≥6 (or DEFUSE 3/DAWN eligible)
Study Design
Arms: Intra-arterial tenecteplase vs. control (no intra-arterial thrombolysis)
Patients per Arm: 269 tenecteplase, 271 control
Outcome
• Any ICH higher with tenecteplase (36.6% vs 27.3%, P=0.02)
• Symptomatic ICH: 6.3% vs 4.4% (NS); mortality: 16.0% vs 19.3% (NS)
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%)
Study Design
- Study Type
- Randomized, open-label, blinded outcome trial
- Randomization
- Yes
- Blinding
- Outcome assessors were blinded; treating physicians were not
- Sample Size
- 540
- Follow-up
- 90 days
- Centers
- 34
- Countries
- China
Primary Outcome
Definition: mRS 0–1 at 90 days
| Control | Intervention | HR/OR | P-value |
|---|---|---|---|
| 44.1% | 49.1% | - (0.97–1.36) | 0.11 |
Limitations & 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
Citation
JAMA. 2025;333(7):579-588. doi:10.1001/jama.2024.23466