ATTENTION-LATE Shows No Functional Gain From Tenecteplase Bridging in Extended-Window Basilary Artery Occlusion

Late-breaking data from the phase 3 ATTENTION-LATE study (NCT05701956) revealed that intravenous tenecteplase followed by endovascular thrombectomy (EVT) did not improve functional outcomes in patients with basilar artery occlusion (BAO) relative to EVT alone.¹

Presented at the International Stroke Conference (ISC) 2026, held February 4 to 6, 2026, in New Orleans, Louisiana, the trial featured patients with BAO presenting beyond 4.5 hours from stroke onset. In the study, these participants were randomly assigned to either intravenous tenecteplase followed by EVT (n = 166) or EVT alone (n = 164), using modified Rankin Scale (mRS) scores of 0-2 (defined as good outcome) as the primary end point.

All told, at 90 days, functional independence occurred in 50 patients (30.3%) in the tenecteplase-plus-EVT group and 50 (30.5%) patients in the EVT alone group (adjusted rate ratio, 0.92; 95% CI, 0.67-1.25). Presented by study author Rui Li, MD, PhD, of the Stroke Center and Department of Neurology, The First Affiliated Hospital, China, symptomatic intracranial hemorrhage also occurred at a similar rate, with 8 cases (5.1%) in the tenecteplase-plus-EVT group and 6 cases (4.0%) in the EVT-alone group.

In the study, safety outcomes included symptomatic intracranial hemorrhage within 72 hours, and 90-day mortality. Overall, the 2 study groups had similar 90-day mortality rates, with 40.0% (n = 66) in the Tenecteplase-plus-EVT group and 42.7% (n = 70) for the EVT alone group. All told, the study authors concluded that while the combination of intravenous tenecteplase to EVT was safe, it did not result in improved functional outcomes in comparison to EVT alone.

In recent years, EVT has emerged as an evidence-based treatment for acute symptomatic BAO, following results from the ATTENTION (NCT04751708) and BAOCHE randomized trials demonstrating significant clinical benefit in this high-risk posterior circulation stroke population. For context, these findings helped solidify EVT as a standard approach in appropriately selected patients with BAO.

ATTENTION Trial

ATTENTION, published in the New England Journal of Medicine, was a multicenter, randomized, controlled trial based in China that featured patients recruited 12 hours after the estimated time of BAO. Of the 507 patients who underwent screening, 340 were in the intention-to-treat population, with 226 assigned to the thrombectomy group and 114 to the control group. Within this patient population, intravenous thrombolysis was used in 31% of patients in the thrombectomy group and in 34% of those in the control group.²

All told, good functional status, defined as mRS scores of 0 to 2 at 90 days, occurred in 104 patients (46%) in the thrombectomy group and in 26 (23%) in the control group (adjusted rate ratio, 2.06; 95% CI, 1.46-2.91; P <.001). Symptomatic intracranial hemorrhage occurred in 5% of patients in the thrombectomy group compared with none in the control group, while secondary clinical and imaging outcomes generally aligned with the primary findings. At 90 days, mortality was lower among patients who underwent thrombectomy (37%) than in controls (55%), corresponding to an adjusted risk ratio of 0.66 (95% CI, 0.52–0.82).

EXTEND-IA TNK Trial

Prior to ATTENTION, the EXTEND-IA TNK trial (NCT02388061) showed that intravenous tenecteplase is superior to alteplase prior to EVT in anterior circulation large vessel occlusion strokes, raising important questions about optimal bridging strategies. However, whether intravenous tenecteplase combined with EVT offers added benefit over EVT alone in patients with BAO—particularly in the extended treatment window—remained unclear, forming the basis for the ATTENTION LATE study.³

EXTEND-IA TNK, also published in the New England Journal of Medicine, included 202 patients with ischemic stroke who had occlusion of the internal carotid, basilar, or middle cerebral artery and who were eligible to undergo thrombectomy. Patients in the study were randomly assigned to receive tenecteplase (at a dose of 0.25 mg per kilogram of body weight; maximum dose, 25 mg) or alteplase (at a dose of 0.9 mg per kilogram; maximum dose, 90 mg) within 4.5 hours after symptom onset.

In this trial, the primary outcome of reperfusion of greater than 50% of the involved ischemic territory was achieved in 22% of patients treated with tenecteplase compared with 10% of those who received alteplase, reflecting an incidence difference of 12 percentage points (95% CI, 2 to 21) and an incidence ratio of 2.2 (95% CI, 1.1 to 4.4; P = 0.002 for noninferiority; P = 0.03 for superiority). Tenecteplase was also associated with improved 90-day functional outcomes, with a median modified Rankin scale score of 2 vs 3 for alteplase (common odds ratio, 1.7; 95% CI, 1.0 to 2.8; P = 0.04), while symptomatic intracerebral hemorrhage occurred in 1% of patients in each treatment group.

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REFERNCES
1. Li R, Yao X, Nogueira R, et al. Intravenous tenecteplase plus endovascular thrombectomy versus endovascular thrombectomy alone on 4.5 to 24 hours after stroke due to basilar artery occlusion -a multicenter, randomized controlled, clinical Trial (ATTENTION LATE). Presented at: ISC 2026; February 4-6, 2026; New Orleans, LA. Abstract LB011.
2. Tao C, Nogueira RG, Zhu Y, et al. Trial of endovascular treatment of acute basilar-artery occlusion. NEJM. 2022;387(15):1361-1372. doi:10.1056/NEJMoa2206317
3. Campbell BCV, Mitchell PJ, Churilov L, et al. Tenecteplase versus alteplase before thrombectomy for ischemic stroke. NEJM. 2018;378(17):1573-1582. doi:10.1056/NEJMoa1716405