Basilar Artery Occlusion Stroke Managed With Tenecteplase Versus Alteplase Before Endovascular Treatment (BAO‐TNK)

OBJECTIVE: To compare the effectiveness and safety of tenecteplase (TNK) versus alteplase (TPA) in patients with basilar artery occlusion prior to endovascular treatment (EVT). METHODS: In this retrospective multicenter study (BAO-TNK), we analyzed consecutive BAO patients from 14 U.S. stroke systems who received TNK or TPA within 4.5 h of last known well and were referred for EVT (01/2020-08/2024). Multivariable logistic regression models were adjusted for age, sex, NIH Stroke Scale (NIHSS), posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS), last-known-well-to-door time, and stroke etiology. Outcomes included 90-day modified Rankin Scale (mRS), reperfusion rates, and intracranial hemorrhage (ICH) per Heidelberg classification. RESULTS: Of 163 BAO patients, 75 (46.0%) received TNK and 88 (54.0%) received TPA. Rates of 90-day good functional outcome (mRS 0-3) were comparable between groups (TNK: 61.8% vs. TPA: 48.8%, adjusted odds ratio [aOR] 1.372, 95% CI 0.616-3.054, p = 0.439). No significant differences were observed in rates of pre-thrombectomy early reperfusion (18.7% vs. 14.8%, aOR 0.933, 95% CI 0.369-2.359, p = 0.884), post-thrombectomy final reperfusion (97.3% vs. 92.0%, aOR 2.133, 95% CI 0.376-12.116, p = 0.393), 90-day mortality (32.4% vs. 39.5%, aOR 0.989, 95% CI 0.436-2.244, p = 0.979), or symptomatic ICH (4.0% vs. 4.5%, aOR 1.319, 95% CI 0.245-7.114, p = 0.747). Predictors of favorable outcome included younger age, lower NIHSS, higher pc-ASPECTS, shorter LKW-to-puncture time, and non-atherothrombotic stroke etiology. INTERPRETATION: In BAO stroke, TNK and TPA administered within 4.5 h pre-EVT were associated with similar functional outcomes, reperfusion success and hemorrhage rates.