From 2015 onwards, significant advancements have been made in endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Despite these advancements, patient outcomes remain suboptimal, with fewer than 30% of early presenting, anterior circulation LVO patients achieving a non-disabled outcome after EVT. Persistent regions of distal hypoperfusion and microcirculatory obstruction are likely contributors to these suboptimal recoveries.
The CHOICE randomized trial provided support for the use of intra-arterial thrombolysis after successful EVT, showing improved outcomes in patients with anterior circulation LVOs. However, patients with posterior circulation ischemic stroke, which comprises about 20% of all ischemic strokes and carries a poor prognosis, were excluded from the CHOICE trial.
The ATTENTION-IA trial aims to fill this gap by evaluating the efficacy and safety of intra-arterial tenecteplase following successful EVT in patients with acute posterior circulation large or medium vessel occlusion. This multicenter, prospective, randomized clinical trial plans to recruit 208 patients across 31 comprehensive stroke centers in China over a year. The primary outcome is defined as a modified Rankin Scale (mRS) score of 0-1 at day 90, indicating no or minor symptoms after stroke.
Patients eligible for the trial are adults with a posterior circulation LVO within 24 hours of stroke onset and a National Institutes of Health Stroke Scale (NIHSS) score of ≥6 at the time of neuroimaging. The trial excludes patients with pre-stroke disability >1 on the mRS, intracranial hemorrhage on neuroimaging, and a posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) <6.
After successful reperfusion, patients will be randomized to receive either intra-arterial tenecteplase or no additional intra-arterial adjunctive therapy. The study will assess various outcomes, including functional outcomes, safety outcomes, and radiologic outcomes, with an independent Data Safety and Monitoring Board overseeing the trial's conduct.
The ATTENTION-IA trial represents a significant step forward in stroke treatment, particularly for patients with posterior circulation occlusions, by exploring the potential benefits of intra-arterial tenecteplase in improving patient outcomes after EVT.
