Abstract Body: Background and Aims
Recent studies have questioned the benefit of IV thrombolysis with alteplase before mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). Other studies suggested that tenecteplase (TNK) before MT might provide higher recanalization rates than alteplase.

Methods
Randomized, prospective, multicenter, placebo-controlled clinical trial in patients with AIS due to LVO of the anterior circulation (ICA, MCA-M1, or MCA-M2) below 4.5 hours from symptoms onset. Randomization is 1:1 according to reperfusion treatment modalities: (A) direct mechanical thrombectomy (placebo-controlled) vs. (B) Intravenous thrombolysis with TNK (0.25 mg/kg) plus mechanical thrombectomy. The primary outcome is the ordinal distribution from the modified Rankin scale (mRS) at 90 days.

Results
The study recruitment is ongoing, with the final analysis planned for late 2026. The study includes 390 patients with completed 90-day follow-ups. Enrollment is ongoing at 15 sites. Until October 2024, 172 patients have been enrolled.

Conclusion
The RESILIENT DIRECT TNK trial will evaluate the hypothesis that in AIS patients with anterior LVO < 4.5 hours of symptoms, MT preceded by TNK is superior to MT alone, achieving more favorable outcomes measured by mRS scores at 90 days. This study is supported by Boehringer Ingelheim (BI) and Medtronic for providing the drug/placebo and devices, respectively. BI and Medtronic have no role in the results' design, analysis, or interpretation. BI was allowed to review the manuscript for medical and scientific accuracy and intellectual property considerations. This research is funded through PROADI-SUS, Hospital Moinhos de Vento. ClinicalTrials.gov registry: NCT05199194.