TASTE Trial: Tenecteplase vs Alteplase with Perfusion-Imaging Selection
In perfusion-imaging selected patients with acute ischemic stroke within 4.5 hours not proceeding to EVT, is IV tenecteplase 0.25 mg/kg non-inferior to IV alteplase 0.9 mg/kg for excellent functional outcome (mRS 0-1) at 3 months?
TASTE Investigators (Lancet Neurol 2024) · 680 patients
Population
Included
- Acute ischemic stroke within 4.5 hours or last known well
- Aged 18 or older
- Not being considered for EVT
- Target mismatch on brain perfusion imaging (CT or MRI)
- Aged 18 years or older
- Within 4.5 hours of symptom onset or last known well
- Eligible to receive intravenous thrombolytic treatment
- Brain imaging confirming the presence of an acute ischaemic stroke
- CT-perfusion target mismatch: a mismatch ratio greater than 1.8 between the perfusion lesion (delay time threshold greater than 3 s) and the ischaemic core lesion (relative cerebral blood flow less than 30% of normal brain)
- An absolute mismatch difference greater than 15 mL
- An ischaemic core lesion volume less than 70 mL
- A volume of severely hypoperfused tissue (delay time greater than 8 s) less than 100 mL
Excluded
- Planned endovascular thrombectomy
- Contraindication to IV thrombolysis
- Large established infarct core on perfusion imaging
- Presence of intracranial haemorrhage identified on baseline imaging
- A pre-stroke modified Rankin Scale score of 2 or greater
- An extracranial or intracranial occlusion for which endovascular therapy could be delivered within an appropriate timeframe
- A standard contraindication to thrombolytics
Source: Parsons MW et al. (TASTE), Lancet Neurol 2024;23:775-786· Retrieved 2026-06-09
Primary Outcome
Small absolute difference — interpret with caution
mRS 0-1 at 3 Months (ITT)
Study Arms
- Agent
- Tenecteplase
- Dose
- 0.25 mg/kg (maximum 25 mg)
- Route
- IV
- Frequency
- Single bolus
- Duration
- One-time
- Co-interventions
- All treatments were guided by local protocols for the standard of care for acute ischaemic stroke. Patients selected by CT-perfusion target mismatch and not being considered for endovascular thrombectomy.
Non-inferiority margin was a standardised risk difference of -0.03 for mRS 0-1 at 3 months. Non-inferiority was established in the per-protocol population (57% vs 55%, SRD 0.05, 95% CI -0.02 to 0.12, one-tailed p=0.01) but was NOT reached in the intention-to-treat population (SRD 0.03, 95% CI -0.033 to 0.10, one-tailed p=0.031), because the lower confidence bound crossed the -0.03 margin. The trial stopped early at 680 of a planned 832 participants. TASTE did not establish a benefit of tenecteplase over alteplase; it provides supportive, not definitive, non-inferiority evidence.
- Agent
- Alteplase
- Dose
- 0.9 mg/kg (maximum 90 mg)
- Route
- IV
- Frequency
- Initial bolus of 0.09 mg/kg, then a 60-min infusion of the remaining 0.81 mg/kg
- Duration
- 60 minutes
Safety
Symptomatic intracranial hemorrhage
3%
2%
sICH was similar between arms (3% vs 2%, unadjusted RD 0.01, 95% CI −0.01 to +0.03). Mortality at 90 days: 7% tenecteplase vs 4% alteplase.
Trial Design
Type
- International, multicenter, open-label noninferiority trial
- Perfusion-imaging selected early-window stroke
- Tenecteplase 0.25 mg/kg vs alteplase 0.9 mg/kg
Timeline
Eight countries; March 2014 to October 2023
N
680
Enrollment
680 patients at multiple centers in 8 countries. International multicenter NI RCT. March 2014 to October 2023. Published Lancet Neurol 2024.
Bedside Pearl
TASTE supports tenecteplase in perfusion-selected early-window stroke (per-protocol NI met, ITT borderline). This does not change practice. Tenecteplase is already endorsed based on larger, cleaner trials (AcT, TRACE-2). TASTE is relevant for centers considering perfusion-CT-guided patient selection for thrombolysis, where it confirms feasibility.