Intra-Arterial Alteplase After Thrombectomy May Improve large vessel Stroke Recovery: JAMA

To evaluate the influence of microvascular obstructions on patient recovery, an investigator was going to conduct an open-labeled study in which patients were randomly enrolled, but outcomes were evaluated blindly. Performed from December 11, 2023, until November 26, 2025, the study involved 3,786 patients with stroke, who had been successfully subjected to mechanical thrombectomy within 24 hours since the symptoms started. Since the aim was to examine the effect of the medicine on microvascular circulation, only patients with angiographically successful thrombectomy, that is, eTICI 2b50 to 3, could participate in the trial.

Out of 3,786 patients, only 440 people could be included. These people have undergone randomization on a 1:1 ratio. Specifically, 221 patients (the intervention group) were treated via successful mechanical thrombectomy along with administration of intra-arterial alteplase (0.225 mg/kg or up to a max dose of 20 mg for 15 min). Another 219 participants (control group) experienced mechanical thrombectomy only. The primary efficacy criterion of this study was considered an excellent function recovery, which is indicated by the mRS score of 0 or 1.

Key findings:

• By day 90, 57.5% (123/214) of patients in the alteplase group had an mRS score of 0 or 1, as opposed to 42.5% (93/219) patients in the thrombectomy-only group.
• The difference is statistically significant with an adjusted risk difference of 15.0% (95% CI, 5.7% to 24.3%; P = 0.002).
• In follow-up computed tomography (CT) perfusion scans, residual hypoperfusion was seen in 28.6% (55/192) of patients in the alteplase group as against 50.5% (96/190) in the control group.
• The difference resulted in a significant adjusted risk difference of −22.0% (P < 0.001).
• There was no significant difference noted in severe bleeding complications, which happened in 1.4% (3/214) of patients in the alteplase group, whereas 0.5% (1/219) of patients suffered from severe bleeding in the control group (adjusted odds ratio, 3.10; 95% CI, 0.32 to 30.0; P = 0.33).
• Death rate within 90 days was considerably higher at 12.1% (26/214) among the alteplase group as against 6.4% (14/219) patients in the control group with an adjusted risk difference of 5.9% (95% CI, 0.5% to 11.3%; P = 0.03).

Conclusively, this study has shown that in cases where successful mechanical reperfusion is achieved in patients suffering from acute ischemic stroke, the administration of intra-arterial alteplase in addition produces a marked improvement in the proportion of individuals attaining a favorable functional status within 90 days without a statistically significant increase in the incidence of symptomatic intracranial hemorrhage. The marked improvement of a 15% absolute value in individuals gaining their full independence from their condition is sufficient proof that mechanical removal of the clot is not enough.

Reference:

Renú A, Fernández-Couto MD, de la Riva P, et al. Adjunctive Intra-Arterial Alteplase After Successful Thrombectomy for Acute Ischemic Stroke: The CHOICE-2 Randomized Clinical Trial. JAMA. Published online May 07, 2026. doi:10.1001/jama.2026.5164