Intra-Arterial Alteplase Safe but Fails to Improve Functional Outcome After Basilar Artery Recanalization: JAMA
China: Researchers have found in a randomized clinical trial that intra-arterial alteplase given after successful endovascular recanalization was safe, but did not improve functional outcomes at 90 days among patients with posterior circulation stroke due to acute basilar artery occlusion.
The study, published in JAMA Neurology, was led by Wenhuo Chen from the Department of Cerebrovascular Disease at Fujian Medical University Union Hospital, China, along with collaborators across multiple stroke centers. The trial aimed to clarify whether adding intra-arterial thrombolysis after a technically successful thrombectomy could enhance recovery in patients with acute ischemic stroke involving the posterior circulation.
For this purpose, the researchers conducted a multicenter, prospective, randomized clinical trial across 37 comprehensive stroke centers in China. Adults presenting within 24 hours of symptom onset with acute basilar artery occlusion who achieved successful recanalization after endovascular thrombectomy were included. Participants were randomly assigned to receive either intra-arterial alteplase or standard care without additional thrombolysis. Alteplase was administered at a dose of 0.225 mg/kg (maximum 22.5 mg) over 15 minutes.
The primary outcome assessed was functional independence at 90 days, defined by a modified Rankin Scale score of 0 to 2. Safety endpoints included mortality at 90 days and the occurrence of symptomatic intracranial hemorrhage within 48 hours. A total of 246 patients were analyzed, with roughly equal distribution between the treatment and control groups.
The trial revealed the following findings:
- Functional independence at 90 days was achieved in 41.9% of patients receiving intra-arterial alteplase compared to 46.7% in the control group, showing no significant benefit.
- Mortality rates at 90 days were similar between the two groups (29.6% vs 27.0%).
- The incidence of symptomatic intracranial hemorrhage was low and nearly identical in both groups.
- These findings support the safety of adjunctive intra-arterial alteplase in this setting.
- Intra-arterial alteplase may improve distal vessel reperfusion.
- However, improved reperfusion did not translate into better functional outcomes at three months.
The study has certain limitations. Its open-label design could introduce bias, although blinded outcome evaluation was implemented to reduce this risk. A substantial proportion of participants had intracranial atherosclerosis requiring additional interventions such as angioplasty or stenting, which may have influenced outcomes. Additionally, the expected treatment benefit used for sample size estimation may have been overly optimistic, limiting the ability to detect smaller differences. The trial also included fewer female participants and was conducted exclusively in China, which may affect generalizability.
Overall, the results suggest that while intra-arterial alteplase after successful thrombectomy appears safe, it does not significantly enhance functional recovery in patients with posterior circulation stroke due to basilar artery occlusion. These findings provide important guidance for clinicians managing complex stroke cases and highlight the need for further research to optimize post-thrombectomy strategies.
Reference:
Chen W, Yang B, Bai X, et al. Intra-arterial Alteplase Thrombolysis After Successful Thrombectomy for AIS in the Posterior Circulation: The IAT-TOP Randomized Clinical Trial. JAMA Neurol. Published online April 24, 2026. doi:10.1001/jamaneurol.2026.1074
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