Intra-arterial alteplase after successful EVT yields excellent functional outcome in adults

The use of intra-arterial (IA) alteplase following a successful endovascular thrombectomy (EVT) improves 90-day functional outcome in patients with large-vessel occlusion (LVO) acute ischaemic stroke compared with EVT-alone, according to the CHOICE 2* trial presented at ISC 2026.

After treatment, significantly more patients who received IA alteplase after thrombectomy achieved excellent function outcome, defined as a modified Rankin Scale score of 0–1 at day 90, than those who underwent EVT only (57.5 percent vs 42.9 percent; adjusted risk difference [aRD], 15 percent; p=0.002). [ISC 2026, abstract LB001]

“Mechanical thrombectomy alone is often not enough to fully restore blood flow to the injured brain, even when the blocked artery appears successfully reopened. Standard imaging can miss persistent blockages in the brain’s smallest blood vessels. IA alteplase given after a successful thrombectomy significantly increased the chances of an excellent recovery,” said lead investigator Dr Ángel Chamorro from the Hospital Clinic of Barcelona & University of Barcelona, Spain.

He further emphasized that ”CHOICE 2 is a positive clinical trial.”

CHOICE 2 is a phase III, multicentre, open-label trial that included 440 adults with LVO acute ischaemic stroke who were randomized in a 1:1 ratio to receive either EVT with IA alteplase (n=214, mean age 77 years) or EVT alone (n=219, mean age 75 years).

At follow-up, a significantly lower percentage of patients had abnormal hypoperfusion on brain CT perfusion performed at 36 hours in the alteplase group compared with the EVT-alone group (29 percent vs 51 percent; aRD, -22 percent; p<0.001).

Also, patients’ self-reported quality of life, assessed using the EQ-5D-5L** questionnaire at 90 days, was significantly improved with alteplase and EVT compared with EVT alone (0.9 vs 0.8; p=0.02).

However, no significant difference in Barthel Index score of 95–100 points at day 90 (64 percent vs 58 percent; p=0.28) was observed between the alteplase and EVT-alone groups.

In terms of safety, the rate of symptomatic intracerebral haemorrhage (sICH) was 1.4 percent in the active group and 0.5 percent in the control group, with mortality rates of 12.1 percent and 6.1 percent, respectively. Chamorro stated that the risk of serious bleeding and mortality for both groups was very low.

Overall, IA alteplase after successful thrombectomy was associated with increased rates of excellent functional outcome at day 90, reduced rates of persistent hypoperfusion, and no increased risk of sICH. This supports its use in appropriately selected patients, said Chamorro.