Giving the clot-busting medication alteplase at the site of a blocked brain artery after blood clot removal may increase the number of patients who fully recover, according to preliminary late-breaking science presented at the American Stroke Association’s International Stroke Conference 2026.
Large-artery ischemic (clot-caused) strokes account for about one in four ischemic strokes, according to study author Ángel Chamorro, M.D., Ph.D., professor of neurology at the University of Barcelona and head of the Comprehensive Stroke Center Hospital Clinic in Barcelona. These types of strokes can cause death and long-term disability because they block large arteries that supply blood to significant areas of the brain.
The 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke, from the American Stroke Association, a division of the American Heart Association, notes that removing clots directly from blocked brain arteries, a procedure called thrombectomy, is a powerful treatment for major strokes caused by large-vessel blockages in select patients.
“However, more than half of stroke survivors who have their large artery successfully cleared do not achieve full recovery 90 days later,” Chamorro said. “Stroke treatment continues to improve, and getting the right care quickly can make a real difference in a patient’s recovery and return to their everyday life. Even when doctors successfully reopen a blocked brain artery, novel treatment strategies such as adding alteplase to thrombectomy can further improve outcomes after a stroke.”
In the CHOICE2 trial reported at the conference, more than 400 adults with large-artery ischemic stroke were treated at stroke centers in Spain within 4.5 to 24 hours of their first stroke symptoms, making it possible to both remove the clot in the large artery and to have the option of treatment with alteplase to the same location immediately afterward. Patients were randomized to receive either clot removal (219 people) or clot removal plus infusion of alteplase into the artery (214 people).
At 90 days after treatment, participants who received clot-busting medication in addition to clot removal:
- were significantly more likely to achieve excellent functional outcome (57.5% vs. 42.5%), with an absolute improvement of 15 percentage points;
- were less likely (28.6% vs. 50.5% for those treated with only thrombectomy) to have inadequate blood flow in small vessels of the brain revealed by imaging, with a decline of 22 percentage points;
- rated themselves higher in mobility, self-care, performing usual activities, lower pain/discomfort and depression/anxiety;
- and were not significantly more likely to have a brain bleed (1.4% vs. 0.5%) or to die (12.1% vs. 6.4%).
“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. Intra-arterial alteplase given after a successful thrombectomy significantly increased the chances of an excellent recovery,” Chamorro said.
In an earlier study, preliminary results from CHOICE, published in 2022, revealed significantly better outcomes in stroke survivors who were treated with alteplase in addition to thrombectomy. However, the number of patients in the study was relatively small (121), and the trial was halted early due to the COVID-19 pandemic, which interfered with patient recruitment and the supply of placebos.
Similar research (the ANGEL-TNK trial) that used the clot-dissolving agent tenecteplase was presented last year at the International Stroke Conference and had comparable results. The PEARL trial used alteplase and had comparable results.
The limitations of this study include the requirement for non-contrast CT scanning during the follow-up period, which reflects real-world clinical practice but may not provide detailed information about brain tissue injury and recovery.
Although the study was conducted only in Spain, participants were from 20 countries across three continents; therefore, the results should be generalizable to many populations.
“These results are practice-informing but not yet practice-changing on their own,” Chamorro said. “While CHOICE2 strengthens the evidence that intra-arterial alteplase given after successful thrombectomy can improve recovery, broader adoption will require confirmation in additional studies, guideline review and careful consideration of patient selection.
“Importantly, this approach should not be viewed as a ‘one-size-fits-all’ treatment. It is most likely to benefit patients who—despite large-vessel reopening—have evidence of inadequate blood flow in their microcirculation. However, if future studies and meta-analyses confirm the safety of this strategy, it may eventually reduce the need to rely on advanced imaging techniques to identify patients with persistent perfusion abnormalities appropriate for this treatment.”
In addition to confirming the findings of CHOICE2, future research will focus on ways to treat the underlying causes leading to the disruption of blood flow in the microcirculation.
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