Adjunctive Intra-Arterial Alteplase Following Thrombectomy Evaluated in Clinical Trial
KEY TAKEAWAYS
- Adjunctive treatment with alteplase after successful thrombectomy increased the proportion of individuals achieving excellent functional outcomes at 90 days after acute ischemic stroke.
- Symptomatic intracranial hemorrhage was uncommon and not significantly increased, but higher mortality in the alteplase group warrants further study.
Adjunctive intra-arterial treatment with Activase (alteplase; Genentech, South San Francisco, CA) after successful endovascular thrombectomy (EVT) was associated with improved functional outcomes vs EVT alone after 90 days for individuals with acute ischemic stroke due to large vessel occlusion (LVO). Results from the phase 3 CHOICE-2 clinical trial (NCT05797792), published in JAMA, suggest that treatment was not linked to a statistically significant increase in symptomatic intracranial hemorrhage, although mortality was higher in the Activase group, highlighting the need for further investigation.
CHOICE-2 was a randomized, open-label, multicenter trial conducted across 14 stroke centers in Spain. In the study, 440 participants with acute ischemic stroke due to LVO who received a successful EVT, defined as an expanded Treatment in Cerebral Ischemia score of 2b50 to 3, were randomized to receive Activase in addition to EVT (0.225 mg/kg; maximum dose, 20 mg/kg) infused over 15 minutes (n=221) or EVT alone (n=219). The primary end point was excellent functional outcome at 90 days, defined as a modified Rankin Scale (mRS) score of 0 or 1.
Key Findings
- At 90 days, excellent functional outcome scores were more common with adjunctive Activase treatment than EVT alone (57.5% vs 42.5%; adjusted risk difference, 15.0%; 95% CI, 5.7% to 24.3%; P=.002).
- Residual hypoperfusion on follow-up CT perfusion imaging was less frequent in the Activase group (28.6% vs 50.5%; adjusted risk difference, -22.0%; 95% CI, -31.5% to -12.4%; P<.001).
- Symptomatic intracranial hemorrhage occurred more commonly in participants treated with adjunctive Activase than those receiving EVT alone, although the difference was not statistically significant (1.4% vs 0.5%; adjusted odds ratio, 3.10; 95% CI, 0.32 to 30.0; P=.33).
- Mortality at 90 days was higher with adjunctive Activase than with EVT alone (12.1% vs 6.4%; adjusted risk difference, 5.9%; 95% CI, 0.5% to 11.3%; P=.03).
Source
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