| Stroke  

Effect of Intra-arterial Alteplase after Angiographically Successful Thrombectomy

A randomized clinical trial of alteplase administered after endovascular stroke treatment showed a statistically significant benefit toward favourable outcomes.

The CHOICE trial investigated a very important and perhaps somewhat overlooked topic in acute stroke treatment, namely the impairment of microcirculation following successful large vessel recanalization in their recently published paper. [1]

The study in question was a Phase 2b randomized clinical trial of intraarterial alteplase vs placebo administered after successful angiographic recanalization of acute large vessel ischemic stroke.

113 patients with acute ischemic stroke successfully recanalized with endovascular treatment (eTICI 2b-3) were included in this study. Exclusion criteria included known contraindications to the use of alteplase (except the time to onset). The active arm of the trial received intraarterial alteplase at a dose of 0.225 mg/kg (max. 22.5 mg) over 15 to 30 minutes. It must be mentioned that the planned enrolment should have included 100 patients per treatment arm but the trial was stopped early because of difficulties secondary to the COVID-19 pandemic and thus only ~60% of planned enrolment was achieved.

Nevertheless, the results of the trial showed a statistically significant difference in favourable outcome (defined as mRS 0-1 three months post-stroke) in the alteplase group with no significant difference in adverse events. 

While still a preliminary finding, owing to the study limitations and early termination, the study supports the concept of treatment with additional intra-arterial alteplase directly after successful endovascular recanalization. While larger future trials are necessary before establishing this concept outside of clinical studies, targeting microcirculation in large vessel occlusion stroke appears to be very worthwhile.