A new study suggests that administering the clot-busting medication alteplase directly into the brain artery after mechanical clot removal may significantly improve recovery for patients with large-artery ischemic stroke. The findings, presented at the American Stroke Association’s International Stroke Conference 2026, indicate that this two-pronged approach could increase the number of patients who achieve excellent functional outcomes.
Large-artery ischemic strokes account for about 1 in 4 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 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 notes that thrombectomy—a procedure to remove clots directly from blocked brain arteries—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, 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. Patients were randomized to receive either clot removal alone (219 people) or clot removal plus infusion of alteplase into the artery (214 people). At 90 days after treatment, participants who received both treatments were significantly more likely to achieve excellent functional outcome (57.5% vs. 42.5%) and less likely to have inadequate blood flow in small vessels of the brain (28.6% vs. 50.5%). They also rated themselves higher in mobility, self-care, and other quality-of-life measures. The rates of brain bleed (1.4% vs. 0.5%) and death (12.1% vs. 6.4%) were not significantly different between groups.
“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 successful thrombectomy significantly increased the chances of an excellent recovery,” Chamorro said.
An earlier study, CHOICE, published in 2022, revealed significantly better outcomes in stroke survivors treated with alteplase in addition to thrombectomy, but the trial was halted early due to the COVID-19 pandemic. Similar research (the ANGEL-TNK trial) using tenecteplase and the PEARL trial using alteplase had comparable results.
Limitations of this study include the requirement for non-contrast CT scanning during follow-up, which may not provide detailed information about brain tissue injury. Although the study was conducted only in Spain, participants were from 20 countries across three continents, so the results should be generalizable to many populations. “These results are practice-informing but not yet practice-changing on their own,” Chamorro said. “Broader adoption will require confirmation in additional studies, guideline review and careful consideration of patient selection.”
