Administering the clot-busting medication alteplase directly into a brain artery immediately after successful mechanical clot removal may substantially improve recovery outcomes for patients suffering from large-artery ischemic strokes, according to preliminary findings from the CHOICE2 trial presented at the American Stroke Association's International Stroke Conference 2026. This two-pronged treatment approach addresses a critical gap in stroke care, where more than half of patients who undergo successful thrombectomy do not achieve full recovery within 90 days despite the artery being reopened.
The Phase 3 trial, conducted at 14 stroke centers in Spain between December 2023 and August 2025, involved 433 adults with a median age of 76 who experienced ischemic strokes in large brain arteries. All participants received mechanical thrombectomy with successful restoration of blood flow. Researchers then randomized patients to receive either standard care (219 patients) or standard care plus a 15-minute infusion of alteplase directly into the affected artery (214 patients). The results showed that patients receiving the combined treatment were significantly more likely to achieve excellent functional outcomes at 90 days—57.5% compared to 42.5% in the thrombectomy-only group, representing a 15 percentage point absolute improvement.
Study author Ángel Chamorro, M.D., Ph.D., professor of neurology at the University of Barcelona, explained that "mechanical thrombectomy alone is often not enough to fully restore blood flow to the injured brain, even when the blocked artery appears successfully reopened." The research revealed that patients receiving intra-arterial alteplase after thrombectomy were less likely to have inadequate blood flow in the brain's smallest vessels (28.6% versus 50.5%), reported higher quality of life across multiple domains including mobility and self-care, and did not show significantly increased risk of brain bleeds (1.4% versus 0.5%) or death (12.1% versus 6.4%).
These findings build upon earlier research, including the initial CHOICE trial published in 2022 and similar studies like the ANGEL-TNK and PEARL trials, which used different clot-dissolving agents. The American Stroke Association's 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke already recognizes thrombectomy as a powerful treatment for select patients with large-vessel blockages. Large-artery ischemic strokes account for approximately one-quarter of all ischemic strokes and can cause significant death and long-term disability by blocking arteries that supply blood to substantial brain areas.
Despite the promising results, Chamorro cautioned that "these results are practice-informing but not yet practice-changing on their own." The study has limitations, including its reliance on non-contrast CT scanning during follow-up, which reflects real-world practice but may not provide detailed information about brain tissue injury. Additionally, while participants came from 20 countries across three continents, the trial was conducted exclusively in Spanish centers. Broader adoption of this approach will require confirmation in additional studies, guideline review, and careful patient selection, particularly for those with evidence of inadequate microcirculation blood flow despite large-vessel reopening.
Future research will focus on treating the underlying causes of microcirculation disruption and confirming the safety of this strategy across diverse populations. If validated, this approach could eventually reduce reliance on advanced imaging techniques to identify patients who would benefit most from combined treatment. According to the American Heart Association's 2026 Heart Disease and Stroke Statistics, stroke remains a leading cause of death and serious disability worldwide, making advancements in treatment recovery critically important for public health.
