NEW ORLEANS — February 4, 2026 — Infusing the clot-busting medication alteplase at the site of a blocked brain artery immediately after mechanical clot removal may significantly improve stroke recovery, according to preliminary findings from the CHOICE2 trial presented at the American Stroke Association’s International Stroke Conference 2026.
Large-artery ischemic strokes, which account for about one in four ischemic strokes, block major arteries supplying blood to large areas of the brain, often causing death or long-term disability. While mechanical thrombectomy—a minimally invasive procedure to physically remove the clot—is a powerful treatment for these strokes, more than half of patients who undergo successful clot removal do not achieve full recovery by 90 days, said 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.
The CHOICE2 trial enrolled 433 adults (median age 76 years; 51% women) treated at 14 stroke centers in Spain between December 2023 and August 2025. All participants had a large-artery ischemic stroke and underwent successful mechanical thrombectomy within 4.5 to 24 hours of symptom onset. After the procedure, patients were randomized to receive either usual care (219 patients) or usual care plus a 15-minute infusion of alteplase directly into the affected artery (214 patients).
At 90 days, those who received the additional alteplase infusion were significantly more likely to achieve excellent functional outcome (57.5% vs. 42.5%), representing an absolute improvement of 15 percentage points. They also had a lower rate of inadequate blood flow in small brain vessels on imaging (28.6% vs. 50.5%). Furthermore, patients in the alteplase group rated themselves higher in mobility, self-care, and usual activities, and reported less pain, discomfort, anxiety, and depression. The rates of brain bleeding (1.4% vs. 0.5%) and death (12.1% vs. 6.4%) were not statistically 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,” Chamorro said. “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.”
These results build on an earlier CHOICE study published in 2022, which showed similar benefits but was halted early due to the COVID-19 pandemic and included only 121 patients. The current findings also align with other recent trials, such as the ANGEL-TNK trial using tenecteplase and the PEARL trial with alteplase, which reported comparable outcomes.
“These results are practice-informing but not yet practice-changing on their own,” Chamorro noted. “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.” He emphasized that patients with evidence of inadequate microcirculatory blood flow despite large-vessel reopening are most likely to benefit.
The study was limited by its use of non-contrast CT scanning during follow-up, which may not provide detailed information about brain tissue injury and recovery. Although conducted only in Spain, participants came from 20 countries across three continents, suggesting the results are generalizable to many populations. Future research will focus on treating the underlying causes of microcirculatory disruption.
