Giving the clot-busting medication alteplase at the site of a blocked brain artery after blood clot removal may increase the number of patients who fully recover, according to preliminary late-breaking science presented at the American Stroke Association’s International Stroke Conference 2026. The meeting, held Feb. 4-6, 2026, in New Orleans, highlights research that could change stroke treatment protocols.
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 from the American Stroke Association notes that removing clots directly from blocked brain arteries, a procedure called thrombectomy, 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. 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 the combination therapy were significantly more likely to achieve excellent functional outcome (57.5% vs. 42.5%), an absolute improvement of 15 percentage points. They also were less likely to have inadequate blood flow in small vessels of the brain (28.6% vs. 50.5%) and reported better quality of life in mobility, self-care, and usual activities.
“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.
Safety outcomes showed no significant increase in brain bleeds (1.4% vs. 0.5%) or death (12.1% vs. 6.4%) with the combination therapy. The study builds on earlier research, including the CHOICE trial published in 2022, which showed similar benefits but was smaller and halted early due to the COVID-19 pandemic. Similar results were seen in the ANGEL-TNK trial using tenecteplase and the PEARL trial using alteplase.
Limitations include the use of non-contrast CT scanning during follow-up, which may not provide detailed information about brain tissue injury. Although conducted only in Spain, participants from 20 countries across three continents suggest generalizability. “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.”
