CHOICE2
(2026)Objective
To evaluate whether intra-arterial alteplase infusion after successful mechanical thrombectomy improves functional outcomes in patients with large-artery ischemic stroke.
Study Summary
• Intra-arterial alteplase after successful thrombectomy significantly increased excellent functional outcome at 90 days (57.5% vs 42.5%, absolute difference 15%)
• Reduced inadequate microvascular perfusion on imaging (28.6% vs 50.5%)
• No significant increase in symptomatic ICH (1.4% vs 0.5%); mortality numerically higher but not statistically significant (12.1% vs 6.4%)
• Confirms findings of the earlier smaller CHOICE trial and aligns with ANGEL-TNK and PEARL results
• Reduced inadequate microvascular perfusion on imaging (28.6% vs 50.5%)
• No significant increase in symptomatic ICH (1.4% vs 0.5%); mortality numerically higher but not statistically significant (12.1% vs 6.4%)
• Confirms findings of the earlier smaller CHOICE trial and aligns with ANGEL-TNK and PEARL results
Intervention
Intra-arterial alteplase infused over 15 minutes directly into the affected artery after successful thrombectomy vs thrombectomy alone (usual care)
Inclusion Criteria
Adults with large-artery ischemic stroke, treated within 4.5–24 hours of symptom onset, successful arterial recanalization after thrombectomy, no prior serious neurological disability, no very severe stroke
Study Design
Arms: Thrombectomy + intra-arterial alteplase vs Thrombectomy alone
Patients per Arm: 214 intervention, 219 control
Outcome
• Excellent functional outcome (mRS 0–1) at 90 days: 57.5% alteplase vs 42.5% control (absolute difference 15 percentage points)
• Inadequate microvascular perfusion: 28.6% vs 50.5% (22 percentage point reduction)
• Symptomatic ICH within 24h: 1.4% vs 0.5% (not significant); death at 90 days: 12.1% vs 6.4% (not significant)
• Inadequate microvascular perfusion: 28.6% vs 50.5% (22 percentage point reduction)
• Symptomatic ICH within 24h: 1.4% vs 0.5% (not significant); death at 90 days: 12.1% vs 6.4% (not significant)