Intra-arterial Alteplase vs Placebo After Successful Thrombectomy and Functional Outcomes in Patients With Large Vessel Occlusion Acute Ischemic Stroke—Reply

Advances in Futile Reperfusion following Endovascular Treatment in Acute Ischemic Stroke due to Large Vessel Occlusion

“…Angiographic and microvascular reperfusion amelioration using glycoprotein IIb/IIIa receptor inhibitors such as eptifibatide has been proven safe and effective when combined with MT for patients with AIS due to LVO [71]. More recently, the CHOICE (Chemical Optimization of Cerebral Embolectomy) trial demonstrated the preliminary efficacy of adjunct intra-arterial alteplase compared with placebo to improve functional independence (a score of 0 or 1 on the mRS) at 90 days among AIS patients with post-thrombectomy eTICI score of 2b50 or greater (adjusted risk difference, 18.4%; 95% CI 0.3–36.4%; p = 0.047), thus suggesting another promising preventive strategy for FR [72]. The ongoing prospective, single-arm, pilot study INSIST-CT (Improving Neuroprotective Strategy for Ischemic Stroke With Sufficient Recanalization After Thrombectomy by Intra-arterial Cocktail Therapy, NCT04202549) trial will explore the safety, feasibility, and efficacy of thrombectomy with sufficient recanalization (TICI 2b–3) bridged by intra-arterial cocktail therapy of a combination of argatroban, dexamethasone, and edaravone in AIS patients to prevent artery re-occlusion, hemorrhagic transformation, and no-reflow phenomenon.…”

Evolving Stroke Systems of Care: Stroke Diagnosis and Treatment in the Post-Thrombectomy Era

“…Another clinical question being investigated is whether thrombolytics administered after thrombectomy are beneficial in stroke patients with large-vessel occlusions [61]. The impetus for this clinical question is the observation that only 27% of people treated with thrombectomy were disability free at 90 days, despite 71% of patients achieving adequate reperfusion [7].…”

“…The impetus for this clinical question is the observation that only 27% of people treated with thrombectomy were disability free at 90 days, despite 71% of patients achieving adequate reperfusion [7]. This "no reflow" phenomenon may be due to lack of reperfusion of the microvasculature distal to the site of the thrombus, despite large arterial recanalization [61,62]. The CHOICE trial was a randomized, double-blind, placebo-controlled multicenter study investigating whether thrombolytics after thrombectomy improve functional outcomes [61].…”

“…This "no reflow" phenomenon may be due to lack of reperfusion of the microvasculature distal to the site of the thrombus, despite large arterial recanalization [61,62]. The CHOICE trial was a randomized, double-blind, placebo-controlled multicenter study investigating whether thrombolytics after thrombectomy improve functional outcomes [61].…”

Intra-arterial Thrombolysis to Target Occlusions in Distal Arteries and the Microcirculation

“…In this issue of JAMA , Renú and colleagues report results from a phase 2b, randomized, double-blind, placebo-controlled, multicenter trial, CHOICE, which was designed to test the safety and preliminary efficacy of intra-arterially administered thrombolysis using alteplase immediately after successful thrombectomy. Successful thrombectomy was defined as greater than 50% reperfusion of the visualized downstream arterial distribution of the initial arterial occlusion.…”