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The CHOICE2 trial coordinated by Hospital Clinic Barcelona and IDIBAPS has provided a rigorous academic basis for a shift in how we’ve traditionally viewed the limitations of mechanical thrombectomy. While the removal of a primary thrombus via a stent retriever has been the standard of care for severe ischemic stroke, this study published in JAMA confirms that simply reopening a major vessel is often insufficient for complete tissue reperfusion.

If you’ve had one of these, you also possibly may have experienced the reality where a technically successful procedure does not translate into functional independence; this discrepancy can occur for many reasons – and one of them has been found to be due to microcirculatory failure in the smaller distal vessels. The research team led by Professor Angel Chamorro and Dr Arturo Renu utilised a randomised clinical trial involving 440 patients to demonstrate that the targeted administration of intra -arterial alteplase immediately following a thrombectomy significantly improves outcomes.

This pharmacological intervention acts upon the ‘side streets’ of the cerebral vasculature… and it ensures that the microcirculation is cleared of the residual fibrin that the mechanical device cannot reach. The trial showed a marked increase in the percentage of patients achieving a mRS score of 0 to 1 at ninety days… moving from 42.5 per cent in the control group to 57.5 per cent in the treatment group. But the success of this combined strategy depends on the precision of the delivery during the angiography… so the drug is applied directly to the affected territory to avoid the systemic risks associated with traditional thrombolysis. Professor Chamorro’s findings suggest that we are entering an era of secondary reperfusion strategies where the focus moves from the macrovascular level to the cellular level of the brain tissue itself.

The data indicates that there was no significant increase in symptomatic intracranial haemorrhage; which tends to reduce the risks of combining surgery with potent lytics. In the UK, the adoption of the CHOICE2 protocol into NHS guidelines will likely require further health economic assessments to justify the additional time spent in the catheterisation suite. It is anticipated that this evidence will begin to influence British specialist stroke centres within the next three to five years as international consensus statements are updated.