ISC 2026 | Intra-arterial thrombolysis as an adjunct to thrombectomy in AIS: encouraging but not conclusive

Acute ischemic stroke patients, mechanical thrombectomy, has become the standard of care. And fortunately, mechanical thrombectomy actually has developed to the point that we can see a very high rate of recanalization of opening occluded blood vessels after the thrombectomy. And in fact, those rates are somewhere between 80 to 90%. But if you look at the clinical outcome, there is a mismatch. Still, somewhere between 40 and 50% of the patients experience death or disability even after successful thrombectomy. So the question is that what is the reason for this mismatch? And it seems that, yes, there is an occlusion in one of the larger blood vessels to the brain, but there’s actually another set of changes that actually happen at smaller blood vessels in the brain that are past the site of the occlusion. So even if you open the occlusion, those secondary changes remain and prevent adequate blood flow from reaching the brain tissue and still leading to infarction and ischemic stroke, and subsequently leading to death or disability. So these devices cannot do anything for the smaller blood vessels that have passed the initial site of occlusion. So intra-arterial thrombolysis has been around for almost 40 years, but has not been tested in this particular context. And essentially the premise is that once you open a blood vessel you have the secondary occlusions, secondary lack of blood flow into these blood vessels that are small and supplying distal parts of the brain and you can actually use the same catheter that you used to do the thrombectomy and inject these intra-arterial thrombolytics at the site of the occlusion. And the thrombolytics will actually dissolve some of these microclots and microthrombi and some of the secondary lack of blood flow into the smaller blood vessels and actually improve the blood flow to the brain that’s still ischemic and actually subsequently reduce the rate of death or disability. Now the clinical trials actually have shown encouraging results but sometimes conflicting results, so really one of the trials have been including a small number of patients, so you really cannot tell conclusively whether the intra-arterial thrombolysis was actually beneficial or not, most of the time it’s actually giving a suggestion, yes, it was beneficial. So essentially, people have done is try to combine these together. And essentially, if you combine all of these together in the form of a meta-analysis, one thing is clear. There’s a suggestion of benefit. All of the trials are showing that there is a suggestion of a benefit. What we don’t know is what particular patient population benefits the most. What is the actual risk in various patient populations of the thrombectomy when we give them intra-arterial thrombolysis? What is the right medication to give intra-arterial thrombolysis? Is it alteplase? Is it tenecteplase? And one trial actually used urokinase. So I think that there is a lot of unanswered questions, but nonetheless, I think that we cannot ignore the intra-arterial thrombolysis that thrombectomy can offer potential for recovery for patients, can improve the outcomes of patients, and clearly needs to be addressed in a conclusive randomized clinical trial so that we can incorporate it in our practices appropriately in the right format so we can make the most difference in reducing death and disability in patients with ischemic stroke.

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