ABSTRACT NUMBER: ESOC2026A1189 ADJUNCTIVE INTRA-ARTERIAL ALTEPLASE AFTER NEAR-COMPLETE OR COMPLETE REPERFUSION IN ACUTE ISCHEMIC STROKE: A POST HOC ANALYSIS OF THE PEARL TRIAL

Abstract Background and aims The benefit of adjunctive intra-arterial alteplase treatment following near-complete to complete reperfusion (defined as an expanded Thrombolysis in Cerebral Infarction [eTICI] score of 2c to 3) by endovascular thrombectomy (EVT) for acute large vessel occlusion stroke remains controversial. The study aimed to evaluate whether intra-arterial alteplase can improve outcomes for patients achieving eTICI 2c/3 following EVT compared to standard management. Methods This was a post-hoc analysis of the PEARL (Intra-arterial Alteplase for Acute Ischemic Stroke After Mechanical Thrombectomy) randomized controlled trial conducted at 28 sites in China between August 1, 2023, and October 16, 2024. Patients who achieved eTICI 2c–3 reperfusion after EVT were included. Baseline characteristics and clinical outcomes were compared between intra-arterial alteplase treatment and standard treatment groups. Results Among 324 randomized patients in the PEARL trial, 136 patients were included with 65 received intra-arterial alteplase treatment, and 71 received standard treatment. Intra-arterial alteplase treatment effect was observed in eTICI 2c/3 patients at 90 days (1 [1–3] versus 3 [1–4]; common odds ratio, 2.07 [95% CI, 1.10–3.92]; □=0.02). Rate of symptomatic intracranial hemorrhage within 36 hours did not differ significantly between groups (adjusted risk ratio, 0.29 [95% CI, 0.03–2.82]; □=0.29). Conclusions Among patients who achieved near-complete to complete reperfusion after EVT in the PEARL trial, adjunctive intra-arterial alteplase was associated with improved functional outcomes at 90 days without an increased risk of symptomatic intracranial hemorrhage. These findings underscore the potential importance of targeting microcirculatory dysfunction even after successful macrovascular recanalization. Conflict of interest Yanting Chen: nothing to disclose