Intra-arterial Thrombolysis After Successful Thrombectomy for Acute Ischemic Stroke in the Posterior Circulation (IAT-TOP)

NCT ID: NCT05897554

Last Updated: 2025-08-13

Basic Information

• Recruitment Status: COMPLETED
• Clinical Phase: NA
• Total Enrollment: 247 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2023-08-11
• Study Completion Date: 2025-03-27

Brief Summary

The CHOICE study suggested that the use of adjunct intra-arterial alteplase after successful endovascular reperfusion in large vessel occlusion acute ischemic strokes may result in a greater likelihood of excellent neurological outcome at 90 days. However, CHOICE was a phase-2 trial and almost exclusively enrolled anterior circulation occlusions. Therefore, data on the safety and efficacy of post-endovascular reperfusion IAT in posterior circulation stroke is lacking.

In general, anterior circulation strokes are associated with a higher risk of ICH than posterior circulation strokes. Therefore, we believe it might be safer to perform post-endovascular reperfusion IAT posterior circulation stroke. Also, there are more perforator artery in the posterior circulation, IAT would be more likely to show its benefit. Therefore, we would like to explore IA rt-PA for posterior circulation stroke after successful MT in our RCT.

In this study, one interim analysis will be performed when the enrollment volume reaches 50% of the total sample size (188 cases). DSMB will determine the premature termination or continuity of research.

Conditions

Acute Ischemic Stroke; Arterial Thrombosis; Posterior Circulation Brain Infarction

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: TREATMENT
• Blinding Strategy: SINGLE

Study Groups

Successful mechanical thrombectomy plus intra-arterial alteplase group

For patients in the successful MT plus intra-arterial alteplase group, after successful recanalization, neurointerventionalists administered intra-arterial thrombolysis with alteplase according to protocol. The angiographic scores will be assessed after intra-arterial thrombolysis.

Group Type: EXPERIMENTAL

intra-arterial alteplase

Intervention Type: DRUG

For patients in the successful MT plus intra-arterial alteplase group, after successful recanalization, neurointerventionalists administered intra-arterial thrombolysis with alteplase according to protocol. The angiographic scores will be assessed immediately after intra-arterial thrombolysis.

Successful mechanical thrombectomy only group

For patients in the successful MT only group, the choice of MT strategy will be made by the qualified neurointerventionalist, including stent retriever, aspiration and a combination technology. Patients who underwent more than 3 thrombectomy procedures were excluded from the study. Rescue therapy was performed at the discretion of the neurointerventionalist in case of the grade of stenosis at the occlusion site was presented to be more than 70% after MT.

Group Type: NO_INTERVENTION

No interventions assigned to this group

Interventions

intra-arterial alteplase

For patients in the successful MT plus intra-arterial alteplase group, after successful recanalization, neurointerventionalists administered intra-arterial thrombolysis with alteplase according to protocol. The angiographic scores will be assessed immediately after intra-arterial thrombolysis.

Intervention Type: DRUG

Other Intervention Names

Intraarterial alteplase recombinant tissue plasminogen activator (r-tPA)

Eligibility Criteria

Inclusion Criteria

1. Symptoms and signs compatible with ischemia in the posterior circulation;

2. Basilar artery occlusion or vertebral artery occlusion without antegrade flow to the basilar artery confirmed by computed tomographic angiography (CTA)/ magnetic resonance angiography (MRA)/ digital subtraction angiography (DSA);

3. Age ≥18 years and ≤80 years;

4. Premorbid mRS ≤1;

5. National Institutes of Health Stroke Score (NIHSS) ≥6 at admission；

6. PC-ASPECTS on CT/CTA-Source Images/MRI-DWI 6-10；

7. Treated with endovascular thrombectomy (EVT) resulting in an eTICI score ≥2b50 at end of the procedure；

8. Time from symptom onset to randomization<24 hours, including wake-up stroke and unwitnessed stroke; Time of onset of symptoms is defined as "last known well" (LKW) if symptoms are not witnessed or time of estimated basilar artery occlusion (defined as the time of sudden onset of basilar artery stroke symptoms, with no consideration of any preceding minor prodromal symptoms, as adjudicated by two neurologists) if symptoms are witnessed;

9. Informed consent obtained from the patient or his/her legal representative.

Exclusion Criteria

1. Contraindication to Intravenous Thrombolysis (except time to treatment);

2. Complete clinical recovery in the angiography suite by end of MT procedure;

3. More than 3 passes of thrombectomy device;

4. Dissection of occluded artery or intraoperative bleeding on DSA after thrombectomy;

5. Patients in sedation and intubated patients could not be included if baseline NIHSS is not obtained by a neurologist or emergency physician prior to sedation or intubation;

6. Seizures at stroke onset which would preclude obtaining a baseline NIHSS;

7. Bilateral dilated pupils;

8. Severe contrast allergy or absolute contraindication to iodinated contrast;

9. Systolic pressure >185 mmHg or diastolic pressure >110 mmHg, and cannot be controlled by antihypertensive drugs;

10. Blood glucose <50 mg/dl (2.8 mmol/L) or >400 mg/dl (22.2 mmol/L);

11. Platelet <50*10^9/L, or aPTT >40 s, or PT >15 s;

12. Known genetic or acquired bleeding diathesis, deficiency of anticoagulant factors, or oral anticoagulant drugs and INR > 1.7, or treated with direct oral anticoagulant agents in the prior 48 hours;

13. Known Severe renal Failure as defined by a serum creatinine > 3.0 mg/dl (or 265.2 μmol/l) or glomerular Filtration Rate [GFR] <30, or patient requires hemodialysis or peritoneal dialysis;

14. Patients that cannot complete 90-day follow-up (e.g. no fixed residence, overseas patients, etc.);

15. Presumed vasculitis or septic embolization;

16. Suspicion of aortic dissection;

17. The patient has neurological disease or mental disorder before onset, which affects the assessment of the condition;

18. Females who are pregnant or in lactation;

19. Participating in other clinical trials that could confound the evaluation of the study;

20. Other circumstances that the investigator considers inappropriate for participation or may pose a significant risk to patients.

• Minimum Eligible Age: 18 Years
• Maximum Eligible Age: 80 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

Xuanwu Hospital, Beijing

OTHER

Sponsor Role: lead

Responsible Party

Responsibility Role: SPONSOR

Locations

Xuanwu Hospital, Capital Medical University.

Beijing, , China

Countries

China

References

Yang B, Bai X, Yi T, Wang H, Liu Y, Ma L, Liu S, Wu S, Zhang L, Peng Y, Nogueira RG, Chen W, Jiao L. Intra-arterial Alteplase Thrombolysis After Successful Thrombectomy for Acute Ischemic Stroke in the Posterior Circulation (IAT-TOP): Study protocol and rationale. Int J Stroke. 2025 Jul;20(6):750-755. doi: 10.1177/17474930251313940. Epub 2025 Jan 23.

Reference Type: DERIVED

PMID: 39754489 (View on PubMed)

Other Identifiers

IAT-TOP

Identifier Type: -

Identifier Source: org_study_id