Practice Patterns, Equipoise, and Trial Priorities for Adjunct Intra-Arterial Thrombolysis After Mechanical Thrombectomy: A Physician Survey

Abstract

Background: Adjunct intraarterial (IA) thrombolysis after mechanical thrombectomy may improve distal or microvascular reperfusion, but randomized trial results vary by agent, dose, vascular territory, and final reperfusion grade.

Objectives: To assess current practice patterns, safety thresholds, clinical equipoise, implementation barriers, and priorities for future trials of adjunct IA thrombolysis after mechanical thrombectomy.

Methods: We conducted a descriptive cross-sectional electronic survey in May 2026 among clinicians who personally performed thrombectomy or were involved in acute ischemic stroke care and thrombectomy decisionmaking. Thirty responses were analyzed overall and by self-reported annual thrombectomy volume. Outcomes included institutional and case-level use, agent and delivery practices, willingness to treat residual distal occlusion or no-reflow, acceptable symptomatic intracranial hemorrhage (sICH) risk, evidence interpretation, equipoise, trial preferences, and implementation readiness.

Results: Among 30 respondents, 25 (83.3%) practiced at comprehensive stroke centers. Although 26 (86.7%) reported at least occasional institutional use of adjunct IA thrombolysis, 25 (83.3%) estimated that adjunct IA thrombolysis was used in 10% or fewer thrombectomy cases, and only 1 (3.3%) reported routine institutional use. Alteplase was used by 21 of 28 respondents with agent data (75.0%). Residual distal branch occlusion was more accepted than no-reflow as an indication (70.0% vs 46.7%). Twenty-four respondents (80.0%) required an acceptable sICH rate below 5%, and 26 (86.7%) reported moderate or strong equipoise regarding adjunct IA thrombolysis after thrombectomy. Insufficient evidence and absent protocols were the leading institutional barriers to routine use. Routine use remained uncommon across thrombectomy-volume groups. Twenty-two respondents (73.3%) required a larger randomized trial to change practice, while 28 (93.3%) would implement treatment after demonstrated efficacy.

Conclusions: Among surveyed clinicians, adjunct IA thrombolysis was already used selectively but was not as standard practice. Persistent equipoise and conservative safety expectations support an enriched, stratified randomized trial with standardized angiographic definitions, dosing, safety monitoring, and parallel implementation planning.

Keywords: acute ischemic stroke, mechanical thrombectomy, intra-arterial thrombolysis, alteplase, tenecteplase, physician survey, clinical equipoise.