Adjunct Pharmacotherapy During EVT

ESCAPE-NA1 found nerinetide neutral overall. CHOICE showed adjunct intra-arterial alteplase after successful EVT may improve excellent outcomes. RESCUE BT found tirofiban did not improve functional outcomes globally, though signals emerged in non-large-artery atherosclerosis.

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Clinical Question

Is neuroprotection or adjunct pharmacotherapy useful during EVT?

Synthesises 3 trialspharmacologic adjuncts to EVT. Nerinetide, tirofiban, and post-EVT IA fibrinolysis

What does the guideline say?

§4.7.4 Endovascular Techniques· 2026
In patients with AIS due to an LVO, EVT with stent retrievers, contact aspiration, or combination techniques is recommended to achieve rapid and adequate reperfusion (COR 1, LOE A). In the management of patients with AIS in the setting of LVO, preoperative administration of tirofiban before EVT is not useful to improve 90-day functional outcome (COR 3 No Benefit, LOE A based on RESCUE-BT). In patients with AIS who achieve complete or near-complete EVT (modified TICI 2b or greater), the administration of adjunctive intraarterial thrombolytics with urokinase, alteplase, or tenecteplase may be reasonable to improve cerebral reperfusion and 90-day functional outcomes (COR 2b, LOE B-R per CHOICE).
Source: 2026 AHA/ASA Guideline — §4.7.4 (Endovascular Techniques)

The trials cited in the guideline's supportive text appear below.

Trials in this question· 3

ESCAPE-NA12020

NSaRR 1.04 (0.96–1.13)

Nerinetide during EVT did not improve 90-day independence overall.

NSaRR 1.04 (0.96–1.13)

CHOICE2022

+18 / 100aRD 18.4% (0.3–36.4)

Adjunct IA alteplase after successful EVT raised excellent outcome 40%→59% (small phase 2b).

+18 / 100aRD 18.4% (0.3–36.4)

RESCUE BT2022

NS / HarmcOR 1.08 (0.87–1.34)

Pre-EVT IV tirofiban did not improve outcome and raised sICH 9.7% vs 6.4%.

NS / HarmcOR 1.08 (0.87–1.34)