Outcomes of Intra‐Arterial Urokinase After Endovascular Reperfusion for Acute Ischemic Stroke Due to Cardioembolism: A Secondary Analysis of the POST‐UK Trial

Background Whether adjunctive intra‐arterial thrombolysis improves outcomes in patients with acute ischemic stroke due to cardioembolism remains unclear. This study aimed to investigate the efficacy and safety of adjunctive intra‐arterial urokinase in patients with acute ischemic stroke due to cardioembolism who achieved near‐complete to complete reperfusion. Methods This study was a secondary analysis of the POST‐UK (Adjunctive Intra‐Arterial Urokinase After Near‐Complete to Complete Reperfusion for Acute Ischemic Stroke) trial, which was conducted from November 15, 2022, to March 29, 2024. Patients were randomly assigned to the intra‐arterial urokinase group or the control group. The primary outcome was disability‐free survival at 90 days, defined as a modified Rankin Scale score of 0 to 1. Safety outcomes included 90‐day all‐cause death, symptomatic intracranial hemorrhage and any intracranial hemorrhage within 48 hours. Results Among 209 patients with cardioembolism (median age 73 [interquartile range, 63–81] years; 45.9% men), 106 were assigned to the control group and 103 to the intra‐arterial urokinase group. Compared with the control group, adjunctive intra‐arterial urokinase significantly increased the odds of disability‐free survival at 90 days (adjusted risk ratio, 1.49 [95% CI, 1.08–2.06]; P =0.01; inverse probability of treatment weighting adjusted risk ratio, 1.47 [95% CI, 1.04–2.09]; P =0.03). No significant differences were found between groups in 90‐day mortality rate, symptomatic intracranial hemorrhage, or any intracranial hemorrhage within 48 hours. Conclusions In patients with acute ischemic stroke due to cardioembolism who achieved near‐complete to complete reperfusion, adjunctive intra‐arterial urokinase significantly improved disability‐free survival at 90 days without increasing the risk of death or intracranial hemorrhage. Registration URL: ChiCTR.org.cn; Unique identifier: ChiCTR2200065617.