Outcomes of Intra-Arterial Urokinase After Endovascular Reperfusion for Acute Ischemic Stroke Due to Cardioembolism: A Secondary Analysis of the POST-UK Trial.
Song J, Zhao X, et al. • Journal of the American Heart Association • 2026
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.
Key Findings
Results
Adjunctive intra-arterial urokinase after near-complete to complete reperfusion significantly increased the likelihood of 90-day disability-free survival (mRS 0-1) in patients with cardioembolic stroke.
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).
Primary outcome was disability-free survival at 90 days, defined as modified Rankin Scale score of 0 to 1.
Analysis included 209 patients with cardioembolism: 106 in the control group and 103 in the intra-arterial urokinase group.
Results
Adjunctive intra-arterial urokinase did not significantly increase 90-day mortality.
The abstract reports no significant difference between groups in 90-day all-cause death.
90-day all-cause death was a prespecified safety outcome.
Results
Adjunctive intra-arterial urokinase did not significantly increase symptomatic intracranial hemorrhage or any intracranial hemorrhage within 48 hours.
No significant differences were found between groups for either hemorrhage outcome.
Both were prespecified safety outcomes.
Methods
The study was a secondary analysis of the randomized POST-UK trial restricted to cardioembolic stroke patients.
POST-UK was conducted from November 15, 2022, to March 29, 2024.
Patients were randomly assigned to the intra-arterial urokinase group or the control group.
Median age was 73 years (IQR 63-81); 45.9% were men.
Registered at ChiCTR.org.cn, identifier ChiCTR2200065617.
Results
The benefit was consistent when analyzed with two statistical approaches (covariate adjustment and inverse probability of treatment weighting).
Adjusted RR 1.49 vs IPTW-adjusted RR 1.47, with similar direction and magnitude.
The IPTW confidence interval (1.04-2.09) was somewhat wider than the covariate-adjusted interval (1.08-2.06).
What This Means
This study looked at patients whose stroke was caused by a blood clot originating from the heart (cardioembolic stroke). All had a clot-removal procedure that restored blood flow almost completely. In the parent POST-UK trial, some patients were then randomly given an additional clot-dissolving drug, urokinase, delivered directly into the brain artery, while others received standard care. This analysis focused on the 209 patients with heart-related clots (103 received urokinase, 106 were controls).
Patients who received urokinase were more likely to be free of disability (little or no disability) at 90 days. The adjusted risk ratio was about 1.5, meaning roughly 50% higher likelihood of this good outcome. Deaths within 90 days and bleeding in the brain within 48 hours, including symptomatic bleeding, were not significantly different between groups.
This research suggests that adding intra-arterial urokinase after successful clot removal may help some cardioembolic stroke patients recover better without clear added safety risks. However, this was a secondary analysis of a trial in a smaller subgroup, so the findings would need confirmation in larger studies before changing practice.
Song J, Zhao X, Li G, Zhou M, Zhang L, Zhu H, et al.. (2026). Outcomes of Intra-Arterial Urokinase After Endovascular Reperfusion for Acute Ischemic Stroke Due to Cardioembolism: A Secondary Analysis of the POST-UK Trial.. Journal of the American Heart Association. https://doi.org/10.1161/JAHA.126.052937