Futile reperfusion (poor functional status despite successful reperfusion) was observed in up to 67% of patients enrolled in recent endovascular treatment (EVT) clinical trials. We investigated the impact of baseline stroke severity on both futile reperfusion and therapeutic benefit of successful EVT. Using a prospective multicenter stroke registry, we identified consecutive ischemic stroke patients with anterior circulation large artery occlusion, who were reperfused successfully by EVT (Thrombolysis in Cerebral Infarction grade 2b–3). The rate of futile reperfusion was assessed across the initial National Institutes of Health Stroke Scale (NIHSS) scores. The frequency of poor outcomes (modified Rankin scale [mRS] 3–6) according to NIHSS scores was compared between patients revascularized successfully by EVT and those who did not receive EVT, after standardizing for age. Among 21,591 patients with ischemic stroke, 972 (4.5%) received EVT within 12 h of onset, including 440 who met study eligibility criteria. Futile reperfusion was observed in 226 of the 440 study-eligible patients (51.4%) and was associated with stroke severity: 20.9% in NIHSS scores ≤5, 34.6% in 6–10, 58.9% in 11–20, and 63.8% in > 20 (p < 0.001). Nonetheless, the therapeutic benefit of EVT also increased with increasing stroke severity (p for interaction < 0.001): 0.1% in NIHSS ≤5, 18.6% in 6–10, 28.7% in 11–20, and 34.3% in > 20. EVT is more beneficial with increasing stroke severity, although futile reperfusion also increases with higher stroke severity.

A significant proportion of patients with mild ischemic stroke become disabled despite receiving intravenous thrombolytic therapy. The purpose of this study was to assess the clinical and radiological factors associated with unfavorable outcomes in patients with minor ischemic stroke that received intravenous recombinant tissue plasminogen activator (rt-PA) therapy. We identified anterior circulation stroke patients with initial National Institutes of Health Stroke Scale (NIHSS) scores ≤5 who received intravenous thrombolysis within 4.5 h of stroke onset and had pretreatment magnetic resonance (MR)/MR angiography using our prospective stroke database. We analyzed baseline characteristics, infarction patterns on diffusion-weighted imaging (DWI), and steno-occlusive lesions on MR angiography. Unfavorable outcome was defined as a modified Rankin Scale (mRS) score ≥ 2 at 90 days. Logistic regression was used to determine independent predictors of unfavorable outcomes. Among 121 patients (85 men; mean age, 63.4 ± 11.3 years) included in this study, 46 (38%) had unfavorable outcomes at 90 days and DWI lesion patterns showing infarction in the deep middle cerebral artery (MCA) territory involving the perforating artery area was observed in 47 (38.8%) patients. On multivariable analysis, unfavorable outcomes at 90 days were associated with diabetes [odds ratio (OR), 3.41; 95% confidence interval (CI), 1.06–10.9; P = 0.039), NIHSS score on admission (OR, 2.11; 95% CI, 1.35–3.30; P = 0.001), and infarction in the deep MCA territory on DWI (OR, 4.19; 95% CI, 1.63–10.8; P = 0.003). Lesions in the deep MCA territory was independently associated with early neurological deterioration (P = 0.032). The patients without deep MCA territory infarction had a higher prevalence of cardiac embolism (P = 0.009). Higher NIHSS scores, diabetes, and deep MCA territory infarction may be useful for predicting unfavorable outcomes in patients with minor stroke treated with intravenous rt-PA therapy.

BACKGROUND: Early neurological deterioration (END) is a frequent complication of acute ischemic stroke. Although END worsens clinical outcomes, standardized treatment strategies remain undefined, resulting in variability in clinical practice. This study examines real-world treatment patterns for END and compares the effects of different strategies on neurological and functional outcomes. METHODS: This study analyzed data from a nationwide, prospective, multicenter stroke registry in South Korea, including patients with noncardioembolic stroke who developed END due to stroke progression between January 2019 and August 2024. END was defined as new or worsening neurological symptoms meeting National Institutes of Health Stroke Scale criteria (≥2-point total or ≥1 point in consciousness or motor subscores) with radiological confirmation. Patients were classified into conservative management, antithrombotics change, and induced hypertension (iHTN). The primary outcomes were neurological improvement, defined as a ≥2-point reduction in the National Institutes of Health Stroke Scale score, and 3-month functional outcome measured by modified Rankin Scale ordinal shift. Secondary outcomes included good functional recovery (modified Rankin Scale score, 0–2) and composite vascular events (death, stroke, and myocardial infarction). Multivariable analyses adjusted for age, sex, prestroke modified Rankin Scale, initial National Institutes of Health Stroke Scale score, vascular risk factors, the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) classification, acute thrombolysis, and laboratory covariates. RESULTS: Among 3067 patients with END due to stroke progression, 1840 (60.0%) received conservative management, 747 (24.4%) underwent antithrombotic changes, and 480 (15.7%) were treated with iHTN. Neurological improvement occurred in 34.2% of patients, with the highest in the iHTN group (41.5%) compared with the conservative (32.2%) and antithrombotics change groups (34.4%; P <0.001). In adjusted analyses, iHTN increased the odds of neurological improvement (adjusted odds ratio, 1.55 [95% CI, 1.25–1.92]) and a favorable 3-month modified Rankin Scale shift (adjusted odds ratio, 1.24 95% CI, 1.03–1.48]) compared with conservative management, particularly in patients with large artery atherosclerosis. Antithrombotics change showed no significant association with neurological or functional recovery. CONCLUSIONS: In patients with noncardioembolic ischemic stroke who developed END due to stroke progression, iHTN was associated with favorable clinical outcomes.