Real-world functional outcomes and predictors of futile recanalization in patients meeting criteria for SELECT2.

BackgroundRecent randomized trials have shown that patients presenting with large core infarctions benefit from endovascular thrombectomy compared to medical management. We report real-world outcomes and factors associated with futile recanalization in patients meeting large core criteria for SELECT2.MethodsRetrospective review of health system records from 1/1/2024 to 12/31/2024 for patients presenting with computed tomography (CT) Alberta Stroke Program Early CT Score (ASPECTS) 3-5 or CT perfusion (CTP) core infarction ≥50 milliliters. Primary and secondary outcomes, 90-day modified Rankin Scale (mRS) score 0-2 and 0-3, respectively, were compared to rates reported in SELECT2. Logistic regression was used to identify factors independently associated with 90-day mRS 5-6 despite successful reperfusion (modified treatment in cerebral ischemia 2b-3).ResultsAmong 59 patients with 90-day outcome data, median CT ASPECTS and CTP core were 7 (5-10) and 78.5 (57-119) mL, respectively. Twelve (20.3%) achieved mRS 0-2, while 18 (30.5%) were ambulatory (mRS 0-3). Recanalization was achieved in 51 subjects, of whom 27 (52.9%) had a devastating neurological outcome (mRS 5-6). Atrial fibrillation was the only factor independently associated with futile recanalization (odds ratio 13.5, 95% confidence interval 1.4-128.8,  < 0.05).ConclusionOur real-world cohort of large core thrombectomy patients from daily clinical practice had identical rates of independent neurological function and lower ambulatory rates at 90 days to that reported in the treatment arm of SELECT2. A history of atrial fibrillation, independent of age and presenting stroke severity, was associated with futile recanalization.