Predictors of futile recanalization following endovascular therapy for acute anterior circulation large vessel occlusion stroke: a retrospective cohort study.
Wen Y, Liu X, et al. • Frontiers in neurology • 2026
Admission NIHSS score, stress hyperglycemia ratio, DWI infarct volume, DWI-ASPECTS score, and procedure time are independent predictors of futile recanalization after endovascular therapy for anterior circulation large vessel occlusion stroke.
Key Findings
Results
Admission NIHSS score was an independent predictor of futile recanalization following successful EVT for anterior circulation LVO stroke.
OR = 1.381 (95% CI: 1.113–1.713, p = 0.003) from multivariate logistic regression
Higher NIHSS score at admission increased the risk of poor functional outcome despite successful reperfusion
Baseline NIHSS scores differed significantly between the effective recanalization group (mRS ≤ 2, n = 150) and the futile recanalization group (mRS > 2, n = 161)
Both univariate and multivariate logistic regression identified this as an independent predictor
Results
DWI infarct volume was an independent predictor of futile recanalization.
OR = 1.057 (95% CI: 1.025–1.090, p < 0.001) from multivariate logistic regression
Larger infarct volume on diffusion-weighted imaging was associated with increased risk of poor functional outcome despite successful reperfusion
DWI infarct volume differed significantly between the two groups in baseline comparisons
Identified as an independent predictor in both univariate and multivariate analyses
Results
DWI-Alberta Stroke Program Early CT Score (DWI-ASPECTS) was an independent predictor of futile recanalization.
OR = 69.240 (95% CI: 9.819–488.254, p < 0.001) from multivariate logistic regression
Lower DWI-ASPECTS score increased the risk of futile recanalization
DWI-ASPECTS score differed significantly between the effective and futile recanalization groups at baseline
This variable had the largest odds ratio among all five independent predictors identified
Results
Procedure time was an independent predictor of futile recanalization following EVT.
OR = 1.011 (95% CI: 1.005–1.018, p < 0.001) from multivariate logistic regression
Prolonged procedure time increased the risk of poor functional outcome despite successful reperfusion
Procedure time differed significantly between the two groups in baseline comparisons
Number of procedure attempts also differed significantly between groups at baseline
Results
Stress hyperglycemia ratio (SHR) was an independent predictor of futile recanalization.
OR = 3.447 (95% CI: 1.302–9.129, p = 0.013) from multivariate logistic regression
Elevated SHR was associated with increased risk of poor functional outcome despite successful reperfusion
SHR differed significantly between the effective and futile recanalization groups at baseline
SHR was among the clinical variables compared between groups alongside age, sex, atrial fibrillation, and C-reactive protein
Results
A combined predictive model incorporating all five independent predictors achieved an AUC of 0.815 for identifying futile recanalization.
AUC = 0.815 with sensitivity of 0.789, specificity of 0.787, and Youden index of 0.576
The model incorporated admission NIHSS score, SHR, DWI infarct volume, DWI-ASPECTS score, and procedure time
Model performance was evaluated using receiver operating characteristic (ROC) curve analysis
The study included 311 patients total: 150 in the effective recanalization group (mRS ≤ 2) and 161 in the futile recanalization group (mRS > 2)
Methods
Among 311 patients with anterior circulation LVO who underwent successful EVT, 161 (51.8%) experienced futile recanalization defined as 90-day mRS score greater than 2.
Total study cohort: n = 311 patients with anterior circulation LVO who underwent successful EVT
Effective recanalization group: n = 150 (mRS ≤ 2 at 90 days)
Futile recanalization group: n = 161 (mRS > 2 at 90 days)
This was a retrospective cohort study design
Baseline comparisons showed significant differences in age, sex, atrial fibrillation, SHR, C-reactive protein, admission NIHSS score, DWI infarct volume, DWI-ASPECTS score, number of procedure attempts, and procedure time between groups
What This Means
This research examines why some stroke patients who receive a procedure to unblock a brain artery (called endovascular therapy or EVT) still end up with poor outcomes despite the procedure technically succeeding. This is called 'futile recanalization' — the artery is reopened, but the patient doesn't recover meaningful function. The study followed 311 patients who all had successful artery reopening and found that about half (161 patients) still had poor functional outcomes three months later.
The researchers identified five key factors that predicted who would experience futile recanalization: how severe the stroke symptoms were at hospital arrival (measured by the NIHSS score), the size of the already-damaged brain tissue seen on specialized MRI scans (DWI infarct volume), a brain scan scoring system measuring how much tissue remained potentially salvageable (DWI-ASPECTS), how long the procedure took, and a measure of stress-related blood sugar elevation called the stress hyperglycemia ratio (SHR). When these five factors were combined into a single predictive model, it correctly identified futile recanalization cases about 79% of the time.
This research suggests that doctors may be able to better predict before or during treatment which patients are unlikely to benefit from artery-opening procedures, which could help improve patient selection and counseling. The findings also highlight that factors like blood sugar stress responses and procedure duration — some of which may be modifiable — are linked to outcomes, potentially pointing toward targets for improving care. However, as a retrospective study, it cannot prove cause and effect, and further research would be needed to validate the predictive model in other patient populations.
Wen Y, Liu X, Liao X, Zhong G, Gu H, Zhang J, et al.. (2026). Predictors of futile recanalization following endovascular therapy for acute anterior circulation large vessel occlusion stroke: a retrospective cohort study.. Frontiers in neurology. https://doi.org/10.3389/fneur.2026.1777164