Predictors of functional outcomes after endovascular therapy in acute large infarct: an ANGEL-ASPECT subanalysis

Background and purpose Recent randomised clinical trials have shown that endovascular treatment (EVT) for patients with acute ischaemic stroke (AIS) and a large infarct core is safe and effective. This study sought to identify which factors predict favourable outcomes in AIS patients with a large infarct core who received EVT in the ANGEL-ASPECT trial. Methods Patients from the ANGEL-ASPECT trial receiving EVT were enrolled in this analysis. They were categorised based on 90-day outcomes: good functional outcome (modified Rankin Scale (mRS) score 0–2) and independent ambulation (mRS score 0–3). A comparison of baseline and procedural characteristics was performed across the groups and logistic regression was performed to identify predictors of favourable outcomes. Results Of 230 AIS participants with large infarct core undergoing EVT, independent predictors differed between outcome levels. For functional independence (mRS 0–2), predictors were male sex, lower systolic blood pressure (SBP) and National Institutes of Health Stroke Scale (NIHSS) score, smaller infarct volume, fewer thrombectomy attempts, and notably, the presence of early neurological improvement (ENI) at 36 hours (OR 19.62, 95% CI 2.28 to 168.52). For independent ambulation (mRS 0–3), predictors were younger age, lower SBP and NIHSS score, successful reperfusion, lower platelet-to-lymphocyte ratio and absence of decompressive hemicraniectomy (OR 20.00, 95% CI 2.04 to 196.08). Conclusions This analysis delineates distinct predictors for different levels of recovery after EVT in large-core stroke. Beyond confirming the prognostic value of established factors (such as age, NIHSS and reperfusion), it highlights the novel high-impact prognostic factors for large-core AIS patients post-EVT: ENI for functional independence. Furthermore, the need for decompressive hemicraniectomy, a marker of severe cerebral oedema, was strongly linked to a lower probability of achieving independent ambulation. These findings may aid in early prognostication and refined patient management for this high-risk population. Trial registration number NCT04551664 .