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Neuroimaging Predictors of Futile Recanalization in Anterior Circulation Stroke: A Systematic Review and Meta-Analysis.

Neuroimaging Predictors of Futile Recanalization in Anterior Circulation Stroke: A Systematic Review and Meta-Analysis. AJNR. American journal of neuroradiology Kiani, I., Mohammadzadeh, S., Mozaffari, S., Mahmoudzadeh, H., Lakhani, D. A., Kakadiya, J., Salim, H. A., Aziz, Y. N., Sriwastwa, A., Majmundar, S., Mei, J., Dmytriw, A. A., Guenego, A., Xu, R., Lu, H., Hillis, A. E., Albers, G. W., Liebeskind, D., Shah, G. V., Nael, K., Heit, J. J., Faizy, T. D., Yedavalli, V. S. 2025

Abstract

Mechanical thrombectomy has transformed the management of large-vessel occlusion stroke; however, a considerable proportion of patients fail to achieve functional recovery despite successful recanalization. This "futile recanalization" underscores the need to better understand imaging biomarkers that may predict poor outcomes following endovascular therapy.To systematically review and synthesize evidence on neuroimaging biomarkers associated with futile recanalization after mechanical thrombectomy in acute ischemic stroke.PubMed, Scopus, Web of Science, and Embase databases were searched up to March 2025, supplemented by manual reference screening.Eligible studies enrolled adult patients with anterior-circulation stroke who underwent thrombectomy, reported pre-treatment neuroimaging findings, and evaluated functional outcomes despite successful reperfusion. Case reports, reviews, abstracts, and non-human studies were excluded.Two reviewers independently screened, extracted data, and assessed study quality using PROBAST. Randomeffects meta-analysis was performed where appropriate. Heterogeneity, publication bias, and sensitivity analyses were undertaken.Fifty-one studies were included. Lower ASPECTS scores were strongly associated with futile recanalization (OR ˜0.81). Core infarct volume showed inconsistent associations, whereas perfusion and collateral markers, including elevated hypoperfusion intensity ratio, delayed venous outflow, and poor collateral scores, demonstrated strong predictive value. Chronic white-matter injury, leukoaraiosis, and cerebral atrophy were also consistently associated with worse outcomes.Heterogeneity in imaging protocols and thresholds; predominance of retrospective single-center cohorts; limited direct comparison across imaging modalities; and variable adjustment for confounders.Neuroimaging biomarkers, particularly ASPECTS, perfusion-derived metrics, collateral status, and markers of chronic small-vessel disease, provide important prognostic information for identifying patients at risk of futile recanalization despite successful thrombectomy.AIS: Acute Ischemic Stroke; CCR: Cerebral Collateral Recycle; EVT: Endovascular Thrombectomy; FR: Futile Recanalization; HIR: Hypoperfusion Intensity Ratio; LVO: Large Vessel Occlusion; MT: Mechanical Thrombectomy; rCBV: Relative Cerebral Blood Volume; rLMC: Regional Leptomeningeal Collateral; VO: Venous Outflow.

View details for DOI 10.3174/ajnr.A9095

View details for PubMedID 41213813