Impact of balloon guide catheter use on procedural efficacy and early neurological outcomes in endovascular thrombectomy for anterior circulation acute ischemic stroke: a propensity-score-matched analysis.

BACKGROUND: The role of balloon guide catheters (BGC) in endovascular thrombectomy for acute ischemic stroke remains controversial, with conflicting evidence regarding clinical outcomes. We evaluated the impact of BGC use on periprocedural metrics and early neurological improvement (ENI). METHODS: In this retrospective study, 541 patients with anterior circulation large vessel occlusion (intracranial ICA/M1/M2) undergoing endovascular thrombectomy at a tertiary stroke center (2018-2025) were 1:1 propensity-score-matched based on baseline characteristics (BGC+ [n = 91] vs. BGC- [n = 91]). Primary outcome was ENI (NIHSS reduction ≥ 8 points at 24 h or NIHSS < 2 at discharge). Secondary outcomes included reperfusion efficacy (groin-to-reperfusion time, first-pass effect [FPE], reperfusion grade), safety outcomes (any intracranial hemorrhage), in-hospital mortality, and length of hospital stay. RESULTS: BGC use was associated with higher FPE (52% vs. 24%, p < 0.001), higher rates of complete reperfusion (mTICI3 65% vs. 43%, p = 0.008), and shorter groin-to-reperfusion times (32 min [IQR 22-58] vs. 69 min [43-95], p < 0.001). ENI occurred more frequently in the BGC group (43% vs. 23%, p = 0.005), and in-hospital mortality was lower (14% vs. 30%, p = 0.01). Length of hospital stay did not differ significantly, and intracranial hemorrhage rate was not increased (18% vs. 22%). In multivariate analysis, BGC use was associated with ENI before, but not after, adjustment for procedural variables. Lower pre-stroke mRS and baseline NIHSS, higher baseline ASPECTS, intravenous thrombolysis, FPE, successful reperfusion, and shorter procedure time were associated with increased odds of ENI. CONCLUSION: BGC use favorably affected reperfusion efficacy, and its association with ENI appeared largely mediated through procedural factors.