Safety and efficacy of endovascular treatment for progressive large vessel occlusion stroke presenting 24-72 h after onset: a propensity score-matched analysis.

BACKGROUND AND PURPOSE: To evaluate the efficacy and safety of endovascular treatment (EVT) versus standard medical therapy (SMT) in patients with progressive large vessel occlusion (LVO) presenting 24-72 h after onset. METHODS: We retrospectively analyzed patients with progressive LVO and perfusion mismatch (tissue window) between 24 and 72 h after onset. Propensity score matching (PSM) was performed to balance baseline characteristics. The primary outcome was functional independence (modified Rankin Scale [mRS] 0-2) at 90 days. Secondary outcomes included 90-day mortality and symptomatic intracranial hemorrhage (sICH). RESULTS: A total of 164 patients were included (EVT, n = 48; SMT, n = 116). The EVT group showed significantly better 90-day functional outcomes (median mRS: 3 [IQR 2-4] vs. 4 [IQR 3-6]; OR 1.86, 95% CI 1.13-5.25; p = 0.018) and higher functional independence rates (43.8% vs. 12.9%; OR 5.24, 95% CI 2.73-10.05; p < 0.001) compared with the SMT group. EVT was also associated with reduced severe disability or death (18.8% vs. 47.4%; OR 0.26, 95% CI 0.12-0.56; p < 0.001) and lower all-cause mortality (12.5% vs. 37.9%; OR 0.23, 95% CI 0.09-0.51; p = 0.001). The incidence of sICH did not differ significantly between groups (10.4% vs. 6.0%; OR 1.81, 95% CI 0.65-5.08; p = 0.409). These findings remained consistent after PSM and in sensitivity analyses excluding non-witnessed strokes. Subgroup analysis indicated that good collateral circulation (Tan 2-3) significantly predicted functional independence (73.1% vs. 9.1%; OR 27.14, 95% CI 4.83-152.45; p < 0.001). CONCLUSION: For progressive LVO patients presenting 24-72 h after onset with favorable perfusion imaging, EVT was associated with improved functional outcomes and lower mortality, without a significant increase in hemorrhage risk. Furthermore, good collateral circulation is a statistically significant factor associated with EVT benefit.