To investigate the efficacy and safety of endovascular treatment (EVT) guided by CT perfusion imaging (CTP) in patients with minor stroke caused by emergent large vessel occlusion (ELVO) in the anterior circulation.

A retrospective, consecutive cohort of patients with anterior circulation ELVO-related minor stroke admitted to 8 hospitals between January 2021 and December 2023 was enrolled. Based on the initial treatment strategy, patients were divided into the EVT group (n=74) and the best medical therapy (BMT) group (n=110). Treatment outcomes [24-hour National Institutes of Health stroke scale (NIHSS) score, 72-hour NIHSS score, discharge NIHSS score, incidence of early neurological deterioration (END)], safety [incidence of symptomatic intracranial hemorrhage (sICH)], and follow-up outcomes [90-day modified Rankin scale (mRS) score, 1-year ischemic stroke recurrence rate, and mortality] were compared between the two groups. Procedural data for the EVT group [door-to-puncture time (DPT), post-procedural modified Thrombolysis in Cerebral Infarction (mTICI) grade] were collected. All patients underwent cranial CTP assessment before treatment, within 3 days after treatment, and at the 90-day follow-up. The volumes of the infarct core (region with relative cerebral blood flow ＜30%) and the hypoperfusion region (region with Tmax ＞6 s) were compared between the two groups. Independent samples t test or Mann-Whitney U test was used for comparison of continuous data between groups. The χ² test was used for comparison of categorical data between groups.

The immediate successful recanalization rate (mTICI grade ≥2b) in the EVT group was 95.95%. Compared with the BMT group, the EVT group demonstrated significantly lower NIHSS scores at 24 hours [2 (0, 8) vs 2 (1, 10)], 72 hours [1 (0, 10) vs 1 (0, 14)], and at discharge [0 (0, 7) vs 1 (0, 12)], along with a significantly lower incidence of END (13.51% vs 30.00%). These differences were statistically significant (Z=-4.007, -4.677, -4.563, χ²=6.714; P＜0.001, ＜0.001, ＜0.001, =0.010). At the 90-day follow-up, the EVT group had significantly higher proportions of patients with favorable functional outcomes (86.49% vs 72.73%, χ²=4.923, P=0.027) and excellent functional outcomes (68.92% vs 47.27%, χ²=8.412, P=0.004), as well as a significantly lower 1-year ischemic stroke recurrence rate (5.41% vs 16.36%, χ²=4.059, P=0.044). The incidence of sICH (2.70% vs 1.82%) and the 1-year mortality rate (4.05% vs 1.82%) were slightly higher in the EVT group than in the BMT group, but the differences were not statistically significant (χ²=0.000, 0.205; P＞0.999, =0.651). Compared with BMT, EVT significantly reduced the volumes of the infarct core and the hypoperfusion region in the early phase (all P＜0.05). At the 90-day follow-up, the hypoperfusion volume decreased significantly from baseline in both the EVT and BMT groups (Z=-10.504, P＜0.001; Z=-12.819, P＜0.001, respectively). Furthermore, the EVT group exhibited a significantly smaller hypoperfusion volume than the BMT group (Z=-9.897, P＜0.001).

EVT is safe and effective for minor strokes caused by anterior circulation ELVO. Early administration of EVT in these patients can significantly reduce the volumes of the infarct core and hypoperfusion region, thereby preventing END and ischemic stroke recurrence.