Full medical support for malignant middle cerebral artery infarction after successful recanalization in patients with large vessel occlusion stroke: trading death for severe disability?

Background A subset of patients with anterior circulation large vessel occlusion (LVO) stroke progressed to malignant middle cerebral artery infarction (mMCAi) despite successful recanalization following endovascular treatment. This study investigated whether full medical support (FMS) could improve functional outcomes beyond reducing mortality in this population. Methods In this retrospective cohort study, consecutive patients from hospital-based stroke registry (May 2015 to August 2021) with anterior LVO stroke who developed mMCAi despite successful recanalization were included. Patients were stratified into two groups based on the intensity of postprocedural care: the FMS group (aggressive neurocritical care) and the non-FMS group (limited medical support or comfort care). The primary outcome was a favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0–4 at 90 days. Secondary outcomes included ordinal shift analysis of the mRS, rates of functional independence (mRS 0–2 and 0–3), and 90-day mortality. Results Among 114 eligible patients, 65 were assigned to the FMS group and 49 to the non-FMS group. The FMS group demonstrated a significantly higher rate of the primary outcome (46.2% vs. 6.1%; P < 0.001) along with a markedly lower 90-day mortality (23.1% vs. 81.6%; P < 0.001) compared to the non-FMS group. After adjustment for age, sex, and confounders, FMS remained independently associated with increased odds of achieving mRS 0–4 (adjusted odds ratio [aOR], 5.88; 95% CI, 1.31–26.40; P = 0.021) and with reduced mortality (aOR, 0.14; 95% CI, 0.05–0.42; P < 0.001), while no statistically significant difference was observed in the proportion of patients achieving an mRS of 0–2 or in those achieving an mRS of 0–3. Conclusions In patients who developed mMCAi after successful recanalization, FMS is associated with a greater meaningful functional recovery (mRS 0–4). These findings challenge the “death over disability” paradigm, suggesting that withdrawal of aggressive medical care in this population should be approached with caution.