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

Full medical support for malignant middle cerebral artery infarction after successful recanalization in patients with large vessel occlusion stroke: trading death for severe disability? | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Full medical support for malignant middle cerebral artery infarction after successful recanalization in patients with large vessel occlusion stroke: trading death for severe disability? yiting guo, chenzi hu, yukai liu, junshan zhou, jie gao, zhihui huang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8728384/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Apr, 2026 Read the published version in Neurocritical Care → Version 1 posted 5 You are reading this latest preprint version Abstract 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. Large vessel occlusion stroke Malignant middle cerebral artery infarction Full medical support Functional recovery Mortality Figures Figure 1 Introduction Acute ischemic stroke (AIS) is the second leading cause of death and the third leading cause of disability worldwide. Approximately 40% of all stroke cases are caused by large vessel occlusion (LVO) 1 . Endovascular treatment, as the key therapy at acute phase, could rescue the ischemic penumbra, protect the blood-brain barrier and improve long-term prognosis in patients with anterior LVO 2 , 3 . However, 13.2% patients presented large infarct size in the following CT after recanalization, which was termed as malignant middle cerebral artery infarction (mMCAi) 4 . The mMCAi might be due to the baseline large-volume infarction or reperfusion injury, and is recognized as a common predictor of poor outcomes. The management of mMCAi after recanalization in patients with anterior LVO is challenging and controversial. On the one hand, prompt recanalization could improve the patient’s outcome; on the other hand, malignant profile on the following CT was usually associated with severe disability or death. Full medical support (FMS) including decompressive craniectomy (DC), mechanical ventilation, and intensive osmotherapy, has been proven to reduce mortality 5 – 7 . However, a pervasive concern has emerged that such FMS merely “traded death for severe disability,” resulting in a high proportion of survivors with bedridden dependency [modified Rankin Scale (mRS) 5] 8 . Recent studies on patients with large-core ischemic stroke compared FMS to withdrawal of life-sustaining therapy (WLST), and found that implementation of FMS saved the lives of 75% patients with 21% patients achieving functional independence (mRS 0–3), while WLST was associated with near-universal mortality 9 . These findings imply that FMS may provide a critical therapeutic window for meaningful recovery and challenged the prevailing “death over disability” paradigm. Whether FMS could meaningfully improve the long-term outcomes in this specific post-recanalization cohort remains to be rigorously elucidated. This study aimed to evaluate the clinical efficacy of FMS in patients who developed mMCAi following successful recanalization, especially on the functional recovery in addition to mortality. Methods From May 2015 to August 2021, patients were retrospectively screened for enrollment from our prospective hospital-based stroke registry. Inclusion criteria were those who 1) received endovascular treatment for anterior LVO stroke, 2) had successful recanalization after procedure, which was defined as reperfusion to modified Thrombolysis in Cerebral Infarction (mTICI) grade of 2b or 3 on the final angiogram, and 3) had malignant infarction on follow-up CT at 24 hours after onset. The definition of malignant infarction was in accordance with previously reported clinical and radiological criteria as follows: 1) National Institutes of Health Stroke Scale (NIHSS) score > 18 and a level of consciousness of ≥ 1 on item 1a of the NIHSS; (2) large space-occupying middle cerebral artery infarction covering at least 2/3 of the middle cerebral artery territory with compression of ventricles or midline shift; and (3) no other cause of neurological deterioration. All patients or their authorized relatives had given informed consent when entering the stroke registry, and this analysis had been approved by the Ethics Committee of Nanjing First Hospital. All progress notes and physician orders were reviewed for any evidence of limitation in overall aggressiveness of care provided for the patients. Limitation in overall aggressiveness of care contained the following categories: do-not-resuscitate order, withdrawal of aggressive treatment including DC or mechanical ventilation, and deferral of other life-sustaining interventions like fluid support, vasopressors or antibiotics when necessary. Patients were categorized into two groups based on the intensity of post-procedural care: FMS group: defined as preferring comprehensive neurocritical care, including mechanical ventilation for airway protection, continuous sedation, targeted osmotherapy (mannitol or hypertonic saline), and/or life-saving DC. Non-FMS group: patients who received limited medical care or preferred comfort care only. All treatments complied with the current guidelines and determined together by the physicians and patients or their authorized relatives. Baseline characteristics, including age, gender, medical history, laboratory examination results, stroke etiology, admission NIHSS score, extent of early cerebral ischemia assessed by the Alberta Stroke Program Early Computed Tomography score (ASPECTS), and collateral circulation status evaluated by the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) scale, were collected. Information including NIHSS score at 24 hours after onset, treatment progress, hemorrhage transformation and midline shift on 24-hour head CT were also recorded. Deterioration in NIHSS score was determined as an increase of ≥ 1 point from admission to 24 hours. Evaluation of hemorrhagic transformation was composed of any intracranial hemorrhage, parenchymal hematoma (hematoma within the ischemic field with space-occupying effect, PH) and PH type 2 (involving > 30% of the infarcted area). Patient outcome was measured using the mRS which scored from 0 to 6 (0: no symptoms at all, 1: no significant disability despite symptoms: able to carry out all usual duties and activities, 2: slight disability: unable to carry out all previous activities but able to look after own affairs without assistance, 3: moderate disability: requiring some help, but able to walk without assistance, 4: moderately severe disability: unable to walk without assistance, and unable to attend to own bodily needs without assistance, 5: severe disability: bedridden, incontinent, and requiring constant nursing care and attention, 6: death). The primary outcome was a mRS score of 0 (no symptoms) to 4 (moderately severe disability) on 90 days from onset. Other outcomes included the median and distribution of mRS, proportion of mRS 0–2 and 0–3, in-hospital death and death within 90 days. Statistical analyses were performed using R software version 3.5.2 (Institute for Statistics and Mathematics, Vienna, Austria) and Statistical Package for the Social Sciences version 20.0 (SPSS Inc., Chicago, IL, USA). Continuous data were presented as mean ± standard deviation or median (interquartile range) and categorical data as number (percentage). Metric and ordinal variables were analyzed by Student T test and Kruskal–Wallis test, respectively, while frequencies were compared using the chi-square test. Baseline data and outcomes were compared between patients with and without FMS. Logistic regression analyses were performed to study the independent impact of FMS on primary and other outcomes. Age, sex, and variables with P 70 vs. ≤70), gender (male vs. female), complete recanalization (mTICI grade 3 vs. mTICI grade 2b), NIHSS deterioration (yes vs. no) and combined PH (yes vs. no).Language polishing and grammatical corrections were performed using the Gemini platform (Google, Mountain View, CA, USA). The authors have reviewed and edited the output as needed and take full responsibility for the content of the published work. Results A total of 659 patients who had anterior LVO stroke and received endovascular treatment were screened. After excluding subjects with failed recanalization or benign profile of infarction on following head CT, 114 patients with mMCAi and successful recanalization were enrolled into the final analysis. Of these, 49 patients or their authorized relatives presented DNR orders or other documents of limitation in aggressive care, and the rest 65 patients received FMS (FIGURE 1 ). The mean age of included participants was 74.1 ± 11.6 years old and 58.8% were male. Compared to the non-FMS group, patients in the FMS group tended to be younger (72.6 ± 12.6 vs. 76.2 ± 9.9 years old, p = 0.083), had lower fasting glucose (8.01 ± 2.38 vs. 9.08 ± 2.92 mmol/L, p = 0.038), lower 24-hour NIHSS score [23 (21–28) vs. 30 (24–35), p < 0.001], less severe midline shift [3.9 (0-6.3) vs. 8.5 (5.2–13.1) mm, p < 0.001], and contained a significantly smaller proportion of diabetes (63.1% vs. 81.6%, p = 0.038), deterioration in NIHSS score (36.9% vs. 69.4%, p = 0.001), intracranial hemorrhage (49.2% vs. 75.5%, p = 0.006), PH (20.0% vs. 53.1%, p < 0.001), and PH type 2 (7.7% vs. 30.6%, p = 0.002). More details of baseline information were shown in Table 1 . Table 1 Baseline information Total patients ( n = 114) FMS ( n = 65) Non-FMS ( n = 49) p Age, years 74.1 ± 11.6 72.6 ± 12.6 76.2 ± 9.9 0.083 Gender, male 67 (58.8%) 39 (60.0%) 28 (57.1%) 0.848 Medical history Hypertension 91 (79.8%) 49 (75.4%) 42 (85.7%) 0.239 Diabetes 81 (71.1%) 41 (63.1%) 40 (81.6%) 0.038 Atrial fibrillation 76 (66.7%) 44 (67.7%) 32 (65.3%) 0.842 Ischemic stroke 25 (21.9%) 13 (20.0%) 12 (24.5%) 0.650 Laboratory test Admission glucose, mmol/L 9.07 ± 3.56 8.71 ± 2.17 9.54 ± 4.78 0.294 Fasting glucose, mmol/L 8.47 ± 2.67 8.01 ± 2.38 9.08 ± 2.92 0.038 HbA1c, % 6.1 ± 1.1 6.2 ± 1.2 6.4 ± 1.0 0.300 Serum creatinine, umol/L 79.8 ± 26.9 77.7 ± 26.6 82.7 ± 27.4 0.344 ASPECTS 8 (7–8) 8 (7–8) 8 (7–8) 0.943 ASITN/SIR grades 1 (1–2) 1 (1–2) 1 (1–2) 0.577 Etiology of stroke 0.841 LAA 25 (21.9%) 15 (23.1%) 10 (20.4%) CE 81 (71.1%) 46 (70.8%) 35 (71.4%) SOE 1 (0.9%) 1 (1.5%) 0 (0.0%) SUE 7 (6.1%) 3 (4.6%) 4 (8.2%) Admission NIHSS score 21 (16–23) 21 (17–22) 20 (16–24) 0.415 NIHSS score at 24–36 hours 25 (21–35) 23 (21–28) 30 (24–35) < 0.001 Deterioration of NIHSS score 58 (50.9%) 24 (36.9%) 34(69.4%) 0.001 Intravenous thrombolysis 53 (46.5%) 30 (46.2%) 23 (46.9%) 1.000 Onset to door time, min 120 (60–235) 115 (45–235) 130 (65–235) 0.659 Door to recanalization time, min 175 (150–220) 175 (149–220) 175 (150–215) 0.823 Number of passes 2 (1–3) 2 (1–3) 2 (1–3) 0.869 Intracranial hemorrhage on CT 69 (60.5%) 32 (49.2%) 37 (75.5%) 0.006 Parenchymal hematoma 39 (34.2%) 13 (20.0%) 26 (53.1%) < 0.001 Parenchymal hematoma type 2 20 (17.5%) 5 (7.7%) 15 (30.6%) 0.002 Length of midline shift, mm 5.4 (2.7–10.3) 3.9 (0-6.3) 8.5 (5.2–13.1) < 0.001 Note : Values are presented as n (%), mean ± SD, or median [interquartile range] (IQR) as appropriate. Abbreviations: ASPECTS, Alberta Stroke Program Early CT Score; ASTTIN/SIR: American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology Collateral; CE, cardioembolism; CT, computed tomography; FMS, full medical support; HbA1c, Hemoglobin A1c; LAA, large-artery atherosclerosis; NIHSS, National Institutes of Health Stroke Scale; SOE, stroke of other determined etiology; SUE, stroke of undetermined etiology. Note: P < 0.05 indicates statistical significance. Outcome comparisons were summarized in Table 2 . A significantly higher proportion of patients in the FMS group achieved mRS 0–4 compared to the non-FMS group (46.2% vs. 6.1%, P < 0.001). Better prognosis was also observed in the FMS group than in the non-FMS group regarding 90-day mRS score [5 (4–5) vs. 6 (6–6), p < 0.001], distribution of 90-day mRS score (p < 0.001), mRS 0–3 (16.9% vs. 2.0%, p = 0.012), in-hospital death (4.6% vs. 30.6%, p < 0.001) and 90-day mortality (23.1% vs. 81.6%, p < 0.001). Patients with FMS had higher proportion of mRS 0–2, whereas the differences failed to reach statistical significance (9.2% vs. 2.0%, p = 0.236). After adjusting for age, gender and other confounders, FMS significantly increased the proportion of mRS 0–4 (adjusted OR 5.88, 95%CI 1.31–26.40, p = 0.021) and decreased 90-day mortality (adjusted OR 0.14, 95%CI 0.05–0.42, p < 0.001), but failed to influence the proportions of mRS 0–2 (p = 0.851), mRS 0–3 (p = 0.356) or in-hospital death (p = 0.303) (Table 3 ). Table 2 Outcomes of patients with and without full medical support Total patients ( n = 114) FMS ( n = 65) Non-FMS ( n = 49) p Primary outcome mRS 0–4 33 (28.9%) 30 (46.2%) 3 (6.1%) < 0.001 Other outcomes mRS at 90 days 5 (4–6) 5 (4–5) 6 (6–6) < 0.001 Distribution of mRS < 0.001 0 1 1 0 1 1 0 1 2 5 5 0 3 5 5 0 4 21 19 2 5 26 20 6 6 55 15 40 mRS 0–2 7 (6.1%) 6 (9.2%) 1 (2.0%) 0.236 mRS 0–3 12 (10.5%) 11 (16.9%) 1 (2.0%) 0.012 In-hospital death 18 (15.8%) 3 (4.6%) 15 (30.6%) < 0.001 Death within 90 days 55 (48.2%) 15 (23.1%) 40 (81.6%) < 0.001 Abbreviations : FMS, full medical support; mRS, modified Rankin Scale. Note: P < 0.05 indicates statistical significance. Table 3 Logistic association of the association of full medical support and outcomes Crude OR (95% CI) p Adjusted OR (95% CI) p Primary outcome mRS 0–4 13.14 (3.71–46.59) < 0.001 5.88 (1.31–26.40) 0.021 Other outcomes mRS 0–2 4.88 (0.57–41.94) 0.149 1.34 (0.06–29.15) 0.851 mRS 0–3 9.78 (1.22–78.55) 0.032 3.12 (0.28–35.01) 0.356 In-hospital death 0.11 (0.03–0.41) < 0.001 0.38 (0.06–2.39) 0.303 Death within 90 days 0.07 (0.03–0.17) < 0.001 0.14 (0.05–0.42) < 0.001 Abbreviations: CI, confidence interval; FMS, full medical support; OR, odds ratio. Note: P < 0.05 indicates statistical significance. Discussion The main finding of this retrospective study is that FMS might not only decrease mortality of patients with mMCAi after successful recanalization, but also improve the prognosis across multiple metrics. 46.2% patients in the FMS group achieved moderately severe disability or better outcome (mRS 0–4) in 90 days, compared to only 6.1% in the non-FMS group. Additionally, FMS was associated with a higher proportion of mRS 0–3 (16.9% vs. 2.0%). After adjusting for confounding factors including age, gender, and baseline clinical variables, FMS remained an independent predictor of increased mRS 0–4 achievement and decreased 90-day mortality. Subgroup analysis revealed no significant interaction effects of age (> 70 vs. ≤70), gender, complete recanalization status (mTICI 3 vs. 2b), stroke severity, or PH on the association between FMS and mRS 0–4, indicating that FMS may confer benefits across diverse patient subgroups. These findings demonstrated that FMS did not merely trade death for severe disability but rather enabled meaningful functional recovery in a substantial proportion of patients with post-recanalization mMCAi. Few studies have examined the impact of full versus limited medical care on the prognosis of mMCAi, particularly in patients who underwent endovascular treatment and achieved successful recanalization. Previous studies have primarily focused on the effect of DC in the management of malignant ischemic stroke 10 , 11 . A recent long-term follow-up study demonstrated that DC for mMCAi could lead to significant functional improvement over time, with favorable outcomes (mRS ≤ 3) increasing from 22% at 6 months to 42% at a mean follow-up of 8 years 12 . Another study reported that among patients with mMCAi who received both DC and thrombectomy, up to 41.2% achieved an mRS score of 0–4 during follow-up 13 . Aligned with these insights, our findings further established that implementing FMS after successful recanalization significantly increased the likelihood of achieving functional independence (mRS 0–4) at 90 days and substantially reduced mortality in patients with malignant infarction. These results strengthened the evidence that FMS was not futile in the population of mMCAi but rather provided a viable pathway to functional recovery after successful recanalization. In patients with mMCAi following successful recanalization, the decision to pursue FMS or limited medical care extended beyond purely medical considerations into the realm of ethics and personal values 14 . This aligned with broader trends in post-stroke care, as demonstrated in an analysis of the Taiwan Stroke Registry, which reported a rising prevalence of DNR or do-not-intubate orders in stroke patients between 2006 and 2020 15 . Ultimately, whether to proceed with aggressive care might depend on whether patients or their families would later regret the decision. A systematic review on mMCAi survivors after DC revealed that, despite high rates of moderate-to-severe disability (46.8%) and depression (56.1%), the majority of patients and/or caregivers (76.6%) expressed life satisfaction without regret 16 . Similarly, a recent cross-sectional study on long-term quality of life after DC for various etiologies reported significant declines in 36-Item Short Form Health Survey (SF-36) role-physical and role-emotional scores, yet concluded that most patients and caregivers still regarded post-surgery life as acceptable 17 . Our study demonstrated that with aggressive intervention, 46.2% of patients with mMCAi achieved a functional outcome of moderately severe disability or better (mRS ≤ 4) after successful recanalization. Although decision regret in stroke patients or their families has been preliminarily explored 18 , its specific impact in patients achieving functional independence after FMS for mMCAi requires further investigation. Therefore, the clinical application of these findings should be carefully individualized, taking into account each patient's values, treatment expectations, and personal preferences. Our study further identified that patients who developed postoperative intracranial hemorrhage demonstrated a higher propensity for selecting orders of limited medical intervention. Hemorrhagic transformation constitutes a critical complication following endovascular treatment for ischemic stroke, profoundly impairing functional recovery 19 , 20 . An analysis of the ESCAPE-NA1 trial cohort (n = 1097) demonstrated that any intracranial hemorrhage occurred in 34% of patients. Crucially, a severity-dependent relationship was established, wherein PH1 and PH2 subtypes were independently associated with significantly reduced odds of achieving a favorable outcome (mRS 0–2), with adjusted risk ratios of 0.77 and 0.41, respectively 21 . A population-based study revealed that asymptomatic hemorrhagic transformation, encompassing all PH categories, was independently associated with an adverse shift across the entire ordinal range of the 90-day mRS scores (common OR 2.24) and increased mortality, with asymptomatic PH2 conferring the greatest detriment (common OR 3.15) 22 . These findings substantiated that PH-type hemorrhage, irrespective of symptomatic status, serves as a principal mediator of unfavorable outcomes. Conversely, our subgroup analysis revealed no significant interaction effect between PH and the association of FMS with favorable outcomes, suggesting that the prognostic impairment attributed to PH might be less pronounced in patients with mMCAi. However, this finding should be interpreted with caution, as the limited sample size in this subgroup may have reduced statistical power to detect a meaningful interaction. Our study had several limitations. First, as a retrospective observational analysis, it was inherently subject to selection bias. The choice between FMS and non-FMS management was not randomly assigned but was made by patients or their families based on multiple clinical, ethical, and personal considerations. Although we adjusted for known confounders in our multivariable analyses, residual confounding from unmeasured variables, such as pre-stroke functional status and degree of social or familial support, might have influenced both treatment selection and outcomes. Second, the study design did not permit a direct comparison of FMS versus non-FMS as therapeutic strategies in a randomized context. Instead, our analysis effectively contrasted outcomes between patients who received FMS and those who received non-FMS, reflecting a comparison of “treatment received” rather than “treatment assigned”. This distinction was particularly relevant because the non-FMS group likely included patients for whom aggressive care was considered inappropriate due to factors such as unrecorded comorbidities or poor pre-stroke functional status, potentially inflating the observed benefit of FMS. Despite this, the substantial magnitude of outcome differences and the consistency of our findings with prior retrospective studies suggested that selection bias alone was unlikely to fully account for the observed effects. Third, outcome assessment was limited to the 90-day follow-up period, which might not capture long-term functional trajectories. Patients with moderate disability (mRS 3–4) at 90 days might achieve further improvement with continued rehabilitation, implying that our results could underestimate the potential long-term benefits of FMS. Moreover, important dimensions of recovery such as quality of life, cognitive function, and caregiver burden were not evaluated, yet these factors were critically relevant to patient- and family-centered decision-making. Fourth, while FMS was defined broadly to include DC, mechanical ventilation, osmotherapy, and continuous sedation, we did not assess the individual contribution of each treatment to clinical outcomes. Notably, the small subgroup of patients undergoing DC (n = 18, 27.7% of the FMS group) precluded meaningful stratified analysis of its specific effect. Further studies with larger cohorts would be needed to elucidate the relative efficacy of each treatment within the FMS approach to inform more personalized treatment protocols. Conclusion In conclusion, this study demonstrates that FMS is associated with significantly better outcomes in patients who developed mMCAi following successful recanalization for anterior LVO stroke. Compared to non-FMS, FMS not only reduces mortality, but also increases the likelihood of achieving meaningful functional recovery (mRS 0–4) at 90 days, challenging the "death over disability" paradigm. For such patients, withdrawal of aggressive medical care should be approached with caution by the clinical team. Declarations Compliance Statement: This manuscript complies with all instructions to authors. Author Contributions: Conceptualization, Liu Yukai; Methodology, Liu Yukai; Software, Guo Yiting and Hu Chenzi; Validation, Gao Jie, Fu Yijia and Huang Zhihui; Formal Analysis, Guo Yiting and Hu Chenzi; Investigation, Guo Yiting and Hu Chenzi; Resources, Liu Yukai; Data Curation, Guo Yiting and Hu Chenzi; Writing – Original Draft Preparation, Guo Yiting and Hu Chenzi; Writing – Review & Editing, Liu Yukai; Visualization, Guo Yiting; Supervision, Zhou Junshan; Project Administration, Liu Yukai; Funding Acquisition, Liu Yukai. Authorship and Approval: All authors have met the authorship requirements and have approved the final manuscript. AI Disclosure: During the preparation of this work, the authors used Gemini for language polishing and grammatical corrections. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication. Compliance Statement: This manuscript is original, has not been published elsewhere, and is not under consideration by another journal. Ethical Approval: The study was approved by the Ethics Committee of Nanjing First Hospital. Informed consent was obtained from all participants or their legal representatives. Conflict of Interest: The authors declare no conflicts of interest. Reporting Checklist: Adherence to the STROBE reporting checklist is confirmed. Funding: This study was funded by National Natural Science Foundation of China with grant 82102011 to Yukai Liu. 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Neurology. 2025;105(1):e213787. 10.1212/WNL.0000000000213787 . Shen H, Ma Q, Jiao L, et al. Prognosis and Predictors of Symptomatic Intracranial Hemorrhage After Endovascular Treatment of Large Vessel Occlusion Stroke. Front Neurol. 2021;12:730940. 10.3389/fneur.2021.730940 . Chalos V, Venema E, Mulder MJHL, et al. Development and Validation of a Postprocedural Model to Predict Outcome After Endovascular Treatment for Ischemic Stroke. JAMA Neurol. 2023;80(9):940–8. 10.1001/jamaneurol.2023.2392 . Ospel JM, Qiu W, Menon BK, et al. Radiologic Patterns of Intracranial Hemorrhage and Clinical Outcome after Endovascular Treatment in Acute Ischemic Stroke: Results from the ESCAPE-NA1 Trial. Radiology. 2021;300(2):402–9. 10.1148/radiol.2021204560 . Guasch-Jiménez M, Ezcurra Díaz G, Lambea-Gil Á, et al. Influence of Asymptomatic Hemorrhagic Transformation After Endovascular Treatment on Stroke Outcome: A Population-Based Study. Neurology. 2025;104(9):e213509. 10.1212/WNL.0000000000213509 . Supplementary Files STROBEStatement.docx Cite Share Download PDF Status: Published Journal Publication published 15 Apr, 2026 Read the published version in Neurocritical Care → Version 1 posted Reviewers agreed at journal 05 Feb, 2026 Reviewers invited by journal 05 Feb, 2026 Editor invited by journal 04 Feb, 2026 Editor assigned by journal 04 Feb, 2026 First submitted to journal 31 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8728384","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":586270407,"identity":"5a196237-baa2-47a7-8c2a-28effcca583d","order_by":0,"name":"yiting guo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvklEQVRIiWNgGAWjYJCCAwkVNnJs7M0HiNXAzHjgw5k0Yz6eYwlEa2E+OLPtcOI8iRwF4jTIR+QfOMzDdji9jSGHgeFHxTbCWgxvJDMc5uFJz21jOHuAsefMbSK0zABpkbDObWPsS2BmbCNaiwFzOhszkCRKi7xEMsPBGQnOCWxsxGox4HlscODDgTTDNh62hINE+UW+PfHxh8R/NvLy8x8ffPCjghhbLiQgOAcIqwfZ0k+culEwCkbBKBjJAACPqj5vPc6NqgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0008-8070-0109","institution":"Nanjing Medical University","correspondingAuthor":true,"prefix":"","firstName":"yiting","middleName":"","lastName":"guo","suffix":""},{"id":586270408,"identity":"4087a75f-50a4-494f-b042-840dfbaddb96","order_by":1,"name":"chenzi hu","email":"","orcid":"","institution":"Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"chenzi","middleName":"","lastName":"hu","suffix":""},{"id":586270409,"identity":"6ba9d9eb-a266-424e-aee7-99470121115d","order_by":2,"name":"yukai liu","email":"","orcid":"https://orcid.org/0000-0002-8456-8781","institution":"Nanjing First Hospital","correspondingAuthor":false,"prefix":"","firstName":"yukai","middleName":"","lastName":"liu","suffix":""},{"id":586270411,"identity":"d3048559-3fb8-4c53-93fb-7830599810f4","order_by":3,"name":"junshan zhou","email":"","orcid":"","institution":"Nanjing First Hospital","correspondingAuthor":false,"prefix":"","firstName":"junshan","middleName":"","lastName":"zhou","suffix":""},{"id":586270413,"identity":"ec429e62-aba9-4276-8cd3-3ea2ec827a8f","order_by":4,"name":"jie gao","email":"","orcid":"","institution":"Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"jie","middleName":"","lastName":"gao","suffix":""},{"id":586270414,"identity":"a75e06b6-8932-44b3-ba01-4508759e6a5f","order_by":5,"name":"zhihui huang","email":"","orcid":"","institution":"Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"zhihui","middleName":"","lastName":"huang","suffix":""},{"id":586270415,"identity":"7d17f69b-64da-40d1-9bc4-0c8164f821c2","order_by":6,"name":"yijia fu","email":"","orcid":"","institution":"Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"yijia","middleName":"","lastName":"fu","suffix":""}],"badges":[],"createdAt":"2026-01-29 07:28:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8728384/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8728384/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s12028-026-02519-x","type":"published","date":"2026-04-15T15:57:47+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":102239741,"identity":"87491209-78da-44ce-b694-8b949ad3b5a4","added_by":"auto","created_at":"2026-02-09 16:47:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":100605,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of patient selection. A total of 659 patients with anterior stroke who received thrombectomy were screened. After excluding subjects with failed recanalization or benign infarction, 114 patients with malignant infarction and successful recanalization were enrolled into the final analysis. Of these, 65 patients received full medical support, and the rest 49 patients did not.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8728384/v1/1af9a2dcd35293ec35993fca.png"},{"id":107350737,"identity":"b0db7af3-61d7-401f-a422-1ad8b3b359e7","added_by":"auto","created_at":"2026-04-20 16:02:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":545839,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8728384/v1/52168c4c-7e3a-4bd2-9746-cfc86ca376bf.pdf"},{"id":102239742,"identity":"6fc421c2-6512-4f61-95bc-6783ddc9c9be","added_by":"auto","created_at":"2026-02-09 16:47:12","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23319,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEStatement.docx","url":"https://assets-eu.researchsquare.com/files/rs-8728384/v1/4db1bc78737527e9091be54d.docx"}],"financialInterests":"","formattedTitle":"Full medical support for malignant middle cerebral artery infarction after successful recanalization in patients with large vessel occlusion stroke: trading death for severe disability?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute ischemic stroke (AIS) is the second leading cause of death and the third leading cause of disability worldwide. Approximately 40% of all stroke cases are caused by large vessel occlusion (LVO)\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Endovascular treatment, as the key therapy at acute phase, could rescue the ischemic penumbra, protect the blood-brain barrier and improve long-term prognosis in patients with anterior LVO\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. However, 13.2% patients presented large infarct size in the following CT after recanalization, which was termed as malignant middle cerebral artery infarction (mMCAi) \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. The mMCAi might be due to the baseline large-volume infarction or reperfusion injury, and is recognized as a common predictor of poor outcomes.\u003c/p\u003e \u003cp\u003eThe management of mMCAi after recanalization in patients with anterior LVO is challenging and controversial. On the one hand, prompt recanalization could improve the patient\u0026rsquo;s outcome; on the other hand, malignant profile on the following CT was usually associated with severe disability or death. Full medical support (FMS) including decompressive craniectomy (DC), mechanical ventilation, and intensive osmotherapy, has been proven to reduce mortality\u003csup\u003e\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. However, a pervasive concern has emerged that such FMS merely \u0026ldquo;traded death for severe disability,\u0026rdquo; resulting in a high proportion of survivors with bedridden dependency [modified Rankin Scale (mRS) 5] \u003csup\u003e8\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRecent studies on patients with large-core ischemic stroke compared FMS to withdrawal of life-sustaining therapy (WLST), and found that implementation of FMS saved the lives of 75% patients with 21% patients achieving functional independence (mRS 0\u0026ndash;3), while WLST was associated with near-universal mortality\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. These findings imply that FMS may provide a critical therapeutic window for meaningful recovery and challenged the prevailing \u0026ldquo;death over disability\u0026rdquo; paradigm. Whether FMS could meaningfully improve the long-term outcomes in this specific post-recanalization cohort remains to be rigorously elucidated. This study aimed to evaluate the clinical efficacy of FMS in patients who developed mMCAi following successful recanalization, especially on the functional recovery in addition to mortality.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eFrom May 2015 to August 2021, patients were retrospectively screened for enrollment from our prospective hospital-based stroke registry. Inclusion criteria were those who 1) received endovascular treatment for anterior LVO stroke, 2) had successful recanalization after procedure, which was defined as reperfusion to modified Thrombolysis in Cerebral Infarction (mTICI) grade of 2b or 3 on the final angiogram, and 3) had malignant infarction on follow-up CT at 24 hours after onset. The definition of malignant infarction was in accordance with previously reported clinical and radiological criteria as follows: 1) National Institutes of Health Stroke Scale (NIHSS) score\u0026thinsp;\u0026gt;\u0026thinsp;18 and a level of consciousness of \u0026ge;\u0026thinsp;1 on item 1a of the NIHSS; (2) large space-occupying middle cerebral artery infarction covering at least 2/3 of the middle cerebral artery territory with compression of ventricles or midline shift; and (3) no other cause of neurological deterioration. All patients or their authorized relatives had given informed consent when entering the stroke registry, and this analysis had been approved by the Ethics Committee of Nanjing First Hospital.\u003c/p\u003e \u003cp\u003eAll progress notes and physician orders were reviewed for any evidence of limitation in overall aggressiveness of care provided for the patients. Limitation in overall aggressiveness of care contained the following categories: do-not-resuscitate order, withdrawal of aggressive treatment including DC or mechanical ventilation, and deferral of other life-sustaining interventions like fluid support, vasopressors or antibiotics when necessary. Patients were categorized into two groups based on the intensity of post-procedural care: FMS group: defined as preferring comprehensive neurocritical care, including mechanical ventilation for airway protection, continuous sedation, targeted osmotherapy (mannitol or hypertonic saline), and/or life-saving DC. Non-FMS group: patients who received limited medical care or preferred comfort care only. All treatments complied with the current guidelines and determined together by the physicians and patients or their authorized relatives.\u003c/p\u003e \u003cp\u003eBaseline characteristics, including age, gender, medical history, laboratory examination results, stroke etiology, admission NIHSS score, extent of early cerebral ischemia assessed by the Alberta Stroke Program Early Computed Tomography score (ASPECTS), and collateral circulation status evaluated by the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) scale, were collected. Information including NIHSS score at 24 hours after onset, treatment progress, hemorrhage transformation and midline shift on 24-hour head CT were also recorded. Deterioration in NIHSS score was determined as an increase of \u0026ge;\u0026thinsp;1 point from admission to 24 hours. Evaluation of hemorrhagic transformation was composed of any intracranial hemorrhage, parenchymal hematoma (hematoma within the ischemic field with space-occupying effect, PH) and PH type 2 (involving\u0026thinsp;\u0026gt;\u0026thinsp;30% of the infarcted area).\u003c/p\u003e \u003cp\u003ePatient outcome was measured using the mRS which scored from 0 to 6 (0: no symptoms at all, 1: no significant disability despite symptoms: able to carry out all usual duties and activities, 2: slight disability: unable to carry out all previous activities but able to look after own affairs without assistance, 3: moderate disability: requiring some help, but able to walk without assistance, 4: moderately severe disability: unable to walk without assistance, and unable to attend to own bodily needs without assistance, 5: severe disability: bedridden, incontinent, and requiring constant nursing care and attention, 6: death). The primary outcome was a mRS score of 0 (no symptoms) to 4 (moderately severe disability) on 90 days from onset. Other outcomes included the median and distribution of mRS, proportion of mRS 0\u0026ndash;2 and 0\u0026ndash;3, in-hospital death and death within 90 days.\u003c/p\u003e \u003cp\u003eStatistical analyses were performed using R software version 3.5.2 (Institute for Statistics and Mathematics, Vienna, Austria) and Statistical Package for the Social Sciences version 20.0 (SPSS Inc., Chicago, IL, USA). Continuous data were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median (interquartile range) and categorical data as number (percentage). Metric and ordinal variables were analyzed by Student T test and Kruskal\u0026ndash;Wallis test, respectively, while frequencies were compared using the chi-square test. Baseline data and outcomes were compared between patients with and without FMS. Logistic regression analyses were performed to study the independent impact of FMS on primary and other outcomes. Age, sex, and variables with P\u0026thinsp;\u0026lt;\u0026thinsp;0.1 in univariate analysis were adjusted in multivariate models. Subgroup analyses were conducted to study the association of FMS and primary outcome according to age (\u0026gt;\u0026thinsp;70 vs. \u0026le;70), gender (male vs. female), complete recanalization (mTICI grade 3 vs. mTICI grade 2b), NIHSS deterioration (yes vs. no) and combined PH (yes vs. no).Language polishing and grammatical corrections were performed using the Gemini platform (Google, Mountain View, CA, USA). The authors have reviewed and edited the output as needed and take full responsibility for the content of the published work.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 659 patients who had anterior LVO stroke and received endovascular treatment were screened. After excluding subjects with failed recanalization or benign profile of infarction on following head CT, 114 patients with mMCAi and successful recanalization were enrolled into the final analysis. Of these, 49 patients or their authorized relatives presented DNR orders or other documents of limitation in aggressive care, and the rest 65 patients received FMS (FIGURE \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The mean age of included participants was 74.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6 years old and 58.8% were male. Compared to the non-FMS group, patients in the FMS group tended to be younger (72.6\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6 vs. 76.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9 years old, p\u0026thinsp;=\u0026thinsp;0.083), had lower fasting glucose (8.01\u0026thinsp;\u0026plusmn;\u0026thinsp;2.38 vs. 9.08\u0026thinsp;\u0026plusmn;\u0026thinsp;2.92 mmol/L, p\u0026thinsp;=\u0026thinsp;0.038), lower 24-hour NIHSS score [23 (21\u0026ndash;28) vs. 30 (24\u0026ndash;35), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001], less severe midline shift [3.9 (0-6.3) vs. 8.5 (5.2\u0026ndash;13.1) mm, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001], and contained a significantly smaller proportion of diabetes (63.1% vs. 81.6%, p\u0026thinsp;=\u0026thinsp;0.038), deterioration in NIHSS score (36.9% vs. 69.4%, p\u0026thinsp;=\u0026thinsp;0.001), intracranial hemorrhage (49.2% vs. 75.5%, p\u0026thinsp;=\u0026thinsp;0.006), PH (20.0% vs. 53.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and PH type 2 (7.7% vs. 30.6%, p\u0026thinsp;=\u0026thinsp;0.002). More details of baseline information were shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline information\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal patients\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;114)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFMS\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-FMS\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.6\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender, male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (58.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (60.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (57.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.848\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91 (79.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (75.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42 (85.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.239\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (71.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (63.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (81.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (67.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (65.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.842\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIschemic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (21.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (24.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.650\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaboratory test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmission glucose, mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.07\u0026thinsp;\u0026plusmn;\u0026thinsp;3.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.71\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.54\u0026thinsp;\u0026plusmn;\u0026thinsp;4.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.294\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFasting glucose, mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.47\u0026thinsp;\u0026plusmn;\u0026thinsp;2.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.01\u0026thinsp;\u0026plusmn;\u0026thinsp;2.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.08\u0026thinsp;\u0026plusmn;\u0026thinsp;2.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHbA1c, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.300\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum creatinine, umol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.8\u0026thinsp;\u0026plusmn;\u0026thinsp;26.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.7\u0026thinsp;\u0026plusmn;\u0026thinsp;26.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.7\u0026thinsp;\u0026plusmn;\u0026thinsp;27.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.344\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASPECTS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (7\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (7\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (7\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.943\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASITN/SIR grades\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.577\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEtiology of stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.841\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (21.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (23.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (20.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (71.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (70.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (71.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSOE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSUE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (8.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmission NIHSS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (16\u0026ndash;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (17\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (16\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.415\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNIHSS score at 24\u0026ndash;36 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (21\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (21\u0026ndash;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (24\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeterioration of NIHSS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (50.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (36.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34(69.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntravenous thrombolysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (46.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (46.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (46.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnset to door time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120 (60\u0026ndash;235)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e115 (45\u0026ndash;235)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e130 (65\u0026ndash;235)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.659\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoor to recanalization time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e175 (150\u0026ndash;220)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e175 (149\u0026ndash;220)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e175 (150\u0026ndash;215)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.823\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of passes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.869\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntracranial hemorrhage on CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (60.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (49.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (75.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParenchymal hematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (34.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (53.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParenchymal hematoma type 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (17.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (30.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of midline shift, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.4 (2.7\u0026ndash;10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.9 (0-6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.5 (5.2\u0026ndash;13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eNote\u003c/b\u003e: Values are presented as n (%), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, or median [interquartile range] (IQR) as appropriate.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAbbreviations:\u0026nbsp;\u003c/strong\u003eASPECTS, Alberta Stroke Program Early CT Score; ASTTIN/SIR: American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology Collateral; CE, cardioembolism; CT, computed tomography; FMS, full medical support; HbA1c, Hemoglobin A1c; LAA, large-artery atherosclerosis; NIHSS, National Institutes of Health Stroke Scale; SOE, stroke of other determined etiology; SUE, stroke of undetermined etiology.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u0026nbsp;\u003c/strong\u003eP \u0026lt; 0.05 indicates statistical significance.\u003c/p\u003e\u003cp\u003eOutcome comparisons were summarized in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. A significantly higher proportion of patients in the FMS group achieved mRS 0\u0026ndash;4 compared to the non-FMS group (46.2% vs. 6.1%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Better prognosis was also observed in the FMS group than in the non-FMS group regarding 90-day mRS score [5 (4\u0026ndash;5) vs. 6 (6\u0026ndash;6), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001], distribution of 90-day mRS score (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), mRS 0\u0026ndash;3 (16.9% vs. 2.0%, p\u0026thinsp;=\u0026thinsp;0.012), in-hospital death (4.6% vs. 30.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and 90-day mortality (23.1% vs. 81.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients with FMS had higher proportion of mRS 0\u0026ndash;2, whereas the differences failed to reach statistical significance (9.2% vs. 2.0%, p\u0026thinsp;=\u0026thinsp;0.236). After adjusting for age, gender and other confounders, FMS significantly increased the proportion of mRS 0\u0026ndash;4 (adjusted OR 5.88, 95%CI 1.31\u0026ndash;26.40, p\u0026thinsp;=\u0026thinsp;0.021) and decreased 90-day mortality (adjusted OR 0.14, 95%CI 0.05\u0026ndash;0.42, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but failed to influence the proportions of mRS 0\u0026ndash;2 (p\u0026thinsp;=\u0026thinsp;0.851), mRS 0\u0026ndash;3 (p\u0026thinsp;=\u0026thinsp;0.356) or in-hospital death (p\u0026thinsp;=\u0026thinsp;0.303) (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcomes of patients with and without full medical support\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal patients\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;114)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFMS\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-FMS\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary outcome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emRS 0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (28.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (46.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emRS at 90 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (4\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (6\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistribution of mRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emRS 0\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (9.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.236\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emRS 0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (10.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (16.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (15.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (30.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeath within 90 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (48.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (23.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (81.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eAbbreviations\u003c/b\u003e: FMS, full medical support; mRS, modified Rankin Scale.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eNote:\u0026nbsp;\u003c/strong\u003eP \u0026lt; 0.05 indicates statistical significance.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic association of the association of full medical support and outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCrude OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary outcome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emRS 0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13.14 (3.71\u0026ndash;46.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.88 (1.31\u0026ndash;26.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emRS 0\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.88 (0.57\u0026ndash;41.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.34 (0.06\u0026ndash;29.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.851\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emRS 0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.78 (1.22\u0026ndash;78.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.12 (0.28\u0026ndash;35.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.356\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.11 (0.03\u0026ndash;0.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.38 (0.06\u0026ndash;2.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.303\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeath within 90 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.07 (0.03\u0026ndash;0.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.14 (0.05\u0026ndash;0.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u0026nbsp;\u003c/strong\u003eCI, confidence interval; FMS, full medical support; OR, odds ratio.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e P \u0026lt; 0.05 indicates statistical significance.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main finding of this retrospective study is that FMS might not only decrease mortality of patients with mMCAi after successful recanalization, but also improve the prognosis across multiple metrics. 46.2% patients in the FMS group achieved moderately severe disability or better outcome (mRS 0\u0026ndash;4) in 90 days, compared to only 6.1% in the non-FMS group. Additionally, FMS was associated with a higher proportion of mRS 0\u0026ndash;3 (16.9% vs. 2.0%). After adjusting for confounding factors including age, gender, and baseline clinical variables, FMS remained an independent predictor of increased mRS 0\u0026ndash;4 achievement and decreased 90-day mortality. Subgroup analysis revealed no significant interaction effects of age (\u0026gt;\u0026thinsp;70 vs. \u0026le;70), gender, complete recanalization status (mTICI 3 vs. 2b), stroke severity, or PH on the association between FMS and mRS 0\u0026ndash;4, indicating that FMS may confer benefits across diverse patient subgroups. These findings demonstrated that FMS did not merely trade death for severe disability but rather enabled meaningful functional recovery in a substantial proportion of patients with post-recanalization mMCAi.\u003c/p\u003e \u003cp\u003eFew studies have examined the impact of full versus limited medical care on the prognosis of mMCAi, particularly in patients who underwent endovascular treatment and achieved successful recanalization. Previous studies have primarily focused on the effect of DC in the management of malignant ischemic stroke\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. A recent long-term follow-up study demonstrated that DC for mMCAi could lead to significant functional improvement over time, with favorable outcomes (mRS\u0026thinsp;\u0026le;\u0026thinsp;3) increasing from 22% at 6 months to 42% at a mean follow-up of 8 years\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Another study reported that among patients with mMCAi who received both DC and thrombectomy, up to 41.2% achieved an mRS score of 0\u0026ndash;4 during follow-up\u003csup\u003e13\u003c/sup\u003e. Aligned with these insights, our findings further established that implementing FMS after successful recanalization significantly increased the likelihood of achieving functional independence (mRS 0\u0026ndash;4) at 90 days and substantially reduced mortality in patients with malignant infarction. These results strengthened the evidence that FMS was not futile in the population of mMCAi but rather provided a viable pathway to functional recovery after successful recanalization.\u003c/p\u003e \u003cp\u003eIn patients with mMCAi following successful recanalization, the decision to pursue FMS or limited medical care extended beyond purely medical considerations into the realm of ethics and personal values\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. This aligned with broader trends in post-stroke care, as demonstrated in an analysis of the Taiwan Stroke Registry, which reported a rising prevalence of DNR or do-not-intubate orders in stroke patients between 2006 and 2020\u003csup\u003e15\u003c/sup\u003e. Ultimately, whether to proceed with aggressive care might depend on whether patients or their families would later regret the decision. A systematic review on mMCAi survivors after DC revealed that, despite high rates of moderate-to-severe disability (46.8%) and depression (56.1%), the majority of patients and/or caregivers (76.6%) expressed life satisfaction without regret\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Similarly, a recent cross-sectional study on long-term quality of life after DC for various etiologies reported significant declines in 36-Item Short Form Health Survey (SF-36) role-physical and role-emotional scores, yet concluded that most patients and caregivers still regarded post-surgery life as acceptable\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Our study demonstrated that with aggressive intervention, 46.2% of patients with mMCAi achieved a functional outcome of moderately severe disability or better (mRS\u0026thinsp;\u0026le;\u0026thinsp;4) after successful recanalization. Although decision regret in stroke patients or their families has been preliminarily explored\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, its specific impact in patients achieving functional independence after FMS for mMCAi requires further investigation. Therefore, the clinical application of these findings should be carefully individualized, taking into account each patient's values, treatment expectations, and personal preferences.\u003c/p\u003e \u003cp\u003eOur study further identified that patients who developed postoperative intracranial hemorrhage demonstrated a higher propensity for selecting orders of limited medical intervention. Hemorrhagic transformation constitutes a critical complication following endovascular treatment for ischemic stroke, profoundly impairing functional recovery\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. An analysis of the ESCAPE-NA1 trial cohort (n\u0026thinsp;=\u0026thinsp;1097) demonstrated that any intracranial hemorrhage occurred in 34% of patients. Crucially, a severity-dependent relationship was established, wherein PH1 and PH2 subtypes were independently associated with significantly reduced odds of achieving a favorable outcome (mRS 0\u0026ndash;2), with adjusted risk ratios of 0.77 and 0.41, respectively\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. A population-based study revealed that asymptomatic hemorrhagic transformation, encompassing all PH categories, was independently associated with an adverse shift across the entire ordinal range of the 90-day mRS scores (common OR 2.24) and increased mortality, with asymptomatic PH2 conferring the greatest detriment (common OR 3.15)\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. These findings substantiated that PH-type hemorrhage, irrespective of symptomatic status, serves as a principal mediator of unfavorable outcomes. Conversely, our subgroup analysis revealed no significant interaction effect between PH and the association of FMS with favorable outcomes, suggesting that the prognostic impairment attributed to PH might be less pronounced in patients with mMCAi. However, this finding should be interpreted with caution, as the limited sample size in this subgroup may have reduced statistical power to detect a meaningful interaction.\u003c/p\u003e \u003cp\u003eOur study had several limitations. First, as a retrospective observational analysis, it was inherently subject to selection bias. The choice between FMS and non-FMS management was not randomly assigned but was made by patients or their families based on multiple clinical, ethical, and personal considerations. Although we adjusted for known confounders in our multivariable analyses, residual confounding from unmeasured variables, such as pre-stroke functional status and degree of social or familial support, might have influenced both treatment selection and outcomes. Second, the study design did not permit a direct comparison of FMS versus non-FMS as therapeutic strategies in a randomized context. Instead, our analysis effectively contrasted outcomes between patients who received FMS and those who received non-FMS, reflecting a comparison of \u0026ldquo;treatment received\u0026rdquo; rather than \u0026ldquo;treatment assigned\u0026rdquo;. This distinction was particularly relevant because the non-FMS group likely included patients for whom aggressive care was considered inappropriate due to factors such as unrecorded comorbidities or poor pre-stroke functional status, potentially inflating the observed benefit of FMS. Despite this, the substantial magnitude of outcome differences and the consistency of our findings with prior retrospective studies suggested that selection bias alone was unlikely to fully account for the observed effects. Third, outcome assessment was limited to the 90-day follow-up period, which might not capture long-term functional trajectories. Patients with moderate disability (mRS 3\u0026ndash;4) at 90 days might achieve further improvement with continued rehabilitation, implying that our results could underestimate the potential long-term benefits of FMS. Moreover, important dimensions of recovery such as quality of life, cognitive function, and caregiver burden were not evaluated, yet these factors were critically relevant to patient- and family-centered decision-making. Fourth, while FMS was defined broadly to include DC, mechanical ventilation, osmotherapy, and continuous sedation, we did not assess the individual contribution of each treatment to clinical outcomes. Notably, the small subgroup of patients undergoing DC (n\u0026thinsp;=\u0026thinsp;18, 27.7% of the FMS group) precluded meaningful stratified analysis of its specific effect. Further studies with larger cohorts would be needed to elucidate the relative efficacy of each treatment within the FMS approach to inform more personalized treatment protocols.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study demonstrates that FMS is associated with significantly better outcomes in patients who developed mMCAi following successful recanalization for anterior LVO stroke. Compared to non-FMS, FMS not only reduces mortality, but also increases the likelihood of achieving meaningful functional recovery (mRS 0\u0026ndash;4) at 90 days, challenging the \"death over disability\" paradigm. For such patients, withdrawal of aggressive medical care should be approached with caution by the clinical team.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompliance Statement:\u0026nbsp;\u003c/strong\u003eThis manuscript complies with all instructions to authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Conceptualization, Liu Yukai; Methodology, Liu Yukai; Software, Guo Yiting and Hu Chenzi; Validation, Gao Jie, Fu Yijia and Huang Zhihui; Formal Analysis, Guo Yiting and Hu Chenzi; Investigation, Guo Yiting and Hu Chenzi; Resources, Liu Yukai; Data Curation, Guo Yiting and Hu Chenzi; Writing – Original Draft Preparation, Guo Yiting and Hu Chenzi; Writing – Review \u0026amp; Editing, Liu Yukai; Visualization, Guo Yiting; Supervision, Zhou Junshan; Project Administration, Liu Yukai; Funding Acquisition, Liu Yukai.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship and Approval:\u0026nbsp;\u003c/strong\u003eAll authors have met the authorship requirements and have approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAI Disclosure:\u0026nbsp;\u003c/strong\u003eDuring the preparation of this work, the authors used Gemini for language polishing and grammatical corrections. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance Statement:\u0026nbsp;\u003c/strong\u003eThis manuscript is original, has not been published elsewhere, and is not under consideration by another journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003e The study was approved by the Ethics Committee of Nanjing First Hospital. Informed consent was obtained from all participants or their legal representatives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReporting Checklist:\u0026nbsp;\u003c/strong\u003eAdherence to the STROBE reporting checklist is confirmed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study was funded by National Natural Science Foundation of China with grant 82102011 to Yukai Liu.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMalhotra K, Gornbein J, Saver JL. Ischemic Strokes Due to Large-Vessel Occlusions Contribute Disproportionately to Stroke-Related Dependence and Death: A Review. Front Neurol. 2017;8:651. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fneur.2017.00651\u003c/span\u003e\u003cspan address=\"10.3389/fneur.2017.00651\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarraj A, Hassan AE, Abraham MG, et al. Trial of Endovascular Thrombectomy for Large Ischemic Strokes. N Engl J Med. 2023;388(14):1259\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMoa2214403\u003c/span\u003e\u003cspan address=\"10.1056/NEJMoa2214403\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuo X, Ma G, Tong X, et al. Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct. 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Neurology. 2025;104(9):e213509. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1212/WNL.0000000000213509\u003c/span\u003e\u003cspan address=\"10.1212/WNL.0000000000213509\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"neurocritical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"neca","sideBox":"Learn more about [Neurocritical Care](http://link.springer.com/journal/12028)","snPcode":"12028","submissionUrl":"https://www.editorialmanager.com/neca/default2.aspx","title":"Neurocritical Care","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Large vessel occlusion stroke, Malignant middle cerebral artery infarction, Full medical support, Functional recovery, Mortality","lastPublishedDoi":"10.21203/rs.3.rs-8728384/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8728384/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eA 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.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn 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\u0026ndash;4 at 90 days. Secondary outcomes included ordinal shift analysis of the mRS, rates of functional independence (mRS 0\u0026ndash;2 and 0\u0026ndash;3), and 90-day mortality.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 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\u0026thinsp;\u0026lt;\u0026thinsp;0.001) along with a markedly lower 90-day mortality (23.1% vs. 81.6%; P\u0026thinsp;\u0026lt;\u0026thinsp;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\u0026ndash;4 (adjusted odds ratio [aOR], 5.88; 95% CI, 1.31\u0026ndash;26.40; P\u0026thinsp;=\u0026thinsp;0.021) and with reduced mortality (aOR, 0.14; 95% CI, 0.05\u0026ndash;0.42; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while no statistically significant difference was observed in the proportion of patients achieving an mRS of 0\u0026ndash;2 or in those achieving an mRS of 0\u0026ndash;3.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn patients who developed mMCAi after successful recanalization, FMS is associated with a greater meaningful functional recovery (mRS 0\u0026ndash;4). These findings challenge the \u0026ldquo;death over disability\u0026rdquo; paradigm, suggesting that withdrawal of aggressive medical care in this population should be approached with caution.\u003c/p\u003e","manuscriptTitle":"Full medical support for malignant middle cerebral artery infarction after successful recanalization in patients with large vessel occlusion stroke: trading death for severe disability?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 16:47:03","doi":"10.21203/rs.3.rs-8728384/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2026-02-05T11:32:35+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T10:24:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Neurocritical Care","date":"2026-02-04T14:56:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-04T08:27:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurocritical Care","date":"2026-01-31T20:55:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurocritical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"neca","sideBox":"Learn more about [Neurocritical Care](http://link.springer.com/journal/12028)","snPcode":"12028","submissionUrl":"https://www.editorialmanager.com/neca/default2.aspx","title":"Neurocritical Care","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"9b274c7b-2f74-4e1b-b106-ff63d69fefa9","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:00:53+00:00","versionOfRecord":{"articleIdentity":"rs-8728384","link":"https://doi.org/10.1007/s12028-026-02519-x","journal":{"identity":"neurocritical-care","isVorOnly":false,"title":"Neurocritical Care"},"publishedOn":"2026-04-15 15:57:47","publishedOnDateReadable":"April 15th, 2026"},"versionCreatedAt":"2026-02-09 16:47:03","video":"","vorDoi":"10.1007/s12028-026-02519-x","vorDoiUrl":"https://doi.org/10.1007/s12028-026-02519-x","workflowStages":[]},"version":"v1","identity":"rs-8728384","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8728384","identity":"rs-8728384","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}