Background and Purpose: Prediction of futile recanalization (FR), where full reperfusion fails to result in long-term functional independence after mechanical thrombectomy (MT), is essential for patient management.

Methods: This retrospective single-center analysis examined patients treated for anterior circulation large vessel occlusion (LVO) with successful MT (mTICI 2c–3) between January 2014 and April 2019. FR was defined as a modified Rankin Scale (mRS) >2 at 90 days or mRS > pre-stroke mRS. Multivariable analysis assessed pre-treatment variables for their association with FR, and performance was compared with a model including post-treatment data.

Results: Of 1146 patients, 549 experienced successful MT, with 262 (47.7%) having FR. Independent predictors of FR included male sex (OR 1.98), age (OR 1.05), NIHSS on admission (OR 1.10), pre-stroke mRS (OR 1.22), neutrophil-lymphocyte ratio (OR 1.03), baseline ASPECTS (OR 0.77), and absence of bridging IV lysis (OR 1.62). The pre-treatment prediction model’s AUC was 0.78, which increased to 0.86 when post-treatment parameters, particularly early neurological improvement (OR 15.0), were included.

Conclusion: Several pre-interventional factors can predict FR with reasonable accuracy, but incorporating post-treatment data, especially early neurological improvement, significantly enhances prediction accuracy.