Futile and Harmful Reperfusion and the Balance Between Treatment Effect and Overall Outcomes in Stroke

作者：Umberto Pensato, Michael D. Hill, Bijoy K. Menon, Andrew M. Demchuk, Johanna Maria Ospel · 发表于：Stroke · 年份：2025 · DOI：10.1161/strokeaha.125.053226 · 被引用次数：10 · 研究领域：Acute Ischemic Stroke Management、Stroke Rehabilitation and Recovery、Neurological Disease Mechanisms and Treatments

Over the past decades, ischemic stroke research has primarily focused on achieving rapid reperfusion. Endovascular thrombectomy has revolutionized the treatment paradigm for patients with large vessel occlusion, with recent trials showing benefit even in patients with large core at baseline. These findings have led some to advocate for reperfusion in all cases, regardless of infarct size and severity. We critically examine this line of reasoning and introduce 2 important caveats. First, in an individual patient, reperfusion does not necessarily or uniformly translate into meaningful improvement and favorable outcomes. The concept of futile reperfusion is real. As a corollary, trial results capture average effects, and individuals have a wider range of outcomes. Furthermore, results are often reported as relative rather than absolute treatment effects. As baseline prognosis worsens, the absolute likelihood of a good outcome may fall below a threshold where the intervention is no longer justified, despite a favorable relative treatment effect. Second, in a small subset of patients, reperfusion may actively worsen outcome; this is harmful reperfusion. While additional harm may seem negligible in such a high-risk population, this rationale is flawed as it encourages therapeutic actionism and violates the foundational medical ethical principle of primum non nocere. To advance patient care, we must move beyond a one-size-fits-all reperfusion model that focuses only on vessel reopen...