Abstract Background and aims Balloon guide catheters (BGC) provide proximal flow arrest during mechanical thrombectomy (MT), potentially improving thrombus retrieval efficiency and reducing distal embolization. However, prospective randomized data comparing BGC versus non-BGC approaches remain limited. We analyzed the impact of BGC use on clinical and angiographic outcomes in the PROST trial. Methods PROST was a multicenter, prospective, randomized trial comparing pRESET versus Solitaire stent retrievers in patients with large vessel occlusion stroke (NCT04102046). In this post-hoc analysis, we compared patients treated with BGC (n=152) versus non-BGC (n=170). The primary outcome was 90-day functional independence (modified Rankin Scale mRS 0-2). Secondary outcomes included first-pass effect (FPE; expanded TICI eTICI ≥2c), complete reperfusion (eTICI ≥2c), and 90-day mortality. Multivariable logistic regression adjusted for age, sex, baseline NIHSS, comorbidities, IV tPA, and anesthesia type. Results Of 322 patients with BGC data, baseline characteristics were balanced between groups (median age 71vs74 years,p=0.11). BGC use was associated with significantly higher rates of 90-day functional independence (63.2% vs 45.3%; OR2.07, 95% CI1.32-3.24;p=0.002). BGC patients demonstrated superior FPE (51.7%vs36.3%;OR1.87,95%CI1.20-2.93;p=0.007). Mortality at 90 days was significantly lower with BGC (9.2% vs 18.2%;OR 0.45,95%CI0.23-0.89;p=0.024). No difference was observed in symptomatic intracranial hemorrhage or embolization to new territory. After multivariable adjustment, BGC remained independently associated with functional independence (adjusted OR1.74,95%CI1.02-3.06). Conclusions In this post-hoc analysis of the PROST trial, BGC use was associated with significantly improved functional outcomes, higher first-pass and complete reperfusion rates, and reduced mortality compared to non-BGC approaches. Conflict of interest None
Samaniego et al. (2026) studied this question.