The Effectiveness of Mechanical Thrombectomy Following the Siriraj Stroke Fast Track Activation Protocol

Background/Objectives: Mechanical thrombectomy (MT) has become the standard treatment for ischemic stroke patients with large vessel occlusion (LVO). However, there is limited understanding of the factors influencing outcomes, particularly in the Thai population. This study aimed to evaluate the effectiveness of MT following the Siriraj Stroke Fast Track Activation Protocol and to identify predictors of favorable outcomes. Methods: A single-center prospective cohort study enrolled 120 consecutive patients with LVO who underwent MT between April 2023 and August 2024. The primary outcome was favorable functional status (modified Rankin Scale 0–2) at 3 months. Univariate and multivariate logistic regression analyses were performed to identify independent predictors. Results: Among 120 patients (median age 68 years; 53% male), 57% achieved favorable outcomes at 3 months. Successful recanalization (modified Treatment in Cerebral Ischemia ≥ 2b) was achieved in 85%, with first-pass effect in 42%. The mortality rate was 7.5%, and symptomatic intracranial hemorrhage occurred in 3.3%. Multivariable analysis was restricted to pre- and intra-procedural variables and estimated by Firth’s penalized-likelihood method. Independent predictors of favorable outcome were successful recanalization (aOR 19.51, 95% CI 2.47–274.05; p = 0.004), absence of diabetes mellitus (aOR 6.22, 95% CI 1.58–32.87; p = 0.008), lower baseline NIHSS (aOR 0.87 per point, 95% CI 0.76–0.96; p = 0.005), and red/mixed thrombus composition (aOR 3.06, 95% CI 1.01–9.96; p = 0.049). Younger age, higher baseline ASPECTS and a minimum intra-procedural diastolic blood pressure ≥ 55 mmHg showed consistent but non-significant associations. Post-procedural measures such as the 24 h NIHSS were deliberately excluded from the model because they lie on the causal pathway to the 3-month outcome. Conclusions: The outcomes of MT at Siriraj Hospital are comparable to those reported in international studies. Successful recanalization, absence of diabetes, lower baseline stroke severity and red/mixed thrombus composition were independently associated with favorable outcome. The thrombus-composition finding is novel in this population but should be regarded as hypothesis-generating and requires confirmation with immunohistochemical and digital-image analysis in larger cohorts. The protocol described here is resource-appropriate and may be transferable to other stroke centers in low- and middle-income settings.