E-028 Cooling strategies integrated with endovascular thrombectomy for acute ischemic stroke: feasibility, safety, and clinical outcomes

Introduction/Purpose Despite advances in endovascular thrombectomy (EVT) for acute ischemic stroke, many patients remain with significant neurological disability even after successful reperfusion. This highlights secondary injury mechanisms, including ischemia-reperfusion injury, cerebral edema, and infarct progression. Therapeutic hypothermia has been explored as a neuroprotective strategy; however, earlier systemic approaches showed limited efficacy and increased complications. In the EVT era, newer cooling strategies aim to improve timing, delivery, and integration with reperfusion therapy. This study synthesizes contemporary evidence on EVT-integrated cooling approaches and evaluates their feasibility, safety, and impact on outcomes. Materials and Methods A structured narrative review of 40 studies was conducted, including randomized trials, prospective cohorts, and feasibility studies evaluating cooling strategies in acute ischemic stroke. Modalities were categorized as systemic hypothermia, selective intra-arterial (IA) cooling, and non-invasive convective or surface cooling. Outcomes included cooling kinetics, integration with EVT, imaging biomarkers (infarct volume and progression), functional recovery (NIHSS and 90-day modified Rankin Scale [mRS]), and safety endpoints (pneumonia, hemorrhage, and mortality). Results Systemic hypothermia showed no significant improvement in functional outcomes in randomized trials (e.g., mRS shift OR 1.01, 95% CI 0.48-2.13) and increased pneumonia risk (OR 1.99 in ICTuS-2). In contrast, selective IA cooling showed signals of efficacy, with reductions in infarct volume of 19.1 mL (p=0.038) and 28.4 mL (p=0.02). A randomized trial reported that patients undergoing selective IA cooling were 47% more likely to achieve favorable outcomes at 90 days. These approaches did not demonstrate increases in intracranial hemorrhage or mortality. Non-invasive cooling strategies demonstrated feasibility and measurable brain temperature modulation without delaying EVT, though quantitative efficacy data remain limited. Across studies, functional outcomes were heterogeneous, with selective approaches suggesting benefit and systemic strategies remaining neutral. Safety profiles were modality-dependent, with systemic approaches associated with higher infection risk, while selective strategies showed acceptable safety. Conclusion Cooling strategies in the EVT era are evolving toward early initiation, targeted delivery, and workflow integration. Selective intra-arterial and non-invasive methods demonstrate feasibility and acceptable safety, with emerging signals of benefit in infarct reduction and functional recovery. However, evidence is limited by heterogeneity, modest sample sizes, and inconsistent endpoints. Large, multicenter trials with standardized parameters and harmonized outcomes are required to determine whether EVT-integrated cooling provides meaningful neuroprotection. Disclosures A. Saloum: None. A. Irshaid: None. C. Rawson: None. A. Mittal: None. M. Karsy: None. M. Pahlevani: None. A. Barber: None. D. Campbell: None.