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Introduction Balloon-guide catheters (BGCs) have been linked to better procedural and functional outcomes in endovascular thrombectomy (EVT) in multiple observational studies, but recent findings from the PROTECT-MT trial has challanged this.Aim of Study This study evaluate the association between BGC use and outcomes in a large real-world prospective cohort.Method Patients who underwent EVT for anterior circulation large vessel occlusions (LVOs) between 2017 and 2021 were included in the Swedish EVAS and Riksstroke registries. Baseline and procedural data were collected from the registers. The relationship between BGC use and outcomes was analyzed using uni- and multivariate methods. Good 90-day functional outcome was defined as modified Rankin Scale-score 0–2. Safety outcomes included iatrogenic dissection, perioperative embolization, early neurological deterioration, and 90-day mortality. Subgroup analyses were conducted based on first-line strategy: contact aspiration or stent-retriever (with or without aspiration).Results Among 4843 patients, 2483 underwent EVT for anterior circulation LVOs, with BGC used in 1449 cases (58.4%). BGCs were more often used with stent-retrievers (83.0%) than with contact aspiration only (24.1%, p<0.001). BGC use was associated with higher rates of excellent recanalization (mTICI 2c-3) and first-pass reperfusion, particularly in stent-retriever cases (p<0.001), but not with good revascularization (mTICI 2b-3). No association was found between BGC use and good functional outcome (p=0.947) nor with 90-day mortality (p=0.539). There was no increased risk for safety events.Conclusion BGC-use during EVT was associated with improved recanalization and first-pass reperfusion, primarily in stent-retriever-treated patients. However, no impact on 90-day functional outcome or safety indicators was observed.Conflict of Interest Yes The authors declared the following potential conflicts of interest: JW is a founder and shareholder of Uman Sense AB and has received speaker honoraria from Siemens Healthineers, Balt group and Medtronic Inc. TA is a consultant for Anaconda, CerenovusJohnson & Johnson/Neuravi, Ceretrieve, Cortirio, Optimize Neurovascular, Rapid Medical and SPRYTE, and a founder and shareholder of Ceroflo.