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Background and Purpose: Different imaging paradigms have been used to select patients for endovascular therapy (ET) in large vessel occlusion stroke (LVOS). We sought to determine whether CT perfusion (CTP) selection improves ET outcomes as compared to non-contrast CT (NCCT) alone.Methods: Review of a prospective single-center interventional database of consecutive patients between September 2010 and March 2016. Patients with anterior circulation strokes undergoing stent-retriever thrombectomy were categorized according to imaging selection: (1) CTP and (2) NCCT alone. Two separate analyses were performed: (1) Uni- and Multivariate analyses of the overall cohort and (2) Matched analysis based on age, baseline NIHSS, and glucose levels.Results: A total of 602 patients were included. CTP-selected patients (n=365; 61%) were younger (p=0.02) and had less comorbidities. On univariate analysis, CTP-selection was associated with higher rates of full reperfusion (mTICI-3, p<0.001), good outcomes (90-day mRS 0-2, p=0.005), lower mortality rates (p=0.005), and a favorable shift in the overall distribution of 90-day mRS (p<0.001) as compared with NCCT alone. The rates of any parenchymal hematoma were comparable between groups (p=0.671). Multivariate logistic regression showed that CTP was independently associated with mTICI-3 (OR=1.79 95%CI [1.27-2.53], p=0.001) and good outcomes (aOR=1.72 95%CI [1.10-2.67], p=0.017). In the matched case-control analysis (n=424 patients), CTP-selection was associated with a favorable shift in the distribution of 90-day mRS (p=0.016), lower 90-day mortality (p=0.02), higher rates of mTICI-3 reperfusion (p<0.001), and a trend towards higher rates of 90-day independence (p=0.06). There was an advantage in the ability of CTP to determine functional outcomes in patients presenting later than 6h (Akaike information criterion (AIC) 199.35 vs. 287.49 and Bayesian information criterion (BIC) 196.71 vs 283.27) and with an ASPECTS ≤7 (AIC 216.69 vs 334.96 and BIC 213.6 vs 329.94).Conclusion: CTP-based selection is associated with a favorable shift in functional outcomes in patients undergoing stent-retriever thrombectomy. Future prospective studies are warranted.