Endovascular treatment in acute ischemic stroke patients with pre-stroke disability: A systematic review and meta-analysis

Abstract

This meta-analysis investigated endovascular thrombectomy (EVT) efficacy and safety versus best medical treatment (BMT), including intravenous thrombolysis or other treatments when applicable, in acute ischemic stroke (AIS) patients with pre-stroke disability (mRS >2), a group frequently excluded from large vessel occlusion trials. Following PRISMA 2020 guidelines, systematic searches of PubMed, Cochrane Central, Web of Science, Scopus, and Embase databases (inception-July 2025) identified English studies (≥4 patients) comparing EVT versus BMT. Data on all-cause mortality, return to baseline mRS, and symptomatic intracranial hemorrhage (sICH) were extracted. OR with 95% CI was estimated via a random-effects model. Five studies (1400 patients; 897 EVT and 503 BMT) with pre-stroke mRS 2–4 were included. EVT significantly reduced all-cause mortality (OR: 0.49, 95% CI: 0.29–0.82, p = .007), demonstrating moderate heterogeneity (I² = 66.9%). It also improved return to baseline mRS (OR: 3.21, 95% CI: 2.02–6.09, p < .001) with negligible heterogeneity (I² = 0%). sICH was more frequent in EVT (OR: 2.24, 95% CI: 0.84–5.94) but not statistically significant (p = .11). EVT offers survival benefits and increased return to baseline functional status for AIS patients with pre-stroke disability, without definitively increasing sICH. Prospective studies are crucial for informing inclusive clinical guidelines.