Endovascular Treatment in Acute Ischemic Stroke Patients with Pre-stroke Disability: A Systematic Review and Meta-analysis
Nicole Baptista de Oliveira1, Mariana Letícia Bastos Maximiano3, Lucca Tamara Alves Carretta1, Rudolfh Batista Arend4, Henrique Padilha Gnoatto4, Rafael Torres Fonseca dos Santos5, Filipe Virgilio Ribeiro6, Ocílio Ribeiro Gonçalves7, Beatriz Gonçalves da Silva Miroski Gerente8, Pedro Rodrigues Teixeira1, Tassiane Cristina Morais2, Fernando Rocha Oliveira2, Leandro de Assis Barbosa9, AHMET GÜNKAN10
1Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), 2Postgraduate department, Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), 3Federal Fluminense University, 4Federal University of Fronteira Sul, 5Medical Education Institute Vista Carioca, 6Barão de Mauá University Center, 7Federal University of Piauí, 8University of Southern Santa Catarina, 9Department of Neurosurgery, Hospital Estadual Central, 10University of Arizona
Objective:
To compare the efficacy and safety of Endovascular Treatment (EVT) with Best Medical Treatment (BMT) in acute ischemic stroke patients with prestroke disability (mRS ≥2).
Background:
Ischemic stroke remains a leading cause of disability and mortality. Although intravenous thrombolysis (IVT) and EVT are central to acute stroke care, pivotal trials largely excluded patients with prestroke disability (modified Rankin Scale [mRS] ≥2), limiting generalizability. This group lacks clear management, as standard favorable outcomes (mRS 0-2) are often inapplicable.
Design/Methods:
Systematic searches were conducted with no date restrictions in PubMed, Cochrane, Web of Science, Scopus, and Embase from inception to July 2025. We identified original research on EVT in patients with prestroke disability, in English and with ≥4 patients. Data extraction and ROBINS-I risk of bias assessment were independently performed by two reviewers. Statistical analyses in R Studio used a random-effects model to estimate ORs (95% CIs), assessing heterogeneity. Primary outcomes were mortality, return to prestroke mRS, and sICH.
Results:
A total of 1,400 patients were analyzed, including 897 (64%) who received EVT and 503 (36%) who received BMT. All patients had pre-stroke disability, with prestroke mRS 2–4. Pooled analysis showed significantly lower mortality for EVT vs. BMT (OR: 0.49, 95% CI: 0.29–0.82, p=0.007). EVT patients were also significantly more likely to return to pre-stroke mRS level (OR: 3.21, 95% CI: 2.02–5.09, p<0.001). sICH was more frequent with EVT (OR: 2.24, 95% CI: 0.84–5.94), but not statistically significant (p=0.11).
Conclusions:
EVT significantly reduces mortality and improves return to baseline functional status in acute ischemic stroke patients with pre-existing disability. While increased sICH was observed with EVT, it was not statistically significant overall but was driven by one study. Our findings support EVT as a beneficial treatment for this often-excluded patient population, guiding clinical decision-making and addressing a crucial evidence gap.
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