Endovascular thrombectomy in patients with acute ischemic stroke and prestroke mRS 3: a multicenter IPTW analysis...

Evidence for reperfusion therapy in patients with acute ischemic stroke and prestroke disability remains limited because individuals with prestroke modified Rankin Scale (mRS) score of 3 have largely been excluded from randomized trials. We evaluated the effectiveness and safety of reperfusion strategies in this population.

We conducted a multicenter registry-based study including patients with acute ischemic stroke due to large vessel occlusion (LVO) and prestroke mRS score of 3 who presented within 4.5 h of symptom onset. Patients were categorized into medical treatment (MT), intravenous thrombolysis (IVT), or endovascular thrombectomy (EVT). The primary outcome was return to prestroke functional status at 3 months (mRS = 3). Secondary outcomes included ordinal mRS shift, symptomatic hemorrhagic transformation (sHT), and mortality. To reduce treatment-selection bias, inverse probability of treatment weighting (IPTW) based on multinomial propensity scores was applied.

Among 183 patients, 101 received MT, 37 IVT, and 45 EVT. After IPTW adjustment, EVT was associated with a significantly higher likelihood of returning to prestroke functional status compared with MT (OR 7.63, 95% CI 3.02-19.28), whereas IVT showed no significant benefit (OR 1.15, 95% CI 0.34-3.85). EVT was also associated with a favorable shift across the full mRS distribution (common OR 0.32, 95% CI 0.14-0.70). Neither EVT nor IVT increased the risk of sHT or mortality.

EVT was associated with substantial functional benefit without increased safety risk in patients with LVO and prestroke mRS 3, supporting consideration of EVT in selected patients with moderate prestroke disability.