Racial disparities in off-guideline endovascular treatments for acute ischaemic stroke

Endovascular thrombectomy (EVT) is an established treatment for large vessel occlusion acute ischaemic stroke, and indications have expanded to include broader patient groups. Whether this expansion has occurred equitably across racial and ethnic populations remains unclear.

We analysed the SVIN (Society of Vascular and Interventional Neurology) Registry+ (2014-2021) to assess disparities in EVT use. Patients were categorised by race/ethnicity (non-Hispanic white (NH-white), NH-black, Hispanic, Asian, other). Off-guideline EVT was defined as treatment in patients with age >85, pre-stroke disability (modified Rankin Scale >1), distal occlusion, large core (Alberta Stroke Program Early CT Score <6), mild symptoms (National Institutes of Health Stroke Scale (NIHSS) <6) or presentation >24 hours. The primary outcome was EVT use by off-guideline criteria and race; secondary outcomes included intracranial haemorrhage (ICH), symptomatic ICH and temporal trends.

Among 7035 EVT treatments, NH-black patients were younger and less likely to present within 6 hours of onset, with lower thrombolysis rates. Multivariable logistic regression showed that compared with NH-white, NH-black patients >85 years old and with NIHSS <6 were less likely to undergo EVT (OR 0.40, 95% CI 0.30 to 0.51 and OR 0.69, 95% CI 0.49 to 0.97, respectively), and Hispanic patients with an NIHSS <6 were more likely to receive EVT (OR 1.42, 95% CI 1.01 to 2.00). Linear regression indicated off-guideline EVT rates increased over time among NH-white (R²=0.82, p=0.005) and Hispanic (R²=0.89, p=0.005) patients.

NH-black patients were less likely to receive EVT in specific off-guideline scenarios, while Hispanic patients were more likely in mild stroke presentations. Off-guideline EVT use has risen over time, particularly among NH-white and Hispanic patients, underscoring the need for equity-focused stroke care strategies.