Endovascular thrombectomy activity as a candidate marker of organised acute stroke-service capacity: a global burden of disease-based European panel study

Acute stroke-care organisation might contribute to variation in ischaemic stroke outcomes across Europe. We assessed whether national endovascular thrombectomy activity was associated with Global Burden of Disease-derived ischaemic stroke burden across European and adjacent countries.

We conducted a repeated cross-sectional ecological analysis of a balanced three-wave panel of 39 countries (2016, 2019 and 2020) using a consistent thrombectomy data source. The primary outcome was the ischaemic stroke mortality-to-incidence ratio. We used a within-between model with wave fixed effects, adjusted for Socio-Demographic Index and population aged 65 years or older.

Between countries, higher thrombectomy activity was associated with a lower mortality-to-incidence ratio (fully standardised β = -0.42, 95% confidence interval -0.79 to -0.05; P = .027), whereas no within-country association was detected (β = +0.10, -0.07 to +0.26). The between-country estimate attenuated after joint adjustment for health expenditure and Universal Health Coverage (β = -0.28; P = .051) and after adjustment for stroke incidence (β = -0.33; P = .061). In leave-one-country-out analyses, P values ranged from .007 to .061.

The between-country estimate is more vulnerable to unmeasured national differences and could not be separated from health-system resources. This ecological study cannot estimate the causal effect of increasing thrombectomy provision.

National thrombectomy activity distinguished countries with lower ischaemic stroke mortality relative to incidence but did not track within-country change. It remains a candidate marker for cross-country comparison, not an established indicator for monitoring change, and should be interpreted alongside directly measured quality-of-care indicators.