Endovascular thrombectomy versus medical management in patients with dementia and acute ischaemic stroke

OBJECTIVE: While pre-existing dementia is a known negative predictor for good endovascular thrombectomy (EVT) outcomes, comparative efficacy and safety data of EVT versus best medical management (BMM) for large vessel occlusion (LVO) patients with dementia are limited. This study compares hospitalisation outcomes of EVT versus BMM for LVO patients with underlying dementia. METHODS: Using the US Nationwide Readmissions Database from 2016 to 2022, we retrospectively identified adult patients with dementia who presented with LVO stroke. The primary outcome was discharge to home. Secondary outcomes included in-hospital mortality, length-of-stay and complications. Patients who underwent EVT were compared to those who received BMM after propensity score matching. Interaction and subgroup analyses assessed treatment effect heterogeneity associated with age and dementia type. RESULTS: Among 37 298 patients included, 6618 EVT and 13 092 BMM patients remained after propensity score matching. Home discharge rates were similar between groups (27.1% vs 26.4%, P = .51). EVT was associated with longer length-of-stay (median 7 vs 6 days, P < .001) and increased intracranial haemorrhage (23.9% vs 11.1%, P < .001), with no significant difference in mortality (15.0% vs 14.9%, P = .87). Patient age significantly moderated EVT effectiveness (interaction P < .001), and EVT among patients <75 years old was significantly associated with higher rates of home discharge (36.7% vs 26.8%, P < .001). Additionally, EVT appeared more effective for patients with vascular dementia (vs Alzheimer's disease, interaction, P = .014), among whom EVT was associated with significantly higher rates of home discharge (32.7% vs 25.2%, P = .007). INTERPRETATION: Treatment response to EVT among LVO stroke patients with dementia was heterogeneous, and EVT was beneficial for patients <75 years old and those with vascular dementia.