Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are effective, established treatments in AIS. Patients with pre-existing dementia were either excluded or underrepresented from the landmark trials that established benefits of these therapies. There is limited evidence regarding impact of these therapies in these patients.

The Florida Stroke Registry prospectively utilizes statewide data of all acute stroke admissions across 182 hospitals using GWTG. Pre-existing dementia defined as diagnosis of dementia or patients taking memory medications on admission. Summary statistics were used for patient characteristics and univariate analysis of acute reperfusion therapies (IVT and/or EVT only, or no reperfusion) was performed. Primary Outcome was discharge modified Rankin score.

From 2016-2023, 197,397 cases of AIS were included, 4344 patients had pre-existing dementia. Patients with pre-existing dementia were more likely to be older (84 vs 71 years, p <0.001), female (63% vs 49% p <0.001), non-Hispanic white (66% vs 65% p < 0.001), have higher baseline mRS, have higher arrival NIHSS, but had similar arrival times compared to those without dementia. They were less likely to receive acute reperfusion therapies (22.1 % vs 47.6%), less likely to be discharged home (31% vs 49% p< 0.001), and with higher rates of death (4% vs 3% p < 0.001). Reperfusion therapy outcomes of death [NA1] during hospitalization occurred in 4.6%, both 8%, IVT only 4.6%, MT only 11%, or no reperfusion 3.5% p 0.0001.

In this real-world analysis, we demonstrate that patients with pre-existing dementia have different demographics, presentation, and outcomes than the general population - it is a strong negative predictor of the utilization of reperfusion therapies in practice. This study is hypothesis generating and supports the rationale for ongoing multistep adaptive platform randomized trials in patients with pre-existing dementia.