Cognitive outcomes after endovascular thrombectomy in ischemic stroke: a systematic review

Background/objective: Endovascular thrombectomy (EVT) is the standard treatment for acute ischemic stroke due to large-vessel occlusion (LVO), but its impact on cognition is less clearly defined despite the high prevalence of post-stroke cognitive impairment. We systematically reviewed randomized controlled trials and observational studies reporting objectively measured cognitive outcomes after EVT in adults with acute ischemic stroke. Methods: Following PRISMA 2020, a systematic search of PubMed, Embase, the Cochrane Library, and Scopus was conducted between 1 March and 31 October 2025 for studies published from 1 January 2015 to 31 October 2025. Eligible studies reported objectively measured post-stroke cognitive outcomes after EVT, with or without intravenous thrombolysis (IVT). Due to substantial heterogeneity in cognitive assessment tools, outcome definitions, and follow-up time points, quantitative pooling was not feasible and results were therefore synthesized narratively. Results: Twenty-three studies (∼3,300 participants; 3 RCTs, 20 observational) met the inclusion criteria. Across most comparative studies, EVT was associated with better cognitive outcomes than IVT or best medical therapy, typically yielding on average 1-4 point higher scores on the Montreal Cognitive Assessment (MoCA) or Mini-Mental State Examination (MMSE) at early to mid-term follow-up. The most consistent benefits were observed in executive functions, with more variable but favorable effects on memory. Worse cognitive outcomes were linked to larger infarct volume, combined gray-white matter involvement, territorial infarct patterns, and longer time to reperfusion. Exploratory proteomic work suggested associations between inflammatory and neurotrophic markers and cognitive recovery. Despite these benefits, post-stroke cognitive impairment remained frequent. Conclusion: Endovascular thrombectomy, particularly when performed rapidly with successful reperfusion, is associated with more favorable cognitive outcomes, especially in global cognition and executive function. However, persistent cognitive deficits remain common, highlighting the need for standardized cognitive assessment and longer-term follow-up in future EVT studies. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251156363, identifier CRD420251156363.