Sodium-Glucose Cotransporter 2 Inhibitor Use and Functional Outcomes After Endovascular Thrombectomy in Diabetic Stroke

BACKGROUND: Although preclinical studies and limited clinical evidence suggest potential benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) after acute ischemic stroke, their effects in patients with moderate-to-severe acute ischemic stroke requiring endovascular thrombectomy remain unclear. This study aimed to evaluate whether SGLT2i use after endovascular thrombectomy is associated with improved 3-month functional outcomes in diabetic patients with acute ischemic stroke. METHODS: This retrospective cohort study analyzed prospectively collected data from January 2020 to March 2025 across 4 comprehensive stroke centers in Korea, Italy, and Switzerland. Consecutive adult patients with diabetes were grouped according to whether SGLT2i was used after their endovascular thrombectomy. Propensity score-based methods-including overlap weighting, inverse probability of treatment weighting, and 1:1 propensity score matching-were applied. Outcomes included the shift in 3-month modified Rankin Scale score, favorable (modified Rankin Scale score 0-2), and excellent outcomes (modified Rankin Scale score 0-1) at 3 months. Ordinal and binary logistic regression analyses were performed. RESULTS: Of 429 eligible patients (mean [SD] age, 73.5 [11.1] years; 249 [58.0%] men; median [interquartile range] initial National Institutes of Health Stroke Scale score, 12 [6-18]), 51 (11.9%) received SGLT2i poststroke. Successful recanalization was achieved in 85.3%. In the overlap weighting model (weighted n=37 per group), SGLT2i use was associated with improved 3-month modified Rankin Scale score distribution (common odds ratio, 2.31 [95% CI, 1.30-4.10]) and higher odds of a favorable outcome (odds ratio, 2.26 [95% CI, 1.15-4.43]). Results were consistent across inverse probability of treatment weighting and propensity score matching models, with inverse probability of treatment weighting analyses additionally demonstrating significant associations with excellent outcomes. No significant effect modification was observed across key clinical subgroups. CONCLUSIONS: Poststroke SGLT2i therapy after endovascular thrombectomy was associated with improved 3-month functional outcomes in this multicenter retrospective analysis of diabetic patients. These findings suggest a potential therapeutic role for SGLT2i in poststroke diabetes management and support future prospective trials.