Post-interventional anxiety and depression in patients undergoing endovascular therapy for acute ischemic stroke: A retrospective cohort study

Abstract

BACKGROUND

Endovascular therapy (EVT) has revolutionized the management of acute ischemic stroke (AIS) caused by large-vessel occlusion, significantly improving functional outcomes. However, the psychological sequelae following EVT, particularly anxiety and depression, remain insufficiently characterized. A clearer understanding of the prevalence and predictors of post-interventional anxiety and depression is essential for delivering comprehensive stroke care.

AIM

To evaluate the prevalence, severity, and risk factors associated with post-interventional anxiety and depression in patients undergoing EVT for AIS.

METHODS

This retrospective cohort study included 228 patients who underwent EVT for AIS at our comprehensive stroke center between January 2022 and December 2025. Anxiety and depression were assessed at 3 months post-intervention using the Hospital Anxiety and Depression Scale. Demographic, clinical, procedural, and functional outcome data were collected. Multivariate logistic regression analyses were performed to identify independent predictors of anxiety and depression.

RESULTS

At 3 months post-EVT, the prevalence of clinically significant anxiety and depression was 31.6% (n = 72) and 38.2% (n = 87), respectively. Comorbid anxiety and depression were observed in 22.4% (n = 51) of patients. Independent predictors of post-interventional depression included female sex [odds ratio (OR) = 2.34, 95% confidence interval (CI): 1.28-4.27, P = 0.006], pre-stroke depression history (OR = 3.89, 95%CI: 1.76-8.61, P = 0.001), higher baseline National Institutes of Health Stroke Scale score (OR = 1.12, 95%CI: 1.04-1.21, P = 0.003), unsuccessful recanalization (OR = 2.67, 95%CI: 1.31-5.44, P = 0.007), and poor functional outcome at 90 days (OR = 3.21, 95%CI: 1.68-6.13, P < 0.001). Independent predictors of post-interventional anxiety included younger age (OR = 0.97, 95%CI: 0.94-0.99, P = 0.018), female sex (OR = 2.18, 95%CI: 1.19-3.99, P = 0.012), and longer hospital stay (OR = 1.08, 95%CI: 1.02-1.15, P = 0.009).

CONCLUSION

Post-interventional anxiety and depression are highly prevalent among patients with AIS following EVT. Routine psychological screening and early intervention strategies should be integrated into post-EVT care pathways, particularly for patients at increased risk.

Key Words: Acute ischemic stroke; Endovascular therapy; Mechanical thrombectomy; Post-stroke depression; Post-stroke anxiety; Psychological outcomes

Core Tip: This study emphasizes the high burden of psychological complications following endovascular therapy for acute ischemic stroke. By identifying distinct clinical and demographic risk factors, our findings underscore the critical need for integrating proactive, risk-stratified mental health screening and targeted psychological interventions into comprehensive post-stroke care pathways.

INTRODUCTION

Acute ischemic stroke (AIS) remains a leading cause of mortality and long-term disability worldwide, imposing substantial burdens on patients, families, and healthcare systems[1]. The introduction of endovascular therapy (EVT), particularly mechanical thrombectomy, has fundamentally transformed the management of AIS caused by large-vessel occlusion (LVO), demonstrating superior efficacy compared with intravenous thrombolysis alone in multiple landmark randomized controlled trials[2]. Since the publication of pivotal studies, including MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND-IA in 2015, EVT has been established as the standard of care for eligible patients presenting with anterior circulation LVO within appropriate time windows[3]. Contemporary evidence has further expanded the therapeutic window, with studies demonstrating benefits in selected patients up to 24 hours from symptom onset based on advanced imaging selection criteria[4]. Despite these remarkable advances in acute stroke intervention, stroke management extends far beyond achieving successful recanalization and infarct reduction. Long-term outcomes depend on addressing the multifaceted sequelae that profoundly impact quality of life and functional recovery.

Among the most significant yet frequently underrecognized complications following stroke are psychological disorders, particularly anxiety and depression, which collectively constitute what has been termed post-stroke mood disorders[5]. Post-stroke depression (PSD) affects approximately one-third of stroke survivors and is consistently associated with poorer functional outcomes, increased mortality, reduced quality of life, and decreased participation in rehabilitation[6]. Post-stroke anxiety, with prevalence estimates of 20%-25%, often co-occurs with depression and further exacerbates adverse recovery trajectories[7].

The pathophysiology underlying these mood disorders is multifactorial, involving complex interactions among neurobiological mechanisms related to stroke-induced brain injury, psychological responses to sudden disability and life changes, and social factors, including altered relationships and vocational disruption[8]. Neuroanatomical studies have implicated lesions in specific brain regions, particularly the left frontal cortex and basal ganglia, in PSD development, although findings remain inconsistent across studies[9]. Furthermore, the disruption of monoaminergic pathways, neuroinflammation, and hypothalamic-pituitary-adrenal axis dysregulation have been proposed as potential neurobiological substrates contributing to post-stroke mood disturbances[10].

The theoretical framework for understanding psychological outcomes following acute medical interventions is grounded in the biopsychosocial model, which posits that health outcomes result from dynamic interactions among biological, psychological, and social factors[11]. Within this framework, patients undergoing EVT for AIS constitute a distinct population characterized by the sudden onset of a life-threatening condition, exposure to an invasive neurovascular procedure, potential awareness of treatment uncertainty, and subsequent confrontation with potential residual neurological deficits. The stress-vulnerability model further suggests that individuals with preexisting psychological vulnerabilities or limited coping resources may be particularly susceptible to developing mood disorders following acute medical events[12]. Additionally, the learned helplessness theory provides insight into how stroke-related functional impairments and dependence on others for activities of daily living may precipitate depressive symptoms through a perceived loss of control[13]. Collectively, these theoretical perspectives underscore the importance of identifying modifiable risk factors and implementing targeted interventions to reduce psychological morbidity among stroke survivors.

Despite extensive research on PSD and post-stroke anxiety in general stroke populations, relatively few studies have specifically examined psychological outcomes in patients treated with EVT[14]. This represents a critical knowledge gap given the distinct characteristics of the EVT population, including the predominance of severe strokes due to LVO, exposure to an emergency invasive procedure, and the potential for either substantial neurological recovery or persistent deficits following intervention. Patients undergoing EVT may experience unique psychological stressors related to the emergency nature of the procedure, limited time for informed decision-making, procedural complications, and the emotional impact of confronting mortality and potential long-term disability[15]. Furthermore, the rapid expansion of EVT eligibility criteria and increasing procedure volumes worldwide highlight the need for a comprehensive understanding of psychological outcomes to inform the development of integrated care pathways that address both physical and mental health needs. The existing literature has largely prioritized functional and neurological outcomes after EVT, with psychological outcomes often treated as secondary endpoints or excluded entirely from outcome evaluations.

Accordingly, the present study aimed to address this gap by investigating the prevalence, severity, and risk factors associated with post-interventional anxiety and depression in a cohort of patients who underwent EVT for AIS. Specifically, we sought to: (1) Determine the prevalence of clinically significant anxiety and depression at 3 months post-EVT; (2) Identify demographic, clinical, procedural, and functional predictors of these outcomes; and (3) Examine the association between psychological outcomes and functional recovery.

MATERIALS AND METHODS

Study design and setting

This retrospective cohort study was conducted at the Affiliated Hospital of Nantong University, China. The study period spanned January 2022 to December 2025, during which all consecutive patients who underwent EVT for AIS were screened for eligibility. The institution maintains a prospectively collected stroke database containing detailed demographic, clinical, imaging, procedural, and outcome data for all patients treated with EVT. This database served as the primary data source for the present investigation. The study protocol was approved by the Institutional Review Board, and the requirement for individual informed consent was waived due to the retrospective nature of the study and the use of de-identified data. All procedures were performed in accordance with the ethical standards of the Declaration of Helsinki and its subsequent amendments.

Participants

The study population comprised adult patients who underwent EVT for AIS during the study period. The inclusion criteria were as follows: (1) Age ≥ 18 years; (2) Confirmed diagnosis of AIS with LVO in either the anterior or posterior circulation; (3) Treatment with EVT, including mechanical thrombectomy with or without intravenous thrombolysis; (4) Completion of psychological assessment at the 3-month follow-up; and (5) Availability of complete medical records, including procedural and outcome data. The exclusion criteria were: (1) Pre-existing severe cognitive impairment that precluded reliable psychological assessment [pre-stroke modified Rankin Scale (mRS) > 3]; (2) Severe aphasia preventing completion of self-report questionnaires; (3) Death prior to the 3-month assessment (all deaths were attributable to severe stroke-related somatic complications rather than to psychological conditions such as suicide); (4) Inability to attend follow-up due to geographic or logistical constraints; (5) Concurrent participation in interventional clinical trials with potential confounding effects on psychological outcomes; and (6) A documented diagnosis of major psychiatric disorders prior to the index stroke event. Sample size calculation was performed a priori based on the primary objective of identifying risk factors for post-interventional depression. Assuming a 35% prevalence of PSD, as reported in prior studies, and an anticipated odds ratio (OR) of 2.0 for the primary predictor, a minimum sample size of 200 patients was estimated. This sample size provides 80% statistical power at a two-sided alpha level of 0.05 for multivariate logistic regression, allowing for the inclusion of up to 10 predictor variables and adhering to the recommended minimum of 10-15 events per predictor. The final sample of 228 patients exceeded this minimum requirement.

Data collection and variables

Data were extracted from the institutional stroke database and supplemented by a review of electronic medical records. Demographic variables included age at stroke onset, sex, marital status, educational level, employment status, and living situation. Clinical variables comprised stroke risk factors (hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, coronary artery disease, previous stroke or transient ischemic attack, and smoking status), pre-stroke functional status (mRS), baseline stroke severity [National Institutes of Health Stroke Scale (NIHSS) score], stroke etiology classified according to the Trial of Org 10172 in Acute Stroke Treatment criteria, and location of vessel occlusion.

Procedural variables included time from symptom onset to groin puncture (onset-to-puncture time), time from symptom onset to recanalization (onset-to-recanalization time), and procedural duration (puncture-to-recanalization time). Additional variables captured the use of intravenous thrombolysis before EVT (bridging therapy), thrombectomy device type, number of thrombectomy passes, use of adjunctive techniques (e.g., balloon angioplasty, intracranial stenting), and procedural complications (arterial dissection, vessel perforation, symptomatic intracranial hemorrhage). Final recanalization status was assessed using the modified Thrombolysis in Cerebral Infarction (mTICI) scale, with successful recanalization defined as mTICI 2b/3.

Outcome variables included NIHSS score at 24 hours post-procedure, length of hospital stay, discharge destination (home, rehabilitation facility, or skilled nursing facility), functional outcome at 90 days assessed using the mRS (with a favorable outcome defined as mRS 0-2), and psychological outcomes at 3 months. Additionally, information regarding pre-stroke history of anxiety or depression, family history of mood disorders, and post-stroke initiation of antidepressant or anxiolytic medications was collected.

Psychological assessment instruments

Psychological outcomes were assessed at the routine 3-month post-stroke follow-up using standardized self-report instruments administered by trained research coordinators. The 3-month follow-up was selected for its clinical relevance, as neurological recovery has largely stabilized, and psychological symptoms are less influenced by acute hospitalization-related stress. The primary psychological outcomes, anxiety and depression, were assessed using the Hospital Anxiety and Depression Scale (HADS), a validated 14-item self-report instrument encompassing two seven-item subscales: HADS-Anxiety (HADS-A) and HADS-Depression (HADS-D)[16]. The HADS-A assesses symptoms of generalized anxiety, whereas the HADS-D evaluates symptoms of anhedonia and loss of interest characteristic of depression. Each item is rated on a 4-point Likert scale (0-3), yielding subscale scores ranging from 0 to 21. Symptom severity is categorized as follows: 0-7 (normal), 8-10 (mild), 11-14 (moderate), and 15-21 (severe). Clinically significant anxiety and depression were defined as scores ≥ 8 on the respective subscales, a validated threshold with optimal sensitivity and specificity for detecting mood disorders in stroke populations. The HADS has been extensively validated among stroke survivors, demonstrating good internal consistency (Cronbach’s α = 0.83-0.87), test-retest reliability, and concurrent validity with diagnostic interviews. In the present sample, Cronbach’s α was 0.86 for HADS-A and 0.84 for HADS-D, indicating excellent internal consistency.

Depressive symptom severity was further characterized using the Patient Health Questionnaire-9 (PHQ-9) as a secondary outcome measure. The PHQ-9 is a nine-item self-report instrument based on the diagnostic criteria for major depressive disorder outlined in the Diagnostic and Statistical Manual of Mental Disorders[17]. Each item assesses symptom frequency over the preceding 2 weeks on a 4-point scale (0 = not at all to 3 = nearly every day), yielding total scores from 0 to 27. Severity categories are defined as: 0-4 (minimal), 5-9 (mild), 10-14 (moderate), 15-19 (moderately severe), and 20-27 (severe). The PHQ-9 has demonstrated excellent psychometric properties in stroke populations, with Cronbach’s α typically exceeding 0.85. In the present sample, Cronbach’s α for the PHQ-9 was 0.88.

Anxiety symptoms were further characterized using the Generalized Anxiety Disorder seven-item scale (GAD-7), a brief self-report measure assessing core symptoms of generalized anxiety disorder[18]. The GAD-7 comprises seven items rated on a 4-point scale (0 = not at all to 3 = nearly every day), yielding total scores ranging from 0 to 21. Severity categories are defined as: 0-4 (minimal), 5-9 (mild), 10-14 (moderate), and 15-21 (severe). The GAD-7 has demonstrated strong psychometric properties, including high internal consistency (Cronbach’s α > 0.90) and good convergent validity with other anxiety measures. In the present sample, Cronbach’s alpha for the GAD-7 was 0.91.

Statistical analysis

All statistical analyses were conducted using IBM SPSS Statistics version 27.0 (IBM Corporation, Armonk, NY, United States). Statistical significance was defined as a two-tailed P value < 0.05. Continuous variables were assessed for normality using the Shapiro-Wilk test and by visual inspection of histograms and Q-Q plots. Normally distributed variables were summarized as mean ± SD and compared between groups using independent-samples t-tests. Non-normally distributed variables were reported as median (interquartile range) and compared using the Mann-Whitney U test. Categorical variables were presented as n (%) and compared using the χ² test or Fisher’s exact test, as appropriate based on expected cell counts. Correlations between continuous variables were evaluated using Pearson’s correlation coefficient for normally distributed data and Spearman’s rank correlation coefficient for non-normally distributed data. Independent predictors of post-interventional anxiety (HADS-A ≥ 8) and depression (HADS-D ≥ 8) were identified using multivariate binary logistic regression. Variables with significant association (P < 0.10) in univariate analyses were included in the multivariate models. Results are reported as ORs with 95% confidence intervals (CIs). Model fit was assessed using the Hosmer-Lemeshow goodness-of-fit test, and model discrimination was evaluated using the area under the receiver operating characteristic curve (AUC). Multicollinearity was assessed using variance inflation factors (VIFs), with variance inflation factor > 5 indicating problematic collinearity. Missing data were handled using listwise deletion due to the low proportion of missingness (< 5% across all variables).

RESULTS

Participant characteristics

A total of 312 patients underwent EVT for AIS at our institution during the study period. After applying the inclusion and exclusion criteria, 228 patients were included in the final analysis. Exclusions were due to death prior to the 3-month assessment (n = 41), severe aphasia precluding evaluation (n = 18), loss to follow-up (n = 16), pre-existing cognitive impairment (n = 6), and incomplete data (n = 3). Table 1 summarizes the demographic and clinical characteristics of the study cohort.

Table 1 Demographic and clinical characteristics of the study population (n = 228), n (%)/mean ± SD/median (interquartile range).

Variable	Total sample (n = 228)	No depression (n = 141)	Depression (n = 87)	P value
Demographics
Age, years	67.4 ± 12.8	66.9 ± 13.1	68.2 ± 12.3	0.446
Female sex	98 (43.0)	50 (35.5)	48 (55.2)	0.003a
Married/partnered	156 (68.4)	101 (71.6)	55 (63.2)	0.181
Education > 12 years	89 (39.0)	58 (41.1)	31 (35.6)	0.403
Employed prior to stroke	94 (41.2)	62 (44.0)	32 (36.8)	0.278
Living alone	52 (22.8)	28 (19.9)	24 (27.6)	0.169
Medical history
Hypertension	168 (73.7)	100 (70.9)	68 (78.2)	0.223
Diabetes mellitus	72 (31.6)	41 (29.1)	31 (35.6)	0.299
Atrial fibrillation	84 (36.8)	50 (35.5)	34 (39.1)	0.577
Dyslipidemia	124 (54.4)	74 (52.5)	50 (57.5)	0.458
Previous stroke/TIA	38 (16.7)	20 (14.2)	18 (20.7)	0.196
Coronary artery disease	46 (20.2)	26 (18.4)	20 (23.0)	0.401
Current smoker	58 (25.4)	38 (27.0)	20 (23.0)	0.497
History of depression	34 (14.9)	12 (8.5)	22 (25.3)	< 0.001a
History of anxiety	28 (12.3)	11 (7.8)	17 (19.5)	0.008a
Stroke characteristics
Baseline NIHSS	16 (12-20)	15 (11-18)	18 (14-22)	< 0.001a
Anterior circulation	196 (86.0)	120 (85.1)	76 (87.4)	0.631
TOAST classification				0.284
Large artery atherosclerosis	68 (29.8)	45 (31.9)	23 (26.4)
Cardioembolism	112 (49.1)	65 (46.1)	47 (54.0)
Other/undetermined	48 (21.1)	31 (22.0)	17 (19.5)
Procedural variables
IV thrombolysis (bridging)	142 (62.3)	90 (63.8)	52 (59.8)	0.536
Onset-to-puncture, minutes	240 (180-340)	235 (175-330)	250 (190-355)	0.187
Procedural duration, minutes	45 (32-68)	42 (30-62)	52 (36-78)	0.018a
Number of passes	2 (1-3)	2 (1-2)	2 (1-3)	0.089
Successful recanalization (mTICI 2b/3)	194 (85.1)	128 (90.8)	66 (75.9)	0.002a
Symptomatic ICH	14 (6.1)	6 (4.3)	8 (9.2)	0.126
Outcomes
24-hour NIHSS	8 (4-14)	6 (3-10)	12 (7-18)	< 0.001a
Hospital stay, days	12 (8-18)	10 (7-15)	16 (11-22)	< 0.001a
Discharge to rehabilitation	98 (43.0)	52 (36.9)	46 (52.9)	0.017a
90-day mRS 0-2	124 (54.4)	96 (68.1)	28 (32.2)	< 0.001a

^aP < 0.05.

TIA: Transient ischemic attack; NIHSS: National Institutes of Health Stroke Scale; TOAST: Trial of Org 10172 in Acute Stroke Treatment; IV: Intravenous; mTICI: Modified Thrombolysis in Cerebral Infarction; ICH: Intracranial hemorrhage; mRS: Modified Rankin Scale.

The mean age of participants was 67.4 ± 12.8 years, and 98 patients (43.0%) were female. The median baseline NIHSS score was 16 (interquartile range: 12-20), reflecting the severity of strokes typically treated with EVT. Anterior circulation strokes accounted for 86.0% of cases. Bridging intravenous thrombolysis was administered to 62.3% of patients. Successful recanalization (mTICI 2b/3) was achieved in 85.1% of patients. At 90 days, 124 patients (54.4%) achieved functional independence (mRS 0-2).

Prevalence of post-interventional anxiety and depression

At the 3-month follow-up, clinically significant depression (HADS-D ≥ 8) was identified in 87 patients (38.2%), while clinically significant anxiety (HADS-A ≥ 8) was observed in 72 patients (31.6%). Comorbid anxiety and depression were present in 51 patients (22.4%), representing 58.6% of patients with depression and 70.8% of those with anxiety. The distribution of depressive symptom severity based on HADS-D scores was as follows: Normal (0-7) in 141 patients (61.8%), mild (8-10) in 42 patients (18.4%), moderate (11-14) in 32 patients (14.0%), and severe (15-21) in 13 patients (5.7%). For anxiety symptoms based on HADS-A scores, the distribution was: Normal in 156 patients (68.4%), mild in 35 patients (15.4%), moderate in 28 patients (12.3%), and severe in nine patients (3.9%).

Secondary outcome measures corroborated these findings. Based on PHQ-9 scores, the prevalence of at least moderate depression (PHQ-9 ≥ 10) was 34.6% (n = 79), with 8.3% (n = 19) meeting criteria for moderately severe to severe depression (PHQ-9 ≥ 15). The mean PHQ-9 score for the entire cohort was 7.8 ± 5.9. Based on GAD-7 scores, the prevalence of at least moderate anxiety (GAD-7 ≥ 10) was 27.2% (n = 62), with a mean GAD-7 score of 6.4 ± 5.2 for the cohort.

As Table 2 shows, strong positive correlations were observed between HADS-D and HADS-A scores (r = 0.68, P < 0.001), indicating substantial overlap between depressive and anxiety symptoms. The PHQ-9 demonstrated excellent convergent validity with HADS-D (r = 0.84, P < 0.001), while the GAD-7 showed a strong correlation with HADS-A (r = 0.86, P < 0.001). Both depression and anxiety scores were significantly correlated with stroke severity indicators, including baseline NIHSS (HADS-D: r = 0.34; HADS-A: r = 0.22), 24-hour NIHSS (HADS-D: r = 0.42; HADS-A: r = 0.28), and 90-day mRS (HADS-D: r = 0.52; HADS-A: r = 0.36), suggesting that greater stroke severity and poorer functional outcomes are associated with increased psychological distress. Notably, younger age was significantly associated with higher anxiety scores (r = -0.16, P = 0.018) but not with depression scores.

Table 2 Psychological outcome measures and correlations with clinical variables (n = 228).

Variable	mean ± SD or n (%)	Correlation with HADS-Depression1	Correlation with HADS-Anxiety
Psychological scales
HADS-Depression score	6.8 ± 4.3		r = 0.68a
HADS-Anxiety score	5.9 ± 4.1	r = 0.68a
PHQ-9 total score	7.8 ± 5.9	r = 0.84a	r = 0.62a
GAD-7 total score	6.4 ± 5.2	r = 0.59a	r = 0.86a
Prevalence of mood disorders
HADS-Depression ≥ 8 (depression)	87 (38.2)
HADS-Anxiety ≥ 8 (anxiety)	72 (31.6)
Comorbid anxiety and depression	51 (22.4)
PHQ-9 ≥ 10 (moderate depression)	79 (34.6)
GAD-7 ≥ 10 (moderate anxiety)	62 (27.2)
Correlations with clinical variables
Age		r = 0.08	r = -0.16a
Baseline NIHSS		r = 0.34a	r = 0.22a
24-hour NIHSS		r = 0.42a	r = 0.28a
Hospital length of stay		r = 0.38a	r = 0.31a
90-day mRS		r = 0.52a	r = 0.36a
Procedural duration		r = 0.18a	r = 0.21a

¹Correlation coefficients were calculated using either Spearman’s or Pearson’s methods, as appropriate.

^aP < 0.05.

HADS: Hospital Anxiety and Depression Scale; PHQ-9: Patient Health Questionnaire-9; GAD-7: Generalized Anxiety Disorder 7-item scale; NIHSS: National Institutes of Health Stroke Scale; mRS: Modified Rankin Scale.

Predictors of post-interventional depression

Univariate analyses comparing patients with and without clinically significant depression (HADS-D ≥ 8) identified several significant differences (Table 1). Patients with depression were more likely to be female (55.2% vs 35.5%, P = 0.003) and to have a history of depression (25.3% vs 8.5%, P < 0.001) or anxiety (19.5% vs 7.8%, P = 0.008). They also presented with higher baseline NIHSS scores (median 18 vs 15, P < 0.001), underwent longer procedures (median 52 minutes vs 42 minutes, P = 0.018), and more frequently had unsuccessful recanalization (24.1% vs 9.2%, P = 0.002). In addition, these patients had higher 24-hour NIHSS scores (median 12 vs 6, P < 0.001), required longer hospital stays (median 16 days vs 10 days, P < 0.001), and were more likely to have unfavorable functional outcomes at 90 days (67.8% vs 31.9% with mRS 3-6, P < 0.001).

Multivariate logistic regression identified five independent predictors of post-interventional depression. Female sex was associated with more than a twofold increase in the odds of depression (OR = 2.34, 95%CI: 1.28-4.27, P = 0.006). A pre-stroke history of depression conferred the highest risk (OR = 3.89, 95%CI: 1.76-8.61, P = 0.001). A higher baseline NIHSS score was independently associated with depression (OR = 1.12 per point increase, 95%CI: 1.04-1.21, P = 0.003). Unsuccessful recanalization also increased depression risk (OR = 2.67, 95%CI: 1.31-5.44, P = 0.007). Finally, poor functional outcome at 90 days (mRS 3-6) was strongly associated with depression (OR = 3.21, 95%CI: 1.68-6.13, P < 0.001). The model demonstrated good discrimination (AUC = 0.79, 95%CI: 0.73-0.85) and adequate fit (Hosmer-Lemeshow P = 0.42).

Predictors of post-interventional anxiety

Similar analyses were conducted to identify predictors of clinically significant anxiety (HADS-A ≥ 8). In univariate analyses, patients with anxiety were significantly younger (mean 64.2 years vs 68.9 years, P = 0.012), more likely to be female (56.9% vs 36.5%, P = 0.003), and more likely to have a history of anxiety (23.6% vs 7.1%, P < 0.001). They also had longer hospital stays (median 15 days vs 11 days, P = 0.001) and were more likely to have poor functional outcomes (59.7% vs 38.5% with mRS 3-6, P = 0.002). Multivariate logistic regression identified three independent predictors of post-interventional anxiety. Younger age was associated with increased anxiety risk (OR = 0.97 per year increase, 95%CI: 0.94-0.99, P = 0.018), indicating greater vulnerability among younger patients. Female sex was associated with approximately a twofold increase in the odds of anxiety (OR = 2.18, 95%CI: 1.19-3.99, P = 0.012). Longer hospitalization duration was also independently associated with anxiety (OR = 1.08 per day, 95%CI: 1.02-1.15, P = 0.009). A pre-stroke history of anxiety showed a trend toward significance but did not reach statistical significance in the multivariate model (OR = 2.14, 95%CI: 0.94-4.88, P = 0.071). The model demonstrated acceptable discrimination (AUC = 0.72, 95%CI: 0.65-0.79) and adequate fit (Hosmer-Lemeshow P = 0.56).

DISCUSSION

The present study provides comprehensive evidence on the prevalence, severity, and predictors of post-interventional anxiety and depression among patients undergoing EVT for AIS. Psychological morbidity was highly prevalent in this cohort: 38.2% of patients experienced clinically significant depression, and 31.6% experienced clinically significant anxiety at 3 months post-intervention. We also identified several independent predictors of these mood disorders, including female sex, pre-stroke psychiatric history, stroke severity, recanalization success, and functional outcomes. These findings have practical implications for targeted screening and intervention strategies and underscore the importance of integrating psychological assessment and support into comprehensive care pathways for EVT-treated stroke survivors.

The prevalence of post-interventional depression and anxiety observed in this cohort is consistent with, though slightly higher than, estimates reported in general stroke populations. A meta-analysis by Hackett and Pickles[6] reported a pooled prevalence of approximately 31% for PSD across all time points, with rates ranging from 25% to 40% depending on assessment timing and methodology[19]. The higher prevalence of depression observed in the present study (38.2%) likely reflects the greater stroke severity typical of EVT-eligible patients, as LVO strokes are associated with larger infarct volumes and more severe neurological deficits. Similarly, the observed anxiety prevalence (31.6%) falls within previously reported ranges of 20% to 35% among stroke survivors, although direct comparisons are limited by heterogeneity in assessment instruments and timing[20].

The substantial comorbidity between anxiety and depression identified in this study, 22.4% of patients experienced both conditions, corroborates prior findings. Campbell Burton et al[21] reported that approximately 60%-70% of patients with one mood disorder also meet criteria for the other. This co-occurrence is clinically significant, as comorbid anxiety and depression are associated with poorer outcomes than either condition alone.

Female sex emerged as an independent predictor of both depression and anxiety following EVT, consistent with findings from both general psychiatric epidemiology and stroke-specific literature. A systematic review by Ayerbe et al[22] identified female sex as a consistent risk factor for PSD across multiple studies, potentially reflecting biological vulnerabilities (e.g., hormonal influences) and psychosocial factors, such as caregiving responsibilities and social role disruption. In the present study, women had more than twice the odds of developing post-interventional depression and anxiety, highlighting the need for heightened clinical vigilance and potentially proactive psychological support. The mechanisms underlying this association may include differences in stress response, coping strategies, social support, and neurobiological susceptibility to mood disorders following brain injury[23].

A pre-stroke history of depression was an important predictor of post-interventional depression in the multivariable model, conferring an approximately fourfold increase in risk. This finding is consistent with the stress-vulnerability model, suggesting that individuals with prior mood disorders may be more vulnerable to psychological distress after stroke and EVT. Previous studies have also reported that pre-existing depression is associated with an increased risk of post-stroke depression during follow-up[24].

Clinically, this association underscores the importance of obtaining a comprehensive psychiatric history during the acute stroke evaluation and implementing early monitoring and, where appropriate, preventive interventions for patients with known mood disorders. Although pre-stroke anxiety was associated with post-interventional anxiety in univariate analysis, it did not remain an independent predictor in the multivariable model. This finding may reflect a smaller effect size or confounding by other variables; however, the observed trend toward significance warrants further investigation.

Significant associations between stroke severity indicators, including baseline NIHSS, and subsequent mood disorders underscore the neurobiological contributions to post-stroke psychological morbidity. More severe strokes are associated with larger infarct volumes, greater disruption of neural circuits involved in mood regulation, and more profound functional impairments, all of which can precipitate psychological distress. The finding that unsuccessful recanalization independently predicted depression provides novel evidence specific to the EVT population. This result suggests that, beyond the direct effects of larger infarcts, failure to achieve procedural success may contribute to psychological distress through mechanisms such as patient awareness of treatment outcomes, perceptions of a poorer prognosis, and objectively worse recovery trajectories[25]. This observation has important implications for post-procedural communication and counseling, particularly for patients in whom optimal recanalization is not achieved.

The strong association between functional outcome at 90 days and post-interventional depression suggests a close relationship between physical disability and psychological distress after stroke. Poor functional outcomes, characterized by persistent disability and dependence in activities of daily living, may contribute to depressive symptoms through mechanisms described in the learned helplessness model and theories of loss and adjustment. At the same time, depression may adversely affect rehabilitation participation, adherence to secondary prevention strategies, and overall recovery. Previous longitudinal studies have suggested an association between depressive symptoms and functional recovery after stroke[26]. Therefore, early recognition and management of depression may have potential benefits for both psychological well-being and rehabilitation outcomes.

The finding that younger age independently predicted post-interventional anxiety, but not depression, is noteworthy and may reflect the distinct psychological impact of stroke in younger individuals. This population often faces concerns related to career disruption, financial stability, family responsibilities, and long-term life expectancy. Younger stroke survivors may also have higher pre-stroke functional expectations and activity levels, making the onset of disability particularly distressing. Morrison et al[27] reported similar patterns, observing higher rates of anxiety and psychological distress among younger stroke survivors despite better functional outcomes. These findings suggest that psychological support services for EVT-treated patients should be tailored to address age-specific concerns and implemented proactively in younger patients, who may otherwise be presumed to cope well because of their physical resilience.

The clinical implications of these findings are substantial. First, the high prevalence of psychological morbidity highlights the need for routine psychological screening in all patients following EVT, ideally at standardized time points such as the 3-month follow-up. Brief, validated instruments, including the HADS or PHQ-9, can be efficiently integrated into existing follow-up protocols, administered routinely by trained stroke specialist nurses. Second, identification of specific risk factors supports a stratified care approach, enabling timely psychiatric referral or initiation of targeted interventions such as cognitive behavioral therapy for high-risk patients.

Collaborative care models that integrate psychological services into stroke care have demonstrated efficacy in reducing depression severity and improving functional outcomes[28]. Third, patient and family education regarding the psychological sequelae of stroke and EVT, initiated during hospitalization and reinforced at follow-up, may normalize these experiences and reduce barriers to help-seeking. Finally, the strong association between functional outcomes and mood disorders reinforces the importance of intensive rehabilitation to optimize recovery and potentially confer secondary psychological benefits[29].

Several limitations warrant consideration. The retrospective design precludes causal inference and introduces potential selection and information biases. As a single-center study with a relatively high recanalization success rate, the findings may not be fully generalizable to other clinical settings. Patients who died or were lost to follow-up may have differed systematically in psychological outcomes, potentially affecting prevalence estimates. In addition, reliance on self-report instruments rather than structured psychiatric diagnostic interviews may have introduced measurement bias. Finally, baseline anxiety and depression were not assessed, limiting the ability to distinguish incident post-interventional mood disorders from pre-existing conditions.

CONCLUSION

Post-interventional anxiety and depression are highly prevalent among patients undergoing EVT for AIS, affecting approximately one-third of survivors at 3 months. Female sex, pre-stroke depression history, greater stroke severity, unsuccessful recanalization, and poor functional outcomes independently predict depression, while younger age, female sex, and longer hospitalization predict anxiety. These findings support integrating routine psychological screening into post-EVT care pathways and developing targeted interventions for high-risk patients. A major limitation of this study is the single-time-point assessment at 3 months, which does not capture the dynamic trajectory of post-stroke psychological outcomes. Future prospective studies with longitudinal designs are therefore warranted to characterize symptom trajectories over time, evaluate the efficacy of preventive and therapeutic interventions, and explore the impact of psychological well-being on long-term functional, social, and quality-of-life outcomes in this vulnerable population.