Aim: Managing stroke patients with premorbid disabilities presents a challenge, as these patients are often excluded from randomized controlled trials on endovascular treatment (EVT) for large vessel occlusion (LVO). This study aimed to assess the effectiveness and safety of EVT versus medical management (MM) in these patients. Material and methods: A systematic search was conducted in PubMed, Embase, and the Cochrane Library for studies on EVT in LVO patients with pre-stroke modified Rankin Scale (mRS) score of 2-4. The primary outcome was functional recovery, defined as returning to at least the pre-stroke mRS score within 90 days. The secondary outcomes included symptomatic intracranial hemorrhage (sICH) and 90-day mortality. The meta-analyses were conducted via random effects models. Results: Six cohort studies involving 2,106 patients were included. Compared with MM, EVT was associated with a higher likelihood of functional recovery (adjusted odds ratio [aOR], 3.26; 95% confidence interval [CI], 2.26-4.70; P<0.001) and lower risk of mortality (aOR, 0.40; 95% CI, 0.20-0.83; P=0.01). EVT was also associated with a potentially increased risk of sICH, although the difference did not reach statistical significance (aOR 2.47, 95% CI 0.81-7.52; P=0.11). Conclusions: Although EVT may be associated with a higher potential risk of sICH, it improves the likelihood of functional recovery and reduces mortality in LVO patients with pre-stroke disability. Therefore, denying EVT solely on the basis of premorbid disability may be unjustified. Further high-quality randomized controlled trials are warranted to validate these findings.