Written by Denrick Cooper
Spoon Feed
Endovascular treatment has no clear benefit over standard care in patients with medium vessel occlusions.
Go big or go home? Why EVT for medium strokes might not cut it
EVT, when combined with usual medical care, benefits patients with large-vessel occlusions (LVOs) within the first 24 hours and across different stroke volumes. But does the same hold true for medium-vessel occlusions (MeVOs)? This study builds on prior stroke research to determine whether EVT is effective for MeVOs.
This multicenter, randomized controlled trial (RCT) enrolled patients with acute ischemic stroke due to MeVO, randomly assigning them to either EVT or best medical therapy within 12 hours of symptom onset. The primary outcome was functional independence at 90 days (mRS 0-2), while secondary outcomes included rates of symptomatic intracranial hemorrhage and mortality.
There was no significant benefit of EVT for MeVOs (mRS 0-2: 59.8% EVT vs. 57.5% control). In fact, EVT was associated with higher mortality (13.3% vs. 8.4%) and symptomatic hemorrhage (5.4% vs. 2.2%).
However, the study had key limitations. It did not use perfusion imaging to identify patients with salvageable brain tissue, which could have influenced patient selection. Additionally, the study included a heterogeneous mix of medium-vessel occlusions, making it unclear whether certain subgroups might still benefit from EVT.
How does this change my practice?
Let’s be honest – we were all aboard the EVT hype train, and now we need to hit the brakes. EVT is a game-changer, but it’s not a one-size-fits-all solution. I’ll still push for EVT in LVOs when appropriate, but for medium-vessel and distal vessel occlusions, the benefits aren’t as clear – at least for now. Future studies are needed to identify subgroups with salvageable brain tissue who might benefit, especially as EVT technology advances.
Source
Endovascular Treatment for Stroke Due to Occlusion of Medium or Distal Vessels. N Engl J Med. 2025 Feb 5. doi: 10.1056/NEJMoa2408954. Epub ahead of print. PMID: 39908430
