Endovascular therapy superior to medical management for distal medium vessel occlusion strokes

1. In patients with acute ischemic stroke due to distal medium vessel occlusions, endovascular therapy was associated with a higher rate of excellent outcomes compared to medical management.

Evidence Rating Level: 2 (Good)

In patients with acute large-vessel occlusion of proximal anterior circulation, endovascular therapy (EVT) for cerebral reperfusion has been considered the gold standard. However, the safety and efficacy of EVT in primary distal, medium vessel occlusions (DMVO) have not been well discussed in external literature. This may be because of the smaller size of these distal cerebral arteries and longer distances to traverse for EVT which may present several challenges for successful reperfusions. In this multicenter, retrospective cohort study, 286 adult patients with acute ischemic stroke and DMVO were examined for 3-month functional independence as defined as prestroke modified Rankin Scale (mRS) scores of 0 to 2 at 90 days and successful reperfusion following EVT or medical management. The results of this study showed that there was no difference between the EVT and medical management groups in terms of 3-month functional independence (51.7% vs 50%, respectively) and rate of symptomatic intracranial hemorrhage (4% vs 3.1%, respectively). However, EVT was associated with a slightly higher 3-month excellent outcome score compared to medical management (aOR 1.71, 95%CI 1.02-2.87). In conclusion, these findings suggest that with more modernized and advancing endovascular technologies, EVT procedures may be conducted in more distal arteries safely. However, there remain several limitations to note. The observational and non-randomized nature of this study may introduce bias as baseline deficit and baseline risk of developing worse outcomes could not be accounted for. Additionally, the sample size of this paper remains small which limits the power and generalizability of this study to a broader population. Further large-scale investigations and randomized controlled trials comparing EVT and medical management in acute ischemic stroke with DMVO could yield beneficial findings.

Click to read the study in JAMA Network Open

Image: PD

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