• Hamza Adel Salim, Vivek Yedavalli, Basel Musmar, Nimer Adeeb, Kareem E L Naamani, Nils Henninger, Sri Hari Sundararajan, Anna Luisa Kühn, Jane Khalife, Sherief Ghozy, Luca Scarcia, Benjamin Yong Qiang Tan, Jeremy J Heit, Robert W Regenhardt, Nicole M Cancelliere, Joshua D Bernstock, Aymeric Rouchaud, Jens Fiehler, Muhammed Amir Essibayi, Sunil A Sheth, Ajit S Puri, Xavier Barreau, Marco Colasurdo, Leonardo Renieri, Christian Dyzmann, Thomas Marotta, Julian Spears, Askan Mowla, Pascal Jabbour, João Pedro Filipe, Arundhati Biswas, Pablo Harker, Frédéric Clarençon, Răzvan Alexandru Radu, James E Siegler, Thanh N Nguyen, Ricardo Varela, Takahiro Ota, Nestor Gonzalez, Markus A Moehlenbruch, David Altschul, Benjamin Gory, Vincent Costalat, Christian Paul Stracke, Mohammad Ali Aziz-Sultan, Constantin Hecker, Hamza Shaikh, David S Liebeskind, Amanda Baker, Alessandro Pedicelli, Andrea Alexandre, Tobias D Faizy, Illario Tancredi, Erwah Kalsoum, Boris Lubicz, Aman B Patel, Mendes PereiraVitorVNeuroimaging Division, Toronto Western Hospital, Toronto, Ontario, Canada., Adrien Guenego, Adam A Dmytriw, and MAD MT Investigators.
• Radiology, Johns Hopkins Medicine, Baltimore, Maryland, USA Hamza.sleeem@gmail.com admytriw@mgh.harvard.edu vyedava1@jhmi.edu.
• J. Neurol. Neurosurg. Psychiatr. 2024 Jul 23.

BackgroundThe efficacy of endovascular treatment (EVT) in acute ischaemic stroke due to distal medium vessel occlusion (DMVO) remains uncertain. Our study aimed to evaluate the safety and efficacy of EVT compared with the best medical management (BMM) in DMVO.MethodsIn this prospectively collected, retrospectively reviewed, multicentre cohort study, we analysed data from the Multicentre Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy registry. Patients with acute ischaemic stroke due to DMVO in the M2, M3 and M4 segments who underwent EVT or received BMM were included. Primary outcome measures comprised 10 co-primary endpoints, including functional independence (mRS 0-2), excellent outcome (mRS 0-1), mortality (mRS 6) and haemorrhagic complications. Propensity score matching was employed to balance the cohorts.ResultsAmong 2125 patients included in the primary analysis, 1713 received EVT and 412 received BMM. After propensity score matching, each group comprised 391 patients. At 90 days, no significant difference was observed in achieving mRS 0-2 between EVT and BMM (adjusted OR 1.00, 95% CI 0.67 to 1.50, p>0.99). However, EVT was associated with higher rates of symptomatic intracerebral haemorrhage (8.4% vs 3.0%, adjusted OR 3.56, 95% CI 1.69 to 7.48, p<0.001) and any intracranial haemorrhage (37% vs 19%, adjusted OR 2.61, 95% CI 1.81 to 3.78, p<0.001). Mortality rates were similar between groups (13% in both, adjusted OR 1.48, 95% CI 0.87 to 2.51, p=0.15).ConclusionOur findings suggest that while EVT does not significantly improve functional outcomes compared with BMM in DMVO, it is associated with higher risks of haemorrhagic complications. These results support a cautious approach to the use of EVT in DMVO and highlight the need for further prospective randomised trials to refine treatment strategies.© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.

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