• Marios Psychogios, Alex Brehm, Marc Ribo, Federica Rizzo, Daniel Strbian, Silja Räty, Juan F Arenillas, Mario Martínez-Galdámez, Steven D Hajdu, Patrik Michel, Jan Gralla, Eike I Piechowiak, Daniel P O Kaiser, Volker Puetz, Frans Van den Bergh, Sylvie De Raedt, Flavio Bellante, Anne Dusart, Victoria Hellstern, Ali Khanafer, Guillermo Parrilla, Ana Morales, Jan S Kirschke, Silke Wunderlich, Jens Fiehler, Götz Thomalla, Robin Lemmens, Jo P Peluso, Manuel Bolognese, Alexander von Hessling, van EsAdriaanADepartment of Radiology, Leiden University Medical Center, and University Neurovascular Center Leiden-the Hague - both in Leiden, the Netherlands., Nyika D Kruyt, Jonathan M Coutinho, Carlos Castaño, Jens Minnerup, Wim van Zwam, Elisabeth Dhondt, Christian H Nolte, Paolo Machi, Christian Loehr, Heinrich P Mattle, Jan-Hendrik Buhk, Johannes Kaesmacher, Tomas Dobrocky, Panagiotis Papanagiotou, Angelika Alonso, Markus Holtmannspoetter, Andrea Zini, Leonardo Renieri, Fee Keil, Ido van den Wijngaard, Georg Kägi, Mikel Terceño, Martin Wiesmann, Sergio Amaro, Nikki Rommers, Luzia Balmer, Isabel Fragata, Mira Katan, Ronen R Leker, Jeffrey L Saver, Julie Staals, Urs Fischer, and DISTAL Investigators.
• Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland.
• N. Engl. J. Med. 2025 Feb 5.

BackgroundEndovascular treatment (EVT) of stroke with large-vessel occlusion is known to be safe and effective. The effect of EVT for occlusion of medium or distal vessels is unclear.MethodsWe randomly assigned participants with an isolated occlusion of medium or distal vessels (occlusion of the nondominant or codominant M2 segment of the middle cerebral artery [MCA]; the M3 or M4 segment of the MCA; the A1, A2, or A3 segment of the anterior cerebral artery; or the P1, P2, or P3 segment of the posterior cerebral artery) to receive EVT plus best medical treatment or best medical treatment alone within 24 hours after the participant was last seen to be well. The primary outcome was the level of disability at 90 days, as assessed with the modified Rankin scale score.ResultsA total of 543 participants (women, 44%; median age, 77 years) were included in the analysis: 271 were assigned to receive EVT plus best medical treatment and 272 to receive best medical treatment alone. The median score on the National Institutes of Health Stroke Scale (range, 0 to 42, with higher scores indicating more severe symptoms) at admission was 6 (interquartile range, 5 to 9). Intravenous thrombolysis was given to 65.4% of the participants. The predominant occlusion locations were the M2 segment (in 44.0% of the participants), M3 segment (in 26.9%), P2 segment (in 13.4%), and P1 segment (in 5.5%). In the comparison between EVT plus best medical treatment and best medical treatment alone, no significant difference in the distribution of modified Rankin scale scores was observed at 90 days (common odds ratio for improvement in the score, 0.90; 95% confidence interval, 0.67 to 1.22; P = 0.50). All-cause mortality was similar in the two groups (15.5% with EVT plus best medical treatment and 14.0% with best medical treatment alone), as was the incidence of symptomatic intracranial hemorrhage (5.9% and 2.6%, respectively).ConclusionsIn persons with stroke with occlusion of medium or distal vessels, EVT did not result in a lower level of disability or a lower incidence of death than best medical treatment alone. (Funded by the Swiss National Science Foundation and others; DISTAL ClinicalTrials.gov number, NCT05029414.).Copyright © 2025 Massachusetts Medical Society.

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