Endovascular Treatment for Medium and Distal Vessel Occlusion Stroke: Are We Missing the Point?

BACKGROUND: Recent randomized controlled trials of endovascular treatment (EVT) for distal and medium vessel occlusion (DMVO) stroke did not demonstrate clinical benefit over best medical therapy and suggested potential safety concerns. We aimed to compare baseline characteristics of patients with DMVO stroke enrolled in these trials with those treated with EVT in routine clinical practice (RCP). METHODS: We conducted a retrospective cohort study of a prospectively recorded dual-center database including all consecutive patients with an acute ischemic stroke due to isolated primary DMVO (distal or nondominant M2, M3, A1, A2, A3, P1, P2) between January 2022 and July 2024 who fulfilled trials inclusion/exclusion criteria. Both centers participated in the DMVO trials during the study period. Patients were categorized in 2 groups: those who underwent EVT under RCP (RCP group) versus those randomized in a trial for DMVO stroke (clinical trial, computed tomography group). The 2 groups were evaluated and compared based on demographic, clinical, imaging, and treatment characteristics. RESULTS: Among 182 patients (median age, 79 years; interquartile range [IQR], 69–86; 46.2% female), 53 (29.1%) were included in a trial, and 129 (70.9%) were treated in RCP. Compared with RCP patients, those in the computed tomography group presented lower baseline stroke severity (median NIHSS, 5 [IQR, 4–7] versus 10 [IQR,7–15]; P