Comparing the Efficacy and Safety of Endovascular Therapy Versus Best Medical Treatment in Acute Ischemic Stroke Patients With Distal Medium Vessel Occlusion: A Systematic Review and Meta-Analysis

Introduction Distal Medium Vessel Occlusions (DMVOs) represent a significant subset of Acute Ischemic Stroke (AIS), with unique treatment challenges due to vessel size and location. While Endovascular Therapy (EVT) shows promise, its efficacy compared to Best Medical Treatment (BMT) remains unclear. Methods PubMed, Cochrane Central, and ScienceDirect were searched from inception till May 2025. Categorical data were pooled as risk ratios (RRs) along with 95% Confidence intervals (CIs) using the Review Manager software. Quality was assessed using the Cochrane Risk of Bias tool and the Newcastle Ottawa Scale. Results Thirty-seven studies pooling a total of 9,505 patients were included in this meta-analysis. The excellent functional outcome (modified Rankin Scale (mRS) 0-1) was comparable between both the EVT and BMT arms (RR= 1.04; 95% CI: [0.96, 1.13]; p= 0.34; I 2 = 59%). Similarly, the functional independence (mRS 0-2) showed no significant difference between the two groups (RR= 1.00; 95% CI: [0.94, 1.06]; p= 0.99; I 2 = 64%). The 90-day mortality (RR= 1.21; 95% CI: [0.97, 1.52]; p= 0.09; I 2 = 46%) and neurological deterioration (RR= 1.39; 95% CI: [0.65, 2.95]; p= 0.40; I 2 = 82%) were also comparable between the two arms. EVT showed a statistically significant increase in early neurological improvement (RR= 1.38; 95% CI: [1.05, 1.82]; p= 0.02; I 2 = 53%) although it was associated with a high risk of symptomatic intracranial hemorrhage (sICH) (RR= 1.56; 95% CI: [1.15, 2.13]; p= 0.005; I 2 = 39%). Conclusion EVT was associated with a significant increase in the early neurological improvement, although the risk of sICH was high in it. Other safety and efficacy outcomes were comparable. Further high-powered randomized trials are needed to confirm these findings.