Endovascular Therapy vs Medical Treatment Alone for Individuals with Medium or Distal Vessel Occlusions

Results of the ESCAPE-MeVO (NCT05151172) and DISTAL (NCT05029414) clinical trials demonstrated that endovascular treatment (EVT) plus medical treatment did not lead to better outcomes vs medical treatment alone in individuals with stroke caused by medium vessel occlusion (MVO) or distal vessel occlusion (DVO). Results of the two studies were published in The New England Journal of Medicine and presented at the American Stroke Association’s International Stroke Conference 2025.

The multicenter, prospective, randomized, open-label ESCAPE-MeVO trial was conducted across 5 countries between April 2022 and June 2024 and included 530 patients with acute ischemic stroke caused by MVO who received EVT plus medical treatment (n=255) vs medical treatment alone (n=275). Researchers included individuals with baseline noninvasive brain imaging who presented within 12 hours from the time that they were last known to be well. The primary outcome measure was the modified Rankin Scale (mRS) score at 90 days and success was defined as a score of 0 or 1.

The DISTAL trial included 543 participants with isolated MVO or DVO (defined as 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) who were randomized 1:1 to receive EVT plus medical treatment (n=271) or medical treatment alone (n=272) within 24 hours after the participant was last seen to be well. The primary outcome measure was the level of disability at 90 days, which was assessed using the mRS score.

Results from the ESCAPE-MeVO trial include the following:

• 41.6% of participants who received EVT achieved a mRS score of 0 or 1 at 90 days compared with 43.1% of participants who received medical treatment alone.
• 90-day mortality was higher in participants who received EVT (13.3%) compared with participants who received medical treatment alone (8.4%).
• Symptomatic intracranial hemorrhage occurred in 5.4% of participants who received EVT plus compared with 2.2% in participants who received medical treatment alone.

Results from the DISTAL trial include the following:

• There was no significant difference in 90-day mRS scores between groups. (common odds ratio for improvement in the score, 0.90; 95% CI, 0.67 to 1.22; P=.50).
• All-cause mortality was similar in both groups (15.5% in EVT group vs 14.0% in medical treatment alone group).
• Symptomatic intracranial hemorrhage rates were similar in both groups (5.9% in EVT group vs 2.6% in medical treatment alone group).

EVT is a safe and effective treatment option for individuals with stroke caused by LVO. The results of these studies suggest that EVT may not be the most optimal treatment for individuals with stroke caused by MVO or DVO, and highlight the need for additional treatment options in these populations.