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Brain & Heart Advances in stroke treatment

Table 5. Main published trials from 2021 to 2023 on endovascular thrombectomy for acute ischemic stroke due to distal medium
vessel occlusions from the anterior cerebral circulation
Trial name No. of patients Design Population Efficacy Safety Results
randomized outcomes outcomes
ESCAPE-MeVO 300 Phase III, open-label, Anterior MeVO in mRS at 90 days sICH, mortality Significant
(2023) EVT+BMT versus eligible patient for EVT improvement
BMT in functional
independence
compared to BMT
alone
DISTAL (2023) 200 Phase III, open-label, Anterior DVO within mRS at 90 days sICH, mortality Benefit for selected
EVT+BMT versus 6-24 h from symptom patients in EVT
BMT onset compared to BMT
alone
ORIENTAL-MeVO 150 Phase III, open-label, Anterior MeVO in mRS at 90 days sICH, Significant
(2022) EVT+BMT versus eligible patient for EVT, procedural improvement
BMT 4.5-24 h from symptom complications in functional
onset independence
compared to BMT
alone
DUSK (2021) 120 Phase II, open-label, Anterior MeVO or DVO mRS at 90 days sICH, Benefit for selected
EVT+BMT versus within 6-24 h from procedural patients in EVT
BMT symptom onset complications compared to BMT
alone
Abbreviations: BMT: Best medical treatment; DISTAL: Distal ischemic stroke trial; DUSK: Distal and small vessel occlusion stroke trial; DVO: Distal
vessel occlusion; ESCAPE-MeVO: Endovascular treatment for small caliber vessel occlusions in the ESCAPE Trial; EVT: Endovascular therapy;
MeVO: Medium vessel occlusion; mRS: Modified Rankin scale; ORIENTAL-MeVO: Optimal reperfusion for ischemic stroke with medium vessel
occlusion trial in Asia; sICH: Symptomatic intracranial hemorrhage.

placebo group, yielding an 18.4% adjusted risk difference Data from the Italian Endovascular Registry (REI) assessed
favoring ALT. Safety data favored ALT as well, with no MT in NIHSS ≤ 6 patients. Among 134 treated with stent
sICH cases versus 3.8% in the placebo group. retrievers or aspiration, 70.9% achieved favorable outcomes
Additional insights come from trials, such as (mRS 0 – 2) at 3 months, with 73.7% revascularization
ATTENTION-IA and ANGEL-ACT registries (Table 6). success (mTICI 2b-3) and low sICH rates (5.3%). Procedural
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ATTENTION-IA 35 investigates intra-arterial TNK complications were minimal (3%), underscoring MT safety
post-MT for posterior circulation strokes, while ANGEL- for mild-symptom patients. Notably, 30% of the patients
ACT registry data suggest IAT may improve outcomes experienced neurological decline before treatment, suggesting
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in minor stroke cases (NIHSS ≤ 5), showing reduced a risk of rapid deterioration in mild-symptom LVO patients.
hemorrhagic risk and lower 90-day mortality compared to Prognostic factors included successful revascularization and
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MT alone. While CHOICE provides preliminary support younger age. Untreated minor strokes with LVO typically fare
for IAT post-MT, its small sample and early termination poorly, supporting MT benefits even in mild cases.
limit conclusions. Larger trials are needed to confirm IAT Further validation through ongoing trials, MOSTE
efficacy in routine practice. If validated, this multimodal and MISTWAVE, is essential. MOSTE includes NIHSS 3 –
approach could significantly enhance AIS revascularization 5 patients, while MISTWAVE enrolls NIHSS 0 – 5 patients
therapies for LVO patients. to evaluate MT impact in cases traditionally managed
with medical therapy. These studies aim to clarify MT
2.7. MT for minor AISs due to LVOs guidelines for mild AIS cases due to LVO, potentially
Numerous RCTs confirm MT advantage over IV rtPA or broadening indications and marking a shift in stroke
medical therapy alone in AIS, with most trials enrolling treatment paradigms (Table 7).
patients with NIHSS scores of six, eight, or higher. The
HERMES collaboration’s pooled analysis revealed limited 2.8. Gender-specific differences in risk factors and
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MT benefits in patients with initial NIHSS scores of 0 – 5. acute revascularization strategies for ischemic stroke
Indeed, recent studies suggest MT potential in low NIHSS Gender differences in risk factors for AIS have been
(LVOLN) LVO cases. increasingly studied, highlighting distinctions that

Volume 3 Issue 3 (2025) 7 doi: 10.36922/bh.6683