EVT improves functional outcomes in select stroke patients

Results from the Oriental MeVo trial show that endovascular thrombectomy (EVT) within 24 hours of symptom onset significantly improves functional outcomes in individuals with medium vessel occlusion (MeVO) stroke and moderate-to-severe deficits.

Approximately 60 percent of participants who received EVT on top of standard therapy achieved the primary outcome of a modified Rankin Scale score of 0–2 (functional independence) at 90 days. In the control arm, only 46.6 percent achieved this outcome. After adjusting for covariates, a comparison between arms yielded an adjusted risk ratio (aRR) of 1.24 (p=0.004). [ISC 2026, abstract LB035]

“The magnitude of benefit was substantial. The outcome distribution indicates that, for every 100 patients treated, 54 had a less disabled outcome, including 12 more who achieved functional independence,” said Dr Xiaozhong Jing from The First Affiliated Hospital of the University of Science and Technology of China, during his presentation at ISC 2026.

EVT similarly outperformed the control regimen for the secondary outcome of mRS score of 0–1 at 90 days (48.9 percent vs 33.2 percent; aRR, 1.47; p<0.001).

EVT was consistently better than control across most subgroups, with the most pronounced effects among patients with NIHSS* score ≥8 (53.3 percent vs 37 percent; aRR, 1.41), those aged ≥70 years (51.3 percent vs 38.9 percent; aRR, 1.39), and those with >4.5 to 8 hrs from onset to randomization (60.9 percent vs 44.6 percent; aRR, 1.38).

Although the rate of symptomatic intracranial haemorrhage (SICH) was numerically higher in the EVT than in the control arm (4.7 percent vs 2.2 percent; aRR, 2.21), the incidences of death were similar between groups (11.1 percent vs 10.2 percent; aRR, 1.11).

No benefit in meta-analysis

A meta-analysis of the DISTAL, ESCAPE-MeVO, and DISCOUNT trials failed to show benefit with EVT, noted Dr Raul Noguiera from the University of Pittsburgh School of Medicine, Pennsylvania, US, at ISC 2026. “There were also signals of harm as demonstrated by the higher rate of SICH and a trend towards mortality.” [J Am Heart Assoc 2025;14:e042299]

The 2026 AHA/ASA** guidelines do not recommend EVT to improve functional outcomes in patients with acute ischaemic stroke from occlusion of the proximal nondominant or codominant division proximal second segment (M2) of the MCA***, distal MCA, ACA***, or PCA***, with high-quality evidence corroborating this recommendation. [Stroke 2026;doi:10.1161/STR.0000000000000513]

“Every treatment, including thrombectomy, has a ceiling effect,” Noguiera pointed out. “The benefits level off the higher you go, and some patients get worse the higher you push the dose.”

The team sought to evaluate the superiority of EVT to standard medical management in achieving more favourable outcomes according to mRS scores at 90 days in individuals with acute ischaemic stroke related to a distal MeVO within 24 hrs from symptom onset. A total of 563 participants (median age 71 years, 57 percent men, median NIHSS score 10) from 48 centres in China were randomized to standard medical management with or without EVT.

The most common occlusion site in both the EVT and control arms was M2 (43.9 percent and 33.9 percent), followed by ACA (23.6 percent and 22.3 percent) and PCA (19.3 percent and 20.1 percent).

Jing noted that the pragmatic interventional design may have introduced heterogeneity. Also, all patients were enrolled in China, thus limiting the generalizability of the findings. The relatively low rate of thrombolysis (approximately 37 percent) may reflect the longer 24-hr recruitment window and regional variations in stroke care infrastructure and prehospital workflows, he added.

“[Nonetheless,] the findings suggest that EVT may be beneficial in carefully selected patients with smaller, more distal occlusions,” Jing concluded. “Future studies should aim to refine imaging-based selection and standardize procedural approaches to optimize outcomes in this emerging patient population.”