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Objective Methods Results Interpretation Venous outflow (VO) impairment predicts unfavorable outcomes in patients with acute ischemic stroke caused by large vessel occlusion (AIS‐LVO). Prolonged venous transit (PVT), a visual qualitative VO marker on CT perfusion (CTP) time to maximum (Tmax) maps, has been associated with unfavorable 90‐day functional outcomes despite successful reperfusion. This study investigates the association between PVT and percent change on the National Institutes of Health Stroke Scale (NIHSS) among AIS‐LVO patients who have undergone successful reperfusion.We performed a retrospective analysis of prospectively collected data from consecutive adult AIS‐LVO patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/2c/3). PVT+ was defined as Tmax ≥10 s in the superior sagittal sinus, torcula, or both. The primary outcome was continuous NIHSS percent change and dichotomous NIHSS percent change ≥70%. Regression analyses were performed to assess the effect of PVT on NIHSS percent change.In 119 patients of median (IQR) age 71 (63–81) years, the admission and discharge NIHSS scores were significantly higher in PVT+ patients compared to PVT− patients (17 [14–23.5] vs. 13 [9.5–19], p = 0.011, and 7.5 [4–12] vs. 3 [1–7], p < 0.001, respectively). After adjusting for age, sex, hypertension, diabetes, atrial fibrillation, administration of intravenous thrombolysis (IVT), Alberta Stroke Program Early CT Scores (ASPECTS), mTICI 2c and/or 3, Tmax >6 s volume, and hemorrhagic transformation, PVT+ was significantly associated with lower NIHSS percent change (B = −0.163, 95%CI −0.326 to −0.001, p = 0.049) and was less likely to achieve higher than 70% NIHSS improvement (OR = 0.331, 95% CI 0.127–0.863, p = 0.024).PVT+ was significantly associated with reduced neurological improvement despite successful reperfusion in AIS‐LVO patients, highlighting the critical role of VO impairment in short‐term functional outcomes. These findings further validate PVT as a valuable adjunct imaging biomarker derived from CTP for assessing VO profiles in AIS‐LVO. [ABSTRACT FROM AUTHOR]

In patients with acute ischemic stroke, midregional proatrial natriuretic peptide (MR-proANP) has shown promise in preliminary studies for risk stratification. The objective of this study is to evaluate the prognostic utility of MR-proANP in AIS, focusing on its ability to predict 90-day functional outcomes, mortality rates, and the presence of atrial fibrillation (Afib). A comprehensive literature search was conducted using PubMed, Web of Science, and Scopus, following PRISMA guidelines. The search strategy employed a combination of keywords and index terms including "Acute Ischemic Stroke," "AIS," "Cerebral Infarction," "Atrial Fibrillation," "AFib," "stroke," "MR-proANP," "Mid-regional pro-atrial natriuretic peptide," and "proatrial natriuretic peptide." Inclusion criteria encompassed any study focusing on MR-proANP and ischemic stroke, published up to October 15, 2023. Primary end points were newly diagnosed Afib, 90-day Modified Rankin Scale (mRS) score, and 90-day mortality. Studies were described in narrative and tabular form. Risk of bias was assessed using the ROBINS-I tool. Pooled estimates for our key end points were generated using a random effects model where appropriate. MR-proANP levels were significantly elevated in newly diagnosed Afib patients compared to no Afib patients (mean difference (MD): 134.4 pmol/l; 95% confidence interval (CI): 119.45 to 149.35, P < 0.0001). Unfavorable functional outcomes, as measured by mRS scores of ≥ 3 at 90 days, were associated with higher levels of MR-proANP (MD: 93.87 pmol/; 95% CI: 76.66 to 111.09, P < 0.0001). Elevated MR-proANP levels were also strongly correlated with increased 90-day mortality rates (MD: 164.43 pmol/; CI: 95.94 to 232.92, P < 0.0001). MR-proANP was significantly associated with functional outcomes, 90-day mortality, and the newly diagnosed AF. The limited number of studies included calls for further large-scale research to confirm these findings and explore the potential for expedited diagnostic procedures and targeted interventions like anticoagulant therapy. [ABSTRACT FROM AUTHOR]

Background and Purpose: Ischemic strokes due to isolated posterior cerebral artery (PCA) occlusions represent 5% of all strokes but have significant impacts on patients' quality of life, primarily due to visual deficits and thalamic involvement. Current guidelines for acute PCA occlusion management are sparse, and the prognostic value of perfusion imaging parameters remains underexplored. Methods: We conducted a retrospective analysis of 32 patients with isolated PCA occlusions treated at Johns Hopkins Medical Institutions between January 2017 and March 2023. Patients underwent pretreatment perfusion imaging, with perfusion parameters analyzed using RAPID software. The primary outcome was short‐term clinical outcome as measured by the National Institutes of Health Stroke Scale (NIHSS) at discharge. Results: The median age of the cohort was 70 years, with 34% female and 66% male. Significant correlations were found between NIHSS at discharge and various perfusion parameters, including time‐to‐maximum (Tmax) >6 seconds (ρ =.55, p =.004), Tmax >8 seconds (ρ =.59, p =.002), Tmax >10 seconds (ρ =.6, p =.001), mismatch volume (ρ =.51, p =.008), and cerebral blood volume (CBV) < 34% (ρ =.59, p =.002). Conclusions: Tmax and CBV volumes significantly correlated with discharge NIHSS with marginal superiority of Tmax >10 seconds and CBV <42% volumes. These findings suggest that CT and MR perfusion imaging can play a crucial role in the acute management of PCA strokes, though larger, standardized studies are needed to validate these results and refine imaging thresholds specific to posterior circulation infarcts. [ABSTRACT FROM AUTHOR]

The Woven EndoBridge (WEB) device is primarily used for treating wide-neck intracranial bifurcation aneurysms under 10 mm. Limited data exists on its efficacy for large aneurysms. We aim to assess angiographic and clinical outcomes of the WEB device in treating large versus small aneurysms. We conducted a retrospective review of the WorldWide WEB Consortium database, from 2011 to 2022, across 30 academic institutions globally. Propensity score matching (PSM) was employed to compare small and large aneurysms on baseline characteristics. A total of 898 patients were included. There was no significant difference observed in clinical presentations, smoking status, pretreatment mRS, presence of multiple aneurysms, bifurcation location, or prior treatment between the two groups. After PSM, 302 matched pairs showed significantly lower last follow-up adequate occlusion rates (81% vs 90%, p = 0.006) and higher retreatment rates (12% vs 3.6%, p < 0.001) in the large aneurysm group. These findings may inform treatment decisions and patient counseling. Future studies are needed to further explore this area. [ABSTRACT FROM AUTHOR]

Objectives: Moyamoya disease (MMD) is a cerebrovascular disorder marked by the progressive steno-occlusion of the bilateral internal carotid arteries and the formation of abnormal collateral vessel networks at the base of the brain. Previous studies have attempted to identify risk factors predictive of postoperative complications to improve patient management. This study aims to identify pretreatment factors associated with post-bypass symptomatic strokes in MMD patients., Methods: This study is a multicenter retrospective analysis conducted across 13 academic institutions in North America. A total of 518 patients with MMD were included. Data collected included patient demographics, disease characteristics, and follow-up duration. Stroke-free survival was analyzed using Kaplan-Meier curves. Univariate and multivariable Cox regression analyses were used to identify risk factors for symptomatic stroke., Results: The median age of the patients was 43 years (IQR, 34-52 years), and 370 (71 %) were females. Multivariable Cox regression identified advanced age (HR 1.03, 95 % CI 1.01-1.05, p = 0.011), female sex (HR 2.03, 95 % CI 1.00-4.11, p = 0.049), diabetes mellitus (HR 2.03, 95 % CI 1.14-3.63, p = 0.016), smoking status (HR 2.27, 95 % CI 1.27-4.05, p = 0.006), and asymptomatic disease (HR 0.37, 95 % CI 0.15-0.93, p = 0.034) as significant factors associated with symptomatic stroke., Conclusion: Advanced age, female sex, diabetes mellitus, and smoking status were significant predictors of symptomatic stroke in MMD patients after bypass surgery. Asymptomatic patients had a reduced risk of stroke. These findings emphasize the importance of managing modifiable risk factors and the potential benefits of early detection in improving clinical outcomes for MMD patients. Further prospective studies are needed to validate these findings., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Jabbour is a consultant for Medtronic, MicroVention, Balt and Cerus Endovascular. Dr. Tjoumakaris is a consultant for MicroVention. Dr. Gooch is a consultant for Stryker. Dr. Spiotta is a consultant for Terumo, Stryker, Penumbra, RapidAI, Cerenovus. Dr. Patel is a consultant for MicroVention and Medtronic. Dr. Du is a consultant for grand rounds. Dr. Burkhardt is a consultant for Longeviti Neuro solutions, Q-Apel Medical, Stryker. Dr. Hanel is a consultant for Medtronic, Balt, Stryker, Q’Apel Medical, Inc, Codman Neuro (J&J), Cerenovus, Microvention, Imperative Care, Inc, Phenox, Inc, Rapid Medical. Dr. Siddiqui is a consultant for Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., Cerenovus , Cerevatech Medical, Inc., Cordis , Corindus , Inc., Endostream Medical, Ltd, Imperative Care, InspireMD , Ltd., Integra , IRRAS AB, Medtronic, MicroVention , Minnetronix Neuro, Inc., Peijia Medical, Penumbra , Q’Apel Medical, Inc., Rapid Medical, Serenity Medical, Inc., Silk Road Medical, StimMed , LLC, Stryker Neurovascular, Three Rivers Medical, Inc., VasSol , Viz.ai, Inc. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Since the first use of embolization for cerebral arteriovenous malformations (AVMs) by Luessenhop and Spence in 1960, this procedure has become a cornerstone in the multimodal treatment approach for brain AVMs. Currently, in the United States, the main embolic agents employed are n-butyl cyanoacrylate (NBCA) and Onyx (Medtronic, Minneapolis, MN). This systematic review and meta-analysis aim to compare these two agents in terms of efficacy and safety. An updated guideline for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. The search strategy involved retrieving articles from PubMed, Scopus, and Web of Science from inception of these databases until June 27th, 2024, using specific search terms. Inclusion criteria were comparative studies of Onyx (Medtronic, Minneapolis, MN) and NBCA, peer-reviewed original studies published in full-text, and studies reporting at least one of the outcomes of interest. Statistical analysis was performed using R software version 4.3.1. After screening 3177 articles, 33 articles were assessed in full-text, and 4 studies were included in the final analysis. These studies included 374 patients, 170 (45.4%) females. There was no significant difference in complication rates between Onyx (Medtronic, Minneapolis, MN) and NBCA (risk ratio [RR]: 0.91; CI: 0.31 to 2.67, p = 0.86) with significant heterogeneity (I²=68%, p = 0.02). Technical success did not differ significantly (RR: 1.38; CI: 0.72 to 2.62, p = 0.33) with significant heterogeneity (I²=73%, p = 0.02). Mortality (RR: 1.5; CI: 0.28 to 8.08, p = 0.64; I²=16%, p = 0.31), morbidity (RR: 1.39; CI: 0.16 to 12.08, p = 0.76; I²=53%, p = 0.14), and blood loss (MD: -0.1; CI: -0.8 to 0.5, p = 0.72; I²=53%, p = 0.15) also showed no significant differences. Both NBCA and Onyx are effective and safe for embolization of cerebral AVMs, with no significant differences in complications, technical success, mortality, morbidity, and blood loss. Further research, particularly randomized controlled trials, is needed to better understand their comparative efficacy and safety., Competing Interests: Declarations Ethical approval Not Applicable. Informed consent and ethical approval N/A. Competing interests The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Purpose: Acute ischemic strokes caused by distal medium vessel occlusions (DMVO) represent a significant proportion of all stroke cases, yet the predictors of excellent functional outcomes in these patients remain poorly understood. This study aims to identify pretreatment computed tomography perfusion (CTP) parameters associated with excellent functional outcomes, defined as a modified Rankin Scale (mRS) score of 0-1 at 90 days, in patients with anterior circulation DMVO., Materials and Methods: We conducted a retrospective multicenter study involving patients with anterior DMVO, from three stroke centers within the Johns Hopkins Medical Enterprise. Baseline demographic, clinical, and imaging data were collected, with CTP parameters analyzed using RAPIDAI software. Univariable and multivariable logistic regression models were used to identify predictors of excellent outcomes. Receiver operating characteristic (ROC) curves were constructed to assess the predictive accuracy of CTP parameters., Results: Among the 82 patients (median age, 71 years; 57% female), occlusions were located in the M2 segment in 89%, M3 in 8.5%, and A2 in 2.4%. IVT was administered to 37% of patients, and EVT was attempted in 59%. Excellent outcomes at 90 days were achieved in 45% of patients. In univariate analysis, white race (OR, 4.14; 95% CI, 1.66-10.9; P=0.003), higher CBV index (OR per 0.1-unit change, 1.45; 95% CI, 1.08-2.05; P=0.022), and lower relative cerebral blood flow (rCBF < 20%) volumes (OR, 0.91; 95% CI, 0.81-0.98; P=0.038) were significantly associated with excellent outcomes. In multivariate analysis adjusting for age, sex, race, IVT administration, EVT attempted, dyslipidemia, and premorbid mRS, higher CBV index remained a significant independent predictor (OR per 0.1-unit change, 1.72; 95% CI, 1.14-2.81; P=0.017), and lower rCBF < 20% volume was associated with better outcomes (OR, 0.91; 95% CI, 0.80-0.98; P=0.05). The multivariate model demonstrated good predictive performance (area under the ROC curve, 80%; 95% CI, 70%-90%; P < 0.001)., Conclusions: In patients with anterior circulation DMVO, a higher CBV index on pretreatment CTP is an independent predictor of excellent functional outcomes at 90 days. These findings suggest that CTP parameters, particularly the CBV index, may be useful in prognostic assessment for this stroke population. Further studies are needed to validate these results and optimize therapeutic approaches., Abbreviations: ABC＝ definition; XYZ＝ definition., (© 2024 by American Journal of Neuroradiology.)

Background and purpose: Cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage (aSAH) may lead to morbidity and mortality. Endovascular mechanical angioplasty may be performed if symptomatic CV is refractory to noninvasive medical management. Compliant and noncompliant balloons and manually adjustable mesh may be used in this indication. We describe our initial experience with the Comaneci (Rapid Medical, Yokneam, Israel) in cerebral vasospasm treatment following aSAH. Methods: All patients included in the prospective observational SAVEBRAIN PWI (NCT05276934 on clinicaltrial.gov) study who underwent cerebral angioplasty using the Comaneci device for the treatment of medically refractory and symptomatic CV after aSAH were identified. Patient demographic information, procedural details, and outcomes were obtained from electronic medical records. Results: Between February 2022 and June 2023, seven consecutive patients underwent CV treatment with the Comaneci. Angioplasty of 37 arterial segments (supraclinoid internal carotid artery, A1, A2, and A3 segments of the anterior cerebral artery and M1 and M2 segments of the middle cerebral artery) was attempted, and 35/37 (95%) were performed. The vessel diameter improved significantly following angioplasty (+64%), while brain hypoperfusion decreased (-45% of the mean T Max ). There was no long-term clinical complication, and 6% per-procedural complications occurred. Conclusions: The Comaneci is effective in the treatment of cerebral vasospasm following aSAH, bringing a new device in the armamentarium of the neurointerventionalist to perform intracranial angioplasty., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2024 The Author(s).)

Objective: The Woven EndoBridge (WEB) device was approved to treat wide-necked bifurcation aneurysms. The device is designed as an intrasaccular flow disruptor covering aneurysm widths up to 10 mm. Although prior studies combined all aneurysm sizes, it is known that aneurysms behave differently in response to endovascular treatment based on their size. Therefore, the authors' objective was to identify ideal middle cerebral artery (MCA) aneurysm width and neck sizes most suitable for WEB treatment., Methods: The WorldWideWEB consortium is a large multicenter retrospective database that analyzes intracranial aneurysms treated with the WEB device. In this study, all unruptured MCA bifurcation aneurysms with available measurements were included. Cutoff values based on aneurysm width and neck in relation to aneurysm occlusion status were measured using the receiver operating characteristic (ROC) curve. Propensity score matching (PSM) was then used to compare treatment outcomes between aneurysms smaller and larger than the cutoff value for both width and neck size., Results: The ideal cutoff values for MCA bifurcation aneurysm width and neck were 6.1 mm and 4.6 mm, respectively. On PSM, 87 matched pairs were compared based on width size (≤ 6.1 mm and > 6.1 mm), and 77 matched pairs were compared based on neck size (≤ 4.6 mm and > 4.6 mm). There was a significant difference in adequate aneurysm occlusion between aneurysms smaller and larger than those cutoff values for both widths (93% vs 76%, p = 0.0017) and neck sizes (90% vs 70%, p = 0.0026). The retreatment rate was also significantly higher for larger aneurysms in both parameters., Conclusions: This study shows that MCA bifurcation aneurysms ≤ 6.1 mm in width and ≤ 4.6 mm in neck size are significantly better candidates for WEB treatment, leading to improved occlusion status and reduced retreatment rate, which are important considerations when using WEB devices.

Background: Arteriovenous malformations (AVMs) are uncommon cerebral lesions that can cause significant neurological complications. Surgical resection is the gold standard for treatment, but endovascular embolization and stereotactic radiosurgery (SRS) are viable alternatives., Objective: To compare the outcomes of endovascular embolization versus SRS in the treatment of AVMs with Spetzler-Martin grades I-III., Methods: This study combined retrospective data from 10 academic institutions in North America and Europe. Patients aged 1 to 90 years who underwent endovascular embolization or SRS for AVMs with Spetzler-Martin grades I-III between January 2010 and December 2023 were included., Results: The study included 244 patients, including 84 who had endovascular embolization and 160 who had SRS. Before propensity score matching (PSM), complete obliteration at the last follow-up was achieved in 74.5% of the SRS group compared with 57.8% of the embolization group (OR=0.47; 95% CI 0.26 to 0.48; P=0.01). After propensity score matching, SRS still achieved significantly higher occlusion rates at last follow-up (78.9% vs 55.3%; OR=0.32; 95% CI 0.12 to 0.90; P=0.03).Hemorrhagic complications were higher in the embolization group than in the SRS group, although this difference did not reach statistical significance after PSM (13.2% vs 2.6%; OR=5.6; 95% CI 0.62 to 50.47; P=0.12). Similarly, re-treatment rate was higher in the embolization group (10.5% vs 5.3%; OR=2.11; 95% CI 0.36 to 12.31; P=0.40) compared with the SRS group., Conclusion: Our findings indicate that SRS has a significantly higher obliteration rate at last follow-up compared with endovascular embolization. Also, SRS has a higher tendency for fewer hemorrhagic complications and lower re-treatment rate. Further prospective studies are needed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Purpose: The management of acute ischemic stroke (AIS) due to distal medium vessel occlusion (DMVO) remains uncertain, particularly in comparing the effectiveness of intravenous thrombolysis (IVT) plus mechanical thrombectomy (MT) versus IVT alone. This study aimed to evaluate the safety and efficacy in DMVO patients treated with either MT-IVT or IVT alone., Methods: This multinational study analyzed data from 37 centers across North America, Asia, and Europe. Patients with AIS due to DMVO were included, with data collected from September 2017 to July 2023. The primary outcome was functional independence, with secondary outcomes including mortality and safety measures such as types of intracerebral hemorrhage., Results: The study involved 1,057 patients before matching, and 640 patients post-matching. Functional outcomes at 90 days showed no significant difference between groups in achieving good functional recovery (modified Rankin Scale 0-1 and 0-2), with adjusted odds ratios (OR) of 1.21 (95% confidence interval [CI] 0.81 to 1.79; P=0.35) and 1.00 (95% CI 0.66 to 1.51; P>0.99), respectively. Mortality rates at 90 days were similar between the two groups (OR 0.75, 95% CI 0.44 to 1.29; P=0.30). The incidence of symptomatic intracerebral hemorrhage was comparable, but any type of intracranial hemorrhage was significantly higher in the MT-IVT group (OR 0.43, 95% CI 0.29 to 0.63; P<0.001)., Conclusion: The results of this study indicate that while MT-IVT and IVT alone show similar functional and mortality outcomes in DMVO patients, MT-IVT presents a higher risk of hemorrhagic complications, thus MT-IVT may not routinely offer additional benefits over IVT alone for all DMVO stroke patients. Further prospective randomized trials are needed to identify patient subgroups most likely to benefit from MT-IVT treatment in DMVO.

Background: Acute ischemic stroke (AIS) caused by distal medium vessel occlusions (DMVOs) represents a significant proportion of overall stroke cases. While intravenous thrombolysis (IVT) has been a primary treatment, advancements in endovascular procedures have led to increased use of mechanical thrombectomy (MT) in DMVO stroke patients. However, symptomatic intracerebral hemorrhage (sICH) remains a critical complication of AIS, particularly after undergoing intervention. This study aims to identify factors associated with sICH in DMVO stroke patients undergoing MT., Methods: This retrospective analysis utilized data from the Multicenter Analysis of Distal Medium Vessel Occlusions: Effect of Mechanical Thrombectomy (MAD-MT) registry, involving 37 centers across North America, Asia, and Europe. Middle cerebral artery (MCA) DMVO stroke patients were included. The primary outcome measured was sICH, as defined per the Heidelberg Bleeding Classification. Univariable and multivariable logistic regression were used to identify factors independently associated with sICH., Results: Among 1708 DMVO stroke patients, 148 (8.7%) developed sICH. Factors associated with sICH in DMVO patients treated with MT included older age (adjusted odds ratio (aOR) 1.01, 95% confidence interval (95% CI) 1.00 to 1.03, P=0.048), distal occlusion site (M3, M4) compared with medium occlusions (M2) (aOR 1.71, 95% CI 1.07 to 2.74, P=0.026), prior use of antiplatelet drugs (aOR 2.06, 95% CI 1.41 to 2.99, P<0.001), lower Alberta Stroke Program Early CT Scores (ASPECTS) (aOR 0.75, 95% CI 0.66 to 0.84, P<0.001), higher preoperative blood glucose level (aOR 1.00, 95% CI 1.00 to 1.01, P=0.012), number of passes (aOR 1.27, 95% CI 1.15 to 1.39, P<0.001), and successful recanalization (Thrombolysis In Cerebral Infarction (TICI) 2b-3) (aOR 0.43, 95% CI 0.28 to 0.66, P<0.001)., Conclusion: This study provides novel insight into factors associated with sICH in patients undergoing MT for DMVO, emphasizing the importance of age, distal occlusion site, prior use of antiplatelet drugs, lower ASPECTS, higher preoperative blood glucose level, and procedural factors such as the number of passes and successful recanalization. Pending confirmation, consideration of these factors may improve personalized treatment strategies., Competing Interests: Competing interests: Dr Regenhardt serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation. Dr Guenego reports consultancy for Rapid Medical and Phenox, not directly related to the present work. Dr Clarençon reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading) and Artedrone (Board); all not directly related to the present work. Dr Henninger received support from W81XWH-19-PRARP-RPA from the CDMRP/DoD, NS131756 and U24NS113844 from the NINDS, and NR020231 from the NINR and received compensation from Myrobalan, Inc and General Dynamics during the conduct of this study unrelated to this work. Dr Liebeskind is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, Rapid Medical. Dr Yeo reports Advisory work for AstraZeneca, substantial support from NMRC Singapore and is a medical advisor for See-mode, Cortiro and Sunbird Bio, with equity in Ceroflo; all unrelated to the present work. Dr Griessenauer reports a proctoring agreement with Medtronic and research funding by Penumbra. Dr Marnat reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt (consulting), Medtronic, Johnson & Johnson and Phenox (paid lectures), all not directly related to the present work. Dr Puri is a consultant for Medtronic Neurovascular, Stryker Neurovascular, Balt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc and Arsenal Medical, he received research grants from NIH, Microvention, Cerenovus, Medtronic Neurovascular and Stryker Neurovascular, and holds stocks in InNeuroCo, Agile, Perfuze, Galaxy and NTI. Dr Tjoumakaris is a consultant for Medtronic and Microvention (funds paid to institution, not personally). Dr Jabbour is a consultant for Medtronic, Microvention and Cerus. HS and VY are guarantors of the study., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The efficacy of endovascular treatment (EVT) in acute ischaemic stroke due to distal medium vessel occlusion (DMVO) remains uncertain. Our study aimed to evaluate the safety and efficacy of EVT compared with the best medical management (BMM) in DMVO., Methods: In this prospectively collected, retrospectively reviewed, multicentre cohort study, we analysed data from the Multicentre Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy registry. Patients with acute ischaemic stroke due to DMVO in the M2, M3 and M4 segments who underwent EVT or received BMM were included. Primary outcome measures comprised 10 co-primary endpoints, including functional independence (mRS 0-2), excellent outcome (mRS 0-1), mortality (mRS 6) and haemorrhagic complications. Propensity score matching was employed to balance the cohorts., Results: Among 2125 patients included in the primary analysis, 1713 received EVT and 412 received BMM. After propensity score matching, each group comprised 391 patients. At 90 days, no significant difference was observed in achieving mRS 0-2 between EVT and BMM (adjusted OR 1.00, 95% CI 0.67 to 1.50, p>0.99). However, EVT was associated with higher rates of symptomatic intracerebral haemorrhage (8.4% vs 3.0%, adjusted OR 3.56, 95% CI 1.69 to 7.48, p<0.001) and any intracranial haemorrhage (37% vs 19%, adjusted OR 2.61, 95% CI 1.81 to 3.78, p<0.001). Mortality rates were similar between groups (13% in both, adjusted OR 1.48, 95% CI 0.87 to 2.51, p=0.15)., Conclusion: Our findings suggest that while EVT does not significantly improve functional outcomes compared with BMM in DMVO, it is associated with higher risks of haemorrhagic complications. These results support a cautious approach to the use of EVT in DMVO and highlight the need for further prospective randomised trials to refine treatment strategies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)