Abstract Background and aims Distal-medium vessel occlusions (DMVO) account for 25-40% of acute ischemic strokes (AIS). Recent RCTs showed no benefit of endovascular therapy (EVT) over medical management in DMVO, and an increased risk of symptomatic intracerebral haemorrhage (sICH). This study explored predictors of intracranial haemorrhage in EVT-treated DMVO. Methods We retrospectively analysed DMVO-AIS patients who underwent EVT and/or intravenous thrombolysis (IVT) at a comprehensive stroke centre (May 2016 - March 2025). DMVO was defined by CT angiography as an isolated occlusion of ACA, PCA, M2 (dominant/non-dominant), M3 and M4 segments of MCA. Univariate and multivariable logistic regression analyses identified predictors of intracranial haemorrhage. Results Among 658 patients, 82.2% underwent EVT, using aspiration as first technique in 97.4%. M2 occlusions predominated (80.8%; 53.6% dominant). Intracranial haemorrhage occurred in 28.4% (ICH in 24.4%, SAH in 9.2%, sICH in two patients). 90-day mRS 0-2 was achieved in 43.8%. For any intracranial haemorrhage, multivariate analysis revealed baseline ASPECTS (OR=0.76, 95%CI 0.64,0.90, p=0.002) as a significant predictor. For parenchymatous ICH, IVT was a significant predictor (OR=2.47, 95% CI 1.01,6.04, p=0.047) whereas the presence of a CT dense artery sign showed a protective trend (OR=0.35, 95% CI 0.12,1.04, p=0.06). Results remained consistent after excluding dominant M2 occlusions in sensitivity analysis. Conclusions Baseline ASPECTS and IVT independently predict intracranial haemorrhage in EVT-treated DMVO. These findings emphasise that baseline parenchymal integrity is a critical factor in assessing haemorrhagic risk. Results support selective bridging therapy in distal occlusions, with careful consideration of baseline tissue status. Conflict of interest Nothing to disclose
Cordeiro et al. (2026) studied this question.