Endovascular Treatment Versus Medical Management of Acute Ischemic Strokes Due to Distal Medium Vessel Occlusions

Introduction: Endovascular treatment (EVT) is effective for acute ischemic strokes due to proximal large vessel occlusions (LVOs). However, its efficacy and safety in distal medium vessel occlusions(DMVOs) are debated. We performed a systematic review and meta-analyses to compare EVT with best medical treatment(BMT) in treating primary DMVOs. Methods A search was performed on Embase, PubMed, and Cochrane up to April 2025. Efficacy outcomes included functional independence and excellent functional outcomes at 90 days. Safety outcomes were symptomatic intracranial hemorrhage(sICH) and 90-day mortality. Statistical analyses used Review Manager (RevMan) version 5.3. Results Three RCTs and 30 observational studies were included in this meta-analysis of 8936 patients. 4049(50.72%) were included in EVT and 4887(49.28%) in BMT arm. Overall, BMT was comparable to EVT in terms of excellent functional outcome(mRS 0-1) (OR 1.06, 95% CI 0.89 to 1.25), functional independence(mRS 0-2) (OR 0.97, 95% CI 0.82 to 1.14) and 90-day mortality (OR 1.15, 95% CI: 0.91 to 1.46). Notably, there was a statistically significant increase in sICH rates with EVT (OR 1.54, p-value=0.01). In studies with mild strokes(NIHSS <6), BMT was superior to EVT in achieving functional independence (OR 0.57, p=0.05), while EVT was associated with significantly higher sICH rates (OR 6.35, p=0.010). Conclusion BMT is equally efficacious and safer than EVT in DMVO ischemic strokes. Based on current evidence, EVT should be avoided for medium and distal vessel occlusions given significantly higher risk of intracranial hemorrhage. Outcomes with EVT are also worse in posterior circulation DMVOs and when EVT is performed >4 hours from the last known normal time.