Thrombectomy versus Medical Management for Pediatric Acute Ischemic Stroke Due to Isolated M2 Occlusion: A Multicenter Cohort Study

Objective Endovascular thrombectomy (EVT) is increasingly used for pediatric large vessel occlusion (LVO) stroke, however, its role in isolated M2 occlusions remains underexplored. This study compared clinical outcomes in children with isolated M2 occlusion treated with EVT versus best medical therapy (BMT). Methods This multicenter cohort study pooled data from 4 pediatric stroke registries (Save ChildS, KidClot, Pediatric LVO Study, and Save ChildS Pro). Children ages 28 days–17 years with isolated M2 occlusion presenting within 24 hours of last seen well were included. Primary outcome was the pediatric modified Rankin scale (ped‐mRS) at 3 to 6 months. Secondary outcomes included changes in Pediatric National Institutes of Health Stroke Scale (PedNIHSS), Pediatric Stroke Outcome Measure (PSOM), and safety endpoints. Results Forty patients were included, of whom 20 were treated with EVT (median age, 12 years; interquartile range IQR, 6–15; 40% female) and 20 with BMT only (10 years; IQR, 5–14; 50% female). Baseline demographics were similar. EVT patients showed superior outcomes: median ped‐mRS at 3 to 6 months was 1 versus 2 ( p = 0.015). EVT resulted in greater PedNIHSS reduction from admission to day 7 (−9 vs −1, p < 0.001) and lower PSOM at 3 to 6 months (0.5 vs 2.5, p = 0.009). This benefit persisted at 24 months with a median ped‐mRS of 1 (IQR, 0–2) in the EVT group and 2 (IQR, 1–3) in the BMT group ( p = 0.012). One symptomatic intracranial hemorrhage occurred in the BMT group, and no deaths or access‐site complications were reported. Interpretation In children with isolated M2 occlusion, EVT was associated with better functional outcomes and neurological recovery than medical therapy alone, with an acceptable safety profile. ANN NEUROL 2025