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Endovascular Treatment of Medium Vessel Occlusion Stroke
Johanna M Ospel1,2, Thanh N Nguyen3, Ashutosh P Jadhav4
1Department of Diagnostic Imaging (J.M.O., M.G.), Foothills Medical Centre, University of Calgary, AB, Canada.
Abstract:
Approximately one-third of acute ischemic strokes with an identifiable vessel occlusion are caused by medium vessel occlusion (MeVO), that is, nonlarge vessel occlusions that are potentially amenable to endovascular treatment (EVT). Management of patients with MeVO is challenging in many ways: detecting MeVOs can be challenging, particularly for inexperienced physicians, and in busy clinical routine, MeVOs, therefore, remain sometimes undiagnosed. While the clinical course of MeVO stroke with medical management, including intravenous thrombolysis, is by no means, benign, it is more favorable compared with large vessel occlusion. At the same time, EVT complication rates are higher, and thus, the marginal benefit of EVT beyond best medical management is expected to be smaller and more challenging to detect if it were present. Several randomized controlled trials are currently underway to investigate whether and to what degree patients with MeVO may benefit from EVT and will soon provide robust data for evidence-based MeVO EVT decision-making. In this review, we discuss different ways of defining MeVOs, strategies to optimize MeVO detection on imaging, and considerations for EVT decision-making in the setting of MeVO stroke. We discuss the technical challenges related to MeVO EVT and conclude with an overview of currently ongoing MeVO EVT trials.
Insights
Medium vessel occlusion (MeVO) strokes are common and challenging to diagnose. This review explores MeVO detection, treatment considerations, and ongoing trials for endovascular treatment (EVT) in acute ischemic stroke.
Area of Science:
- Neurology
- Vascular Medicine
- Interventional Radiology
Background:
- Medium vessel occlusion (MeVO) accounts for about one-third of acute ischemic strokes amenable to endovascular treatment (EVT).
- Diagnosis and management of MeVO strokes present unique challenges, including detection difficulties and higher complication rates with EVT compared to large vessel occlusions.
- The clinical outcomes of MeVO strokes treated with medical management, including intravenous thrombolysis, are less favorable than large vessel occlusions.
Purpose of the Study:
- To review current definitions and imaging strategies for optimizing MeVO detection.
- To discuss considerations for endovascular treatment (EVT) decision-making in MeVO stroke.
- To provide an overview of ongoing randomized controlled trials evaluating EVT for MeVO.
Main Methods:
- Literature review of MeVO definitions and diagnostic imaging techniques.
- Analysis of clinical outcomes and complication rates associated with EVT for MeVO.
- Summary of ongoing clinical trials investigating EVT efficacy in MeVO stroke.
Main Results:
- MeVO detection remains a clinical challenge, often leading to underdiagnosis.
- EVT for MeVO carries higher complication risks, necessitating careful benefit-risk assessment.
- Robust data from ongoing trials are anticipated to guide evidence-based EVT decision-making for MeVO.
Conclusions:
- Optimizing MeVO detection and refining EVT decision-making are crucial for improving patient outcomes.
- Ongoing clinical trials are essential for establishing the efficacy and safety of EVT in MeVO stroke.
- Further research is needed to address technical challenges and define optimal treatment paradigms for MeVO.
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