MeVO: To Treat or Not To Treat? Review of the Latest Evidence

Endovascular thrombectomy (EVT) is standard care for large vessel occlusion, but its role in medium vessel occlusion (MeVO) is contested. We appraise randomized and real-world evidence and ask whether, and in whom, MeVO should be treated.

DISTAL, ESCAPE-MeVO and DISCOUNT found no functional benefit from adding EVT to medical treatment, with more hemorrhage and serious adverse events; DISTAL's 12-month results were also neutral. ORIENTAL-MeVO, restricted to deficits of NIHSS ≥ 6 within 24 h, reported greater functional independence with EVT (58.6% versus 46.6%). The MEMENTO registry (164 patients, 15 Middle East and North Africa centres) reproduced trial-level outcomes - 69% recanalization, 54% independence, 3% symptomatic hemorrhage - while modelled cost-effectiveness ratios of $26,875-71,333/QALY exceeded regional thresholds. DISTALS achieved high reperfusion without symptomatic hemorrhage using a MeVO-dedicated stentretriever. Routine MeVO thrombectomy is unjustified. Benefit concentrates in moderate-to-severe deficits, eloquent territory, salvageable tissue and technically accessible primary occlusions.