OBJECTIVE: To evaluate functional and safety outcomes of Endovascular thrombectomy(EVT) vs Medical Management(MM) in patients with M2 occlusion and examine their association with perfusion imaging mismatch and stroke severity.METHODS: In a pooled, patient-level analysis of 3 randomized controlled trials(EXTEND-IA, EXTEND-IA-TNK part 1&2) and 2 prospective non-randomized studies(INSPIRE&SELECT), we evaluated EVT association with 90-day functional independence(mRS 0-2) in isolated M2 occlusions as compared to medical management overall and in subgroups by mismatch profile status and stroke severity.RESULTS: We included 517 patients(EVT=195, MM=322), baseline median(IQR) NIHSS was 13(8-19) in EVT vs 10(6-15) in MM, p<0.001. Pre-treatment ischemic core did not differ(EVT=10(0-24)mL vs MM=9(3-21)mL, p=0.59). Compared to MM, EVT was more frequently associated with functional independence(68.3% vs 61.6%, aOR=2.42,95%CI=1.25-4.67, p=0.008,IPTW-OR=1.75,95% CI=1.00-3.75,p=0.05) with a shift towards better mRS outcomes(adjusted cOR=2.02,95%CI:1.23-3.29,p=0.005), and lower mortality(5% vs 10%, aOR=0.32,95%CI=0.12-0.87,p=0.025). EVT was associated with higher functional independence in patients with a perfusion mismatch profile(EVT=70.7% vs MM=61.3%, aOR=2.29, 95%CI=1.09-4.79,p=0.029, IPTW-OR=2.02,1.08-3.78,p=0.029), whereas no difference was found in those without mismatch(EVT=43.8% vs MM=62.7%,p=0.17, IPTW-OR: 0.71,95% CI=0.18-2.78,p=0.62). Functional independence was more frequent with EVT in patients with moderate or severe strokes, as defined by baseline NIHSS above any thresholds from 6-10, whereas there was no difference between groups with milder strokes below these thresholds.INTERPRETATION: In patients with M2 occlusion, EVT was associated with improved clinical outcomes when compared to medical management. This association was primarily observed in patients with a mismatch profile and those with higher stroke severity. This article is protected by copyright. All rights reserved.
View details for DOI 10.1002/ana.26331
View details for PubMedID 35184327