ABSTRACT NUMBER: ESOC2026A934 CT PERFUSION–GUIDED MECHANICAL THROMBECTOMY FOR M2 OCCLUSION USING A ONE-STOP ANGIO-CT WORKFLOW

Abstract Background and aims The benefit of endovascular thrombectomy (EVT) for medium-vessel occlusions remains uncertain, particularly when patients are selected based on tissue viability. We evaluated clinical and imaging outcomes of EVT for M2 occlusions using CT perfusion (CTP)–based selection in a one-stop Angio-CT workflow, compared with ICA/M1 occlusions and conservative management. Methods We retrospectively reviewed patients with acute ischemic stroke transported to our hospital. All patients underwent CTP on arrival in an Angio-CT suite, and tissue-based criteria determined EVT eligibility. We compared clinical, procedural, and functional outcomes between EVT-treated ICA/M1 and M2 occlusions. Among patients with M2 occlusions, we also compared EVT with conservative management. Imaging analysis focused on CTP-derived infarct core and penumbral volumes. Results EVT was performed in 55 patients with ICA/M1 occlusions and 21 with M2 occlusions. Baseline characteristics, recanalization rates, and functional outcomes were similar between the groups. CTP showed larger penumbral volumes in ICA/M1, while infarct core volumes were comparable. Among patients with M2 occlusion, those treated with EVT had higher baseline NIHSS scores than those managed conservatively yet achieved similar functional outcomes. Conclusions Using CT perfusion–based selection, EVT can be safely offered to patients with M2 occlusions, achieving outcomes comparable to more proximal occlusions. These findings suggest that, even when penumbral volume is small, patients with severe neurological deficits may benefit from EVT if tissue viability is preserved. For M2 occlusion, treatment decisions should therefore be guided by symptoms and tissue viability, rather than occlusion site alone. Conflict of interest Nothing to disclose