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

PURPOSE OF REVIEW: 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. RECENT FINDINGS: 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.