Thrombectomy for Acute Stroke Due to Medium Vessel Occlusion Across Perfusion Mismatch Profiles

Importance: Recent trials have not demonstrated a benefit of endovascular thrombectomy (EVT) over medical therapy in acute stroke due to medium vessel occlusion (MeVO). However, it remains uncertain whether selected patients with favorable perfusion may benefit from EVT. Objective: To investigate the association between perfusion mismatch profiles and functional outcomes in MeVO stroke and to determine whether these profiles modify the effect of EVT. Design, Setting, and Participants: This study was a post hoc analysis of ESCAPE-MeVO (Endovascular Treatment to Improve Outcomes for Medium Vessel Occlusion), a multicenter randomized clinical trial conducted in North America, Europe, and the United Kingdom between April 2022 and June 2024, with a 90-day follow-up. Trial participants included patients with acute MeVO stroke presenting within 12 hours from last known well and evidence of salvageable brain tissue. This analysis included only patients with interpretable baseline perfusion imaging. Data were analyzed from March to July 2026. Interventions: Randomization to EVT plus usual care vs usual care alone. Main outcomes and measures: The primary outcome was the 90-day ordinal modified Rankin Scale (mRS) score. Secondary outcomes included 24-hour follow-up infarct volume and 90-day mRS score of 0 to 1 and 0 to 2. Perfusion mismatch ratio and volume were defined as the ratio and difference between the critically hypoperfused area and the ischemic core, with volume thresholds defined by site-specific postprocessing software. Results: Of 530 enrolled patients, 309 (58.3%) had available baseline perfusion imaging and were included in this study (EVT: n = 146; usual care: n = 163). Patient median (IQR) age was 73 (63-82) years, and 141 (45.6%) were women. Median (IQR) perfusion mismatch volume was 37.2 (22.1-57.2) mL, and the median (IQR) mismatch ratio was 6.1 (2.8-10.0). Ordinal 90-day mRS score was not associated with perfusion mismatch volume (adjusted odds ratio [AOR], 1.03 [95% CI, 0.99-1.07] per 10-mL increase) or perfusion mismatch ratio (AOR, 1.03 [95% CI, 0.97-1.09] per 1-unit increase). There was no modification of EVT effect by perfusion mismatch volume or ratio on ordinal 90-day mRS. Results were consistent across secondary outcomes and subgroups. Conclusions and Relevance: In this exploratory post hoc analysis of acute MeVO stroke, perfusion mismatch profiles were not associated with functional outcomes and did not modify the effect of EVT. These findings suggest that perfusion imaging profiles based on currently used thresholds and cutoffs did not identify patients likely to benefit from EVT in the ESCAPE-MeVO trial. Trial Registration: ClinicalTrials.gov Identifier: NCT05151172.

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Journal
JAMA Network Open
Published
2026-10-13
DOI
https://doi.org/10.1001/jamanetworkopen.2026.38823
Primary Topic
Acute Ischemic Stroke Management
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article
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article

Thrombectomy for Acute Stroke Due to Medium Vessel Occlusion Across Perfusion Mismatch Profiles

Franziska Dorn, Umberto Pensato, Christian Hametner, Sven Poli et al.
JAMA Network Open
Acute Ischemic Stroke Management
article

Thrombectomy for Acute Stroke Due to Medium Vessel Occlusion Across Perfusion Mismatch Profiles

Franziska Dorn, Umberto Pensato, Christian Hametner, Sven Poli, Jai Shankar, Santiago Ortega‐Gutiérrez, Yogish Joshi, Andrew M. Demchuk, Brian H Buck, Johanna Maria Ospel, David Volders, Arno Reich, Aravind Ganesh, Gunjan Jindal, Ayokunle Ogungbemi, Fabio Settecase, Timo Krings, Ronald Budzik, J. Berrouschot, Rob Crossley, Sándor Nardai, Mayank Goyal, Alexander Stebner, Thant Hlaing, Pattarawut Charatpangoon, Thien Huynh, Sachin Pandey, Dar Dowlatshahi, Jennifer Mandzia, Shahid Nimjee, Richard Perry, Richard Swartz, Richard Marigold, Paul Burns, Ethan MacDonald, Liqun Zhang, Markus Möhlenbruch, Atif Zafar, Michael Chen, Albert Yoo, Lissa Peeling, Jason Tarpley, Negar Asdashi, Ravinder-Jeet Singh, James Kennedy, Adewumi Amole, Michael D. Hill, Maxim Mokin, Changez Jadun, Gabor Lenzser, Levansri Makalanda, Babak Jahromi, Seon-Kyu Lee, Thomas Booth, Mchael Levitt, Salome Bosshart, Reade De Leacy, Demetrios Sahlas, Thalia Field, Eric Sauvageau, Pual (Inder) Singh, Adnan Siddiqui, Jesse Klostranec, Thanhn Nguyen, Mouhammad Jumaa, Koji Ebersole, Kyriakos Lobotesis, Hauke Scheider, Tufail Patankar, Joanna Schaafsma, William Diprose, Robert Lenthall, Dileep Yavagal, Christian Taschner, George Lopez, ESCAPE-MEVO Investigators, Aubrey Smith
article en

Abstract

Importance: Recent trials have not demonstrated a benefit of endovascular thrombectomy (EVT) over medical therapy in acute stroke due to medium vessel occlusion (MeVO). However, it remains uncertain whether selected patients with favorable perfusion may benefit from EVT. Objective: To investigate the association between perfusion mismatch profiles and functional outcomes in MeVO stroke and to determine whether these profiles modify the effect of EVT. Design, Setting, and Participants: This study was a post hoc analysis of ESCAPE-MeVO (Endovascular Treatment to Improve Outcomes for Medium Vessel Occlusion), a multicenter randomized clinical trial conducted in North America, Europe, and the United Kingdom between April 2022 and June 2024, with a 90-day follow-up. Trial participants included patients with acute MeVO stroke presenting within 12 hours from last known well and evidence of salvageable brain tissue. This analysis included only patients with interpretable baseline perfusion imaging. Data were analyzed from March to July 2026. Interventions: Randomization to EVT plus usual care vs usual care alone. Main outcomes and measures: The primary outcome was the 90-day ordinal modified Rankin Scale (mRS) score. Secondary outcomes included 24-hour follow-up infarct volume and 90-day mRS score of 0 to 1 and 0 to 2. Perfusion mismatch ratio and volume were defined as the ratio and difference between the critically hypoperfused area and the ischemic core, with volume thresholds defined by site-specific postprocessing software. Results: Of 530 enrolled patients, 309 (58.3%) had available baseline perfusion imaging and were included in this study (EVT: n = 146; usual care: n = 163). Patient median (IQR) age was 73 (63-82) years, and 141 (45.6%) were women. Median (IQR) perfusion mismatch volume was 37.2 (22.1-57.2) mL, and the median (IQR) mismatch ratio was 6.1 (2.8-10.0). Ordinal 90-day mRS score was not associated with perfusion mismatch volume (adjusted odds ratio [AOR], 1.03 [95% CI, 0.99-1.07] per 10-mL increase) or perfusion mismatch ratio (AOR, 1.03 [95% CI, 0.97-1.09] per 1-unit increase). There was no modification of EVT effect by perfusion mismatch volume or ratio on ordinal 90-day mRS. Results were consistent across secondary outcomes and subgroups. Conclusions and Relevance: In this exploratory post hoc analysis of acute MeVO stroke, perfusion mismatch profiles were not associated with functional outcomes and did not modify the effect of EVT. These findings suggest that perfusion imaging profiles based on currently used thresholds and cutoffs did not identify patients likely to benefit from EVT in the ESCAPE-MeVO trial. Trial Registration: ClinicalTrials.gov Identifier: NCT05151172.

JAMA Network OpenVol. 9(10)
Humanitas University (IT), University of Ottawa (CA), University of Auckland (NZ), University of Alberta (CA), University of Calgary (CA), King's College London (GB), Heidelberg University (DE), Toronto Western Hospital (CA), University Hospital Bonn (DE), University Hospital Heidelberg (DE), ProMedica Toledo Hospital (US), The Ohio State University Wexner Medical Center (US), University of Oxford (GB), King's College Hospital NHS Foundation Trust (GB), ProMedica Russell J. Ebeid Children's Hospital (US), IRCCS Humanitas Research Hospital (IT), Ottawa Hospital Research Institute (CA), University of Manitoba (CA), University of Toledo (US)
Openalex Percentile: Top 13%
Acute Ischemic Stroke Management
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