7 ISC NEWS DAY 2 | THURSDAY, FEBRUARY 6, 2025 StrokeConference.org #ISC25 the transfemoral angiography group (95.8%, 409 patients); incidence difference, −4.8% [95% CI, −8.1% to -1.5%]; RR, 0.95 [95% CI, 0.92-0.98]; P = 0.46). Duration of both angiography and fluoroscopy was longer in the transradial group than in the transfemoral group. But patient bedridden time and visual analog scale score were lower in the transradial angiography group. Also, no significant difference was found between the groups in the incidence of angiographic complications during and within 24 hours after the procedure. “Our findings offer valuable insights into these two access routes, helping to clarify the trade-offs between procedural success, patient comfort and complication rates, which are critical for informed clinical decision-making,” said principal investigator Wei Ni, MD, a neurosurgeon at Huashan Hospital and Fudan University in China. “Although the transradial approach for cerebral angiography may have a slightly lower success rate and longer procedural time compared to the transfemoral approach, it provides notable advantages in patient comfort, shorter bedridden time and comparable complication rates.” Ni noted that developing more efficient transradial angiography devices is essential for enhancing the success rate of transfemoral angiography. Endovascular therapy did not provide an added benefit in patients with distal or medium vessel occlusion stroke The DISTAL trial is one of the first and largest randomized-controlled trials reporting on the effect of endovascular thrombectomy (EVT) plus best medical therapy versus best medical therapy alone for patients with acute ischemic stroke due to a medium or distal vessel occlusion. Results of the trial described Wednesday showed that EVT did not reduce disability or death compared with the best medical therapy alone. DISTAL — a multicenter, international, prospective, openlabel, blinded-endpoint superiority trial — studied 543 patients 1:1 with an acute ischemic stroke due to a medium or distal vessel occlusion. The patients were randomized 1:1 to EVT plus usual careor usual care alone over three years. The primary efficacy outcome was the distribution of disability levels on the modified Rankin Scale at 90 days. “Based on previous evidence, we limited the target vessels to previously understudied vessel segments in which evidence of a treatment benefit was missing, which included the non- or co-dominant M2 segment; M3 or M4 segment of the middle cerebral artery; the A1, A2 or A3 segment of the anterior cerebral artery; and the P1, P2 or P3 segment of the posterior cerebral artery,” said principal investigator Marios Psychogios, MD, director of diagnostic and interventional neuroradiology at University Hospital Basel in Switzerland. Co-principal investigator Urs Fischer, MD, director of the neurology department at the University Hospital Bern in Switzerland, noted that the study’s limitation to non- or co-dominant M2 occlusions, which perfuse less than half of the media territory, is a key strength of the DISTAL trial compared with other trials. For dominant M2 occlusions, there was compelling evidence from a HERMES sub-analysis that endovascular therapy would be beneficial, he said. Still, EVT in addition to best medical therapy did not lead to a reduction in disability or death compared with best medical therapy alone. This finding was consistent among all studied subgroups, particularly in patients with moderate to severe strokes with a National Institute of Health Stroke Scale score of 6 or above, people who did not receive intravenous thrombolysis, and those age 70 or younger. No patient was lost to follow-up. Although the results of the DISTAL trial were neutral, the researchers suggest that clinicians should consider offering EVT to selected patients on a case-to-case basis. “Endovascular therapy in addition to best medical therapy does not lead to increased rates of symptomatic intracranial hemorrhage or death, and overall endovascular therapy for medium or distal vessel occlusion appears to be a safe procedure,” Dr. Psychogios said. “An important finding from DISTAL was that the natural course of medium distal vessel occlusion stroke is worse than expected, increasing the pressure on finding novel effective treatment options.” DISTAL will serve to inform the design of future randomized clinical trials studying the effects of EVT in people with distal or medium vessel occlusion stroke. The study was published simultaneously in the New England Journal of Medicine. Endovascular therapy did not provide an added benefit in patients with medium vessel occlusion stroke The ESCAPE-MeVO trial, reporting on the effect of endovascular thrombectomy (EVT) plus usual care for patients with acute ischemic stroke due to a medium distal vessel occlusion, found EVT did not provide an added benefit. The study —a prospective, open-label, blinded-endpoint trial — included 530 patients in five countries who had an acute ischemic stroke due to a medium distal vessel occlusion (in A2, M2, P2 or more distal arterial segments). The patients were randomized 1:1 within 12 hours from the last known well/favorable baseline noninvasive brain imaging to EVT plus usual care (255 patients) or usual care only (274 patients). The study period ran from April 2022 to June 2024. Eligible patients in both treatment groups received guidelinedirected anti-thrombolytic therapy. The primary outcome was the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included the Barthel Index score, mortality at 90 days, infarct volume and patient reported quality of life. In the study, EVT treatment did not improve outcomes at 90 days, compared with usual care. Excellent functional outcomes (mRS 0-1 at 90 days) occurred in 41.6% of patients in the EVT group and 43.1% in the usual care group [adjRR = 0.95, CI 0.79-1.15, p=0.61]. In the EVT group, 13.3% of patients died, compared with 8.4% in the usual care group. Symptomatic intracranial hemorrhage occurred in 2.2% of patients in the usual care group and 5.4% of patients in the EVT group (p=0.08). “Ten years ago, we tackled large vessel occlusion, showing in multiple scenarios that endovascular therapy treatment is good for patients with large vessel occlusion. In ESCAPEMeVO, we asked the next question: ‘Is endovascular therapy efficacious when the clots are smaller and the strokes are less severe?’” said principal investigator Mayank Goyal, MD, FAHA, a clinical professor of radiology and clinical neurosciences at the University of Calgary Fischer Goyal Hill see LATE-BREAKING SCIENCE, page 12 Psychogios
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