March 2026 | Issue 61
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Featured in this issue:
Randomised stroke trials elucidate latewindow role for tenecteplase page 4
Profile David Liebeskind
“New era” in radiation protection heralded by European study results
page 14
page 22
NEW DATA
Refined patient selection and tailored devices revitalise thrombectomy for MeVO stroke Late-breaking data from two randomised controlled trials (RCTs) presented at this year’s International Stroke Conference (ISC; 4–6 February, New Orleans, USA) have found mechanical thrombectomy to be a safe and effective treatment option in certain patients with ischaemic strokes caused by medium-vessel occlusions (MeVOs). By utilising refined patient selection strategies and purpose-built devices, the ORIENTAL MEVO and DISTALS studies may have breathed new life into the endovascular treatment of more distally located occlusions— 12 months after multiple trials suggested the approach carried no significant benefits over the existing standard of care.
“T
he ORIENTAL MEVO trial indicates potential benefits of endovascular therapy for selected patients—higher NIHSS [National Institutes of Health stroke scale] scores—with MeVOs and DVOs [distal-vessel occlusions], supported by DISTALS, which showed that specialised devices improve reperfusion without increasing
CAROTID symptomatic haemorrhage compared to medical management alone,” commented Urs Fischer (University Hospital Bern, Bern, Switzerland), co-principal investigator for the DISTAL RCT, which was presented at last year’s ISC. “However, with three earlier trials showing neutral results, further research is needed to validate these findings.” “ORIENTAL MEVO and DISTALS suggest MeVO thrombectomy is not a routine default, but it is not dead,” added Levansri Makalanda (Royal London Hospital, London, UK), an investigator for the ESCAPE-MeVO trial, from which late-breaking data were also shared at ISC 2025. “The signal looks strongest when we select higher-NIHSS, clearly disabling patients rather than broad, low-severity cohorts, which the initial trails fell foul of. DISTALS also underlines the need for distal specific devices to improve safety and technical success. Key open questions are the right selection thresholds and whether adjuncts like intra-arterial lysis—as in CHOICE— will return for selected MeVO cases.”
ORIENTAL MEVO results
Presented by leading investigators Raul Nogueira (University of Pittsburgh School of Medicine, Pittsburgh, USA), XiaoZhong Jing, and Wei Hu (both University of Science and Technology of China, Hefei, China), the ORIENTAL MEVO trial homed in on a more specific patient population relative to prior RCTs in this space, restricting enrolment to MeVO stroke with moderate or higher clinical severity. Nogueira noted that broader inclusion criteria saw earlier trials like DISTAL and ESCAPE-MeVO enrol patients with low NIHSS scores, which has been cited as one of the key reasons for their neutral results with thrombectomy. ORIENTAL MEVO therefore targeted a population with baseline NIHSS scores ≥6 as well as less frequent usage of intravenous thrombolysis (IVT) therapies, comparing 90-day modified Rankin scale (mRS) scores between
“Historical” CREST-2 results establish stenting’s role in asymptomatic carotid disease THE LONG-AWAITED presentation of results from the CREST-2 randomised controlled trial (RCT) have shown that the addition of carotid artery stenting (CAS) alongside medical management can reduce stroke risks in patients with asymptomatic high-grade carotid stenosis, while no such reduction was seen with carotid endarterectomy (CEA). These data were met with a positive reception by many in the neurointerventional community but have drawn a more sceptical response from those in other arenas, sparking ongoing debates over the design of CREST-2 and to what extent the trial’s findings can be considered definitive. Arguably foreshadowing the divided reception they have gone on to receive, the key results from CREST-2 were presented in two different places on the same day, with latebreaking data being shared by James Meschia (Mayo Clinic, Jacksonville, USA) at the Society of Vascular and Interventional Neurology (SVIN) annual meeting (19–22 November 2025, Orlando, USA) and also by co-principal investigator (PI) Brajesh Lal (University of Maryland, Baltimore, USA) at the VEITHsymposium (18–22 November 2025, New York, USA). Continued on page 8
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