ESCAPE-MeVO
Endovascular Treatment of Stroke Due to Medium-Vessel Occlusion
Clinical Question
Does endovascular thrombectomy improve outcomes in patients with acute ischemic stroke due to medium-vessel occlusion within 12 hours?
Bottom Line
EVT did not improve functional outcomes in medium-vessel occlusion (MeVO) stroke: mRS 0-1 at 90 days 41.6% vs 43.1% (adjusted RR 0.95; 95% CI 0.79-1.15; P=0.61). Mortality was significantly higher with EVT (13.3% vs 8.4%; adjusted HR 1.82; 1.06-3.12). SAEs higher with EVT (33.9% vs 25.7%), including more sICH (5.4% vs 2.2%). First RCT of EVT for MeVO. 529 patients, 58 sites, 5 countries.
Major Points
- EVT did NOT improve outcomes in MeVO: mRS 0-1 41.6% vs 43.1% (adjusted RR 0.95; P=0.61).
- EVT associated with HIGHER mortality: 13.3% vs 8.4% (adjusted HR 1.82; 95% CI 1.06-3.12).
- More SAEs with EVT: 33.9% vs 25.7% — including sICH 5.4% vs 2.2%, pneumonia 7.0% vs 3.3%.
- Reperfusion achieved in 75.1% (MeVO-eTICI 2b/2c/3) — but didn't translate to benefit.
- Longer workflow than LVO trials: onset-to-recanalization 359 min (vs 241 min in ESCAPE-LVO).
- 15% of EVT patients had spontaneous recanalization before angiography (82% had IV tPA).
- MeVO defined: M2/M3, A2/A3, P2/P3 segments. MCA branch occlusion in 84.7%.
- Contradicts prior observational data suggesting EVT benefit for MeVO — selection bias likely.
- Does not support routine EVT for MeVO at current workflow speeds.
- 529 patients (255 EVT, 274 UC), 58 sites, 5 countries (Canada, US, Germany, Hungary, Japan). PROBE design.
Design
Study Type: Multicenter, open-label, randomized controlled trial with blinded outcome assessment
Randomization: 1
Blinding: Open-label with blinded outcome adjudication
Enrollment Period: April 2022 – June 2024
Follow-up Duration: 90 days
Countries: Canada, Germany, Spain, South Korea, Australia
Sample Size: 530
Analysis: Modified intention-to-treat; adjusted analyses with generalized linear models and Cox regression
Inclusion Criteria
- Age ≥18 years
- Acute ischemic stroke with medium-vessel occlusion (e.g., M2, M3, A2, A3, or P2, P3 segments)
- Last known well within 12 hours
- Favorable baseline imaging (ASPECTS ≥6 or equivalent)
Exclusion Criteria
- Large-vessel occlusion
- Severe disability (pre-stroke mRS >2)
- Large core infarct or extensive early ischemic changes
- Contraindications to thrombectomy or usual care
Arms
| Field | EVT + Usual Care | Control |
|---|---|---|
| Intervention | Endovascular thrombectomy with adjunctive medical care | Standard medical therapy (including IV thrombolysis when indicated) |
| Duration | Single intervention; follow-up at 90 days | Follow-up at 90 days |
Outcomes
| Outcome | Type | Control | Intervention | HR / OR / RR | P-value |
|---|---|---|---|---|---|
| Proportion of patients with modified Rankin Scale score 0 or 1 at 90 days | Primary | 43.1% | 41.6% | 1.50% | 0.61 |
| Secondary | 8.4% | 13.3% | 1.82 | ||
| Symptomatic ICH | Adverse | 2.2% | 5.4% |
Subgroup Analysis
No major subgroup showed benefit of EVT over usual care; consistent findings across strata
Criticisms
- Open-label design may introduce performance bias
- Study may be underpowered to detect small treatment effects
- Baseline core volumes and vessel segment distributions not stratified
- Unclear generalizability to lower-resource settings or different imaging protocols
Funding
Canadian Institutes of Health Research, Medtronic
Based on: ESCAPE-MeVO (New England Journal of Medicine, 2025)
Authors: M. Goyal, J. M. Ospel, A. Ganesh, ..., M.A. Mühlenbruch
Citation: N Engl J Med 2025; DOI:10.1056/NEJMoa2411668
Content summarized and formatted by NeuroTrials.ai.