ESCAPE-MeVO Trial: EVT for Medium Vessel Occlusions
In patients with acute ischemic stroke from medium vessel occlusion, does endovascular thrombectomy plus best medical therapy improve functional independence at 90 days compared with best medical therapy alone?
Goyal et al. (NEJM 2025) · 530 patients
Population
Included
- Age 18 years or older
- Acute ischemic stroke with medium vessel occlusion confirmed on vessel imaging (M2, M3, A1, A2, P1, P2 segments)
- NIHSS score above 5, or disabling neurological deficit with NIHSS 3 to 5
- Treatment possible within 12 hours of last known well
- Favorable baseline imaging without large established infarct
- Pre-stroke modified Rankin Scale 0 to 2
- Acute ischemic stroke clinically eligible for immediate EVT
- Age ≥18 years at randomization
- Time from onset / last-known-well to randomization <12 hours
- Disabling stroke: NIHSS >5, OR NIHSS 3–5 with a disabling deficit
- Confirmed symptomatic, endovascularly treatable medium-vessel occlusion at M2 or M3 of the MCA, A2 or A3 of the ACA, or P2 or P3 of the PCA on mCTA or MRA (A1 and P1 segments specifically not included)
- Clinical deficit commensurate with the MeVO location
- Favorable baseline noninvasive imaging: lack of extensive ischemic changes on noncontrast CT/MRI, plus at least moderate collaterals on CTA/MRA or core–penumbra mismatch on perfusion imaging
- Signed informed consent (or emergency consent per local standards)
Excluded
- Large vessel occlusion (ICA, M1, basilar). EVT-eligible by established evidence
- Large established infarct on baseline imaging
- Pre-stroke mRS above 2
- Recent major surgery or intracranial bleeding within 3 months
- Contraindication to contrast or thrombectomy procedure
- ASPECTS ≤5
- Imaging evidence of extensive hypodensity / diffusion restriction or absent collaterals (per modality-specific criteria)
- Any evidence of intracranial hemorrhage
- Nursing-home residence or requirement for daily care
- Major comorbidities preventing follow-up
- Pregnancy
- Concurrent participation in another therapeutic trial
Source: ClinicalTrials.gov NCT05151172 (ESCAPE-MeVO)· Retrieved 2026-06-08
Primary Outcome
Negligible absolute difference
mRS 0-2 at 90 Days
Study Arms
- Agent
- Endovascular thrombectomy (Solitaire X family device, Medtronic, for first retrieval attempt) + guideline-based usual care
- Route
- Endovascular (intra-arterial)
- Co-interventions
- First retrieval with Solitaire X ± concurrent aspiration; additional attempts with any approved device/combination at operator discretion; general anesthesia encouraged for safe distal deployment. Guideline-based usual care (Canadian/US/European) including IV thrombolysis (tenecteplase or alteplase) when indicated (given in 56.5% of this arm), stroke-unit care, rehabilitation, secondary prevention.
Successful reperfusion (final MeVO-eTICI 2b/2c/3) 75.1%; median onset-to-recanalization 359 min (Goyal NEJM 2025 p.1389-1391).
- Agent
- Guideline-based usual care alone (no endovascular thrombectomy)
- Route
- Systemic / supportive
- Co-interventions
- Standard of care per Canadian/US/European guidelines, including IV thrombolysis (tenecteplase or alteplase) when indicated (given in 60.2% of this arm), stroke-unit care, rehabilitation, stroke-mechanism workup, vascular-risk reduction.
3 usual-care patients crossed over to EVT (Goyal NEJM 2025 p.1389).
Safety
Symptomatic ICH
5.4%
2.2%
Symptomatic intracranial hemorrhage occurred in 5.4% of the EVT group vs 2.2% of the usual-care group. Procedural risk in medium-caliber vessels contributed to the absence of net benefit. Source: ESCAPE-MeVO Investigators, NEJM 2025, Table 2.
Mortality at 90 days
13.3%
8.4%
All-cause mortality at 90 days was 13.3% (EVT) vs 8.4% (usual care), HR 1.82 (95% CI 1.06-3.12). Higher sICH and mortality without functional gain led to the NEGATIVE overall verdict. Source: ESCAPE-MeVO Investigators, NEJM 2025, Table 2.
Trial Design
Type
- Multicenter prospective randomized trial
- Open-label (PROBE design)
- 1:1 allocation (EVT + Usual Care vs. Usual Care)
Timeline
Enrolled 2019-2024
N
530
Enrollment
530 patients at 48 centers across 8 countries. Enrolled 2019 to 2024. Published NEJM 2024.
ClinicalTrials.gov
NCT05151172Bedside Pearl
ESCAPE-MeVO stopped the routine-EVT-for-MeVO question: sICH was 5.4% vs 2.2% and mortality was 13.3% vs 8.4% with no gain in excellent functional outcome (mRS 0-1). Medium vessel occlusion is not a thrombectomy trigger by default. Procedural risk vs uncertain benefit must be discussed individually.
Trial lineage
Endovascular therapy for medium-vessel and distal occlusions
ESCAPE-MeVO and DISTAL, both published in 2024, were the first RCTs in medium-vessel and distal occlusions (M2/M3, ACA, PCA). Neither met its primary functional endpoint. Together they define the negative boundary of LVO-EVT — the closer a patient is to a non-large-vessel target, the less benefit EVT confers. Practice has shifted toward selective EVT for MeVOs only with severe deficit and accessible anatomy.
- 2025DISTAL TrialNEGATIVE
EVT for medium and distal vessel occlusions; negative trial (NEJM 2025).
- 2025ESCAPE-MeVO Trial· this pageNEGATIVE
EVT for medium vessel occlusion (MeVO); no functional benefit, higher sICH and mortality (NEJM 2025).