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Ahmed Koriesh: MeVO Thrombectomy – How The Evidence Evolved
Ahmed Koriesh/LinkedIn
Mar 3, 2026, 15:38

Ahmed Koriesh: MeVO Thrombectomy – How The Evidence Evolved

Ahmed Koriesh, Director of Hospital Neurology Service at Cleveland Clinic Florida, shared on LinkedIn:

”MeVO Thrombectomy – How The Evidence Evolved

A few years ago, we asked:

‘If thrombectomy works for LVO, why not distal occlusions?’

Then the randomized era began.

PLATO (2023) — PCA Occlusion

  • Inclusion: Isolated PCA (≤24h)
  • Imaging: Standard CT
  • NIHSS: No strict cutoff

Result:

  • Better vision recovery
  • No improvement in overall mRS (not a good marker for vision though)
  • Higher sICH and mortality

Functional endpoint neutral. Improved vision but increased sICH.

DISCOUNT (2024)

  • Inclusion: Distal M2/M3/A2/P2, NIHSS >5 or disabling
  • Imaging: CT if ≤6h or DWI-FLAIR 6-24h

Result:

  • mRS 0–2 worse with EVT (60% vs 77%)
  • Higher ICH and serious adverse events
  • Trial stopped early

First major harm signal.

DUSK (2024)

  • Inclusion: M3/M4/A2/A3/P1/P2 ≤24h
  • Imaging: Standard CT

Result:

  • No difference in mRS shift
  • Possible signal in NIHSS ≥8
  • Safety comparable

Equipoise. Severity may matter.

ESCAPE-MeVO (2025)

  • Inclusion: M2/M3/A2/A3/P2/P3 ≤12h
  • NIHSS: >5 (or 3–5 disabling)
  • Imaging: ASPECTS ≥6 (perfusion optional)

Result:

  • No benefit in mRS 0–1 or 0–2
  • Mortality higher (13.3% vs 8.4%)
  • sICH numerically higher

Possible contributors:

  • Long onset-to-recanalization times (median 359 minutes)
  • Moderate reperfusion rates (~75%)
  • 15% spontaneous recanalization

Still no overall benefit.

At this point, enthusiasm cooled.

Then came a different signal.

ORIENTAL MEVO (2026 – Interim results)

  • Inclusion: MeVO, NIHSS ≥6 (not just disabling stroke)
  • Imaging: ≤24h
  • Severity threshold enforced

Result:

  • mRS 0–2 improved (58.6% vs 46.6%)
  • mRS 0–1 improved
  • Mild increase in sICH
  • Benefits were seen most if NIHSS ≥ 8

Benefit appears in more severe MeVO.

DISTALS (2026 – still going)

  • Inclusion: MeVO/DVO ineligible for IVT
  • Imaging: Tissue-based reperfusion endpoint
  • Device: New device, very small profile, manually expandable, low radial force for smaller arteries.

Result:

  • 86% reperfusion vs 28% medical
  • 0% sICH so far
  • Clinical outcomes pending

Device refinement may matter.

The Evolution

We moved from:

Treating all distal occlusions

  • To recognizing harm in mild/moderate cases
  • To identifying severity (NIHSS ≥8) as a key selector
  • To refining device strategy and imaging

The MeVO door is not closed – it’s being refined.

Mild distal stroke – likely no benefit

Moderate-severe MeVO – possible benefit, pending final results of Oriental-MeVO/DISTALS

Dominant proximal M2 – strongest evidence”

Ahmed Koriesh: MeVO Thrombectomy - How The Evidence Evolved

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