Endovascular Thrombectomy Versus Standard Medical Management in Acute Anterior Cerebral Artery Occlusion Stroke: The ORIENTAL-MeVO Registry Study

BACKGROUND: The benefit of endovascular thrombectomy (EVT) in patients with stroke with proximal large vessel occlusion in the anterior circulation has been confirmed by several randomized controlled trials. However, evidence regarding EVT for anterior cerebral artery occlusion (ACAo) remains limited. This study aimed to compare clinical outcomes between EVT and standard medical management (SMM) in patients with ACAo. METHODS: This retrospective multicenter study examined data from patients with acute ischemic stroke caused by ACAo (A1/A2/A3 segments) within 24 hours of symptom onset across 25 Chinese centers between September 2019 and September 2024. Eligible patients had ACAo verified by computed tomography angiography, magnetic resonance angiography, and digital subtraction angiography, a prestroke modified Rankin Scale score of ≤2, and received either EVT or SMM exclusively. Patients were excluded due to clot migration from proximal major arteries to the anterior cerebral artery, multiterritory occlusion, or absence of 90-day modified Rankin Scale score data. The primary outcome was the 90-day modified Rankin Scale score distribution. Safety outcomes encompassed 24-hour symptomatic intracranial hemorrhage and 90-day mortality rates. Propensity score matching and inverse probability of treatment weighting analyses were conducted to equilibrate baseline confounders between the EVT and SMM groups. RESULTS: A total of 343 patients with ACAo met the inclusion criteria and were enrolled across all participating centers. Following adjustment for confounders using inverse probability of treatment weighting, the EVT group had statistically significant improvement in 90-day modified Rankin Scale score (adjusted odds ratio, 2.14 [95% CI, 1.59–2.89]; P <0.001), excellent functional outcome (adjusted risk ratio, 1.77 [95% CI, 1.27–2.48]; P <0.001) and functional independence (adjusted risk ratio, 2.35 [95% CI, 1.63–3.39]; P <0.001) compared with the SMM group. Safety outcomes, including symptomatic intracranial hemorrhage and mortality, showed no significant differences between groups. Subgroup analysis revealed improved secondary outcomes in patients with baseline National Institutes of Health Stroke Scale score ≥6. CONCLUSIONS: EVT for ACAo is associated with better clinical outcomes compared with SMM, particularly in patients with moderate to severe stroke, without increased risk of symptomatic intracranial hemorrhage or 90-day mortality. REGISTRATION: URL: www.chictr.org.cn ; Unique identifier: ChiCTR2500096954.