ESCAPE-MeVO
(2025)Objective
To evaluate whether EVT plus usual care improves functional outcomes compared to usual care alone in patients with acute ischemic stroke due to medium-vessel occlusion presenting within 12 hours.
Study Summary
• Mortality was higher in the EVT group (13.3% vs 8.4%; adjusted HR 1.82, 95% CI 1.06–3.12), and sICH was numerically higher (5.4% vs 2.2%).
• Possible explanations include long onset-to-recanalization times (median 359 min), suboptimal reperfusion rates (75.1%), high general anesthesia use (43.1%), and 15% spontaneous recanalization before EVT.
Intervention
EVT (Solitaire X first-line) + usual care vs. usual care alone (including IVT when eligible)
Inclusion Criteria
Acute ischemic stroke due to MeVO (M2/M3, A2/A3, P2/P3), within 12 hours of last known well, NIHSS >5 (or 3–5 with disabling deficit), favorable baseline imaging with salvageable tissue
Study Design
Arms: EVT + usual care vs. usual care alone
Patients per Arm: 530 total (EVT: 255, Usual care: 275 [274 in ITT])
Outcome
• Secondary: mRS 0–2 — 54.1% vs 58.8% (adjusted RR 0.92); Barthel ≥95 — 53.5% vs 64.7% (adjusted RR 0.81); infarct volume similar (~31 vs 29 ml).
• Safety: Mortality 13.3% vs 8.4% (adjusted HR 1.82, P=0.03); sICH 5.4% vs 2.2%; SAEs 33.9% vs 25.7%.
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.
Study Design
- Study Type
- Multicenter, open-label, randomized controlled trial with blinded outcome assessment
- Randomization
- Yes
- Blinding
- Open-label with blinded outcome adjudication
- Sample Size
- 530
- Follow-up
- 90 days
- Countries
- Canada, Germany, Spain, South Korea, Australia
Primary Outcome
Definition: Proportion of patients with modified Rankin Scale score 0 or 1 at 90 days
| Control | Intervention | HR/OR | P-value |
|---|---|---|---|
| 43.1% | 41.6% | - (0.79–1.15) | 0.61 |
Limitations & 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
Citation
N Engl J Med 2025; DOI:10.1056/NEJMoa2411668