Evaluation of Endovascular Treatment in Acute Intracranial Distal Medium Vessel Occlusion Stroke

NCT06146790 | Recruiting DMC

• 1 other identifier: ORIENTAL-MeVO
• Study Type: interventional
• Target: 564
• Locations: 1 country
• Sites: 1

Brief Summary

Rationale: Distal Medium Vessel Occlusion (MeVO) are thought to cause as many as 25% to 40% of all acute ischemic strokes (AIS). Despite their relatively high frequency, there is no consensus regarding the optimal management of these patients. However, the fact that AIS related to MeVO often results in significant disability despite best medical treatment (including intravenous thrombolysis, IVT) calls for novel treatment approaches. Fortunately, a growing number of non-randomized studies have now been published demonstrating the feasibility of endovascular treatment (EVT) for MeVO strokes. These studies have demonstrated that distal EVT leads to high rates of successful reperfusion and may be performed with a comparable safety profile to that of EVT for proximal arterial occlusions. Therefore, a strong rational exists to test the safety and efficacy of EVT for MeVO stokes in a prospective randomized clinical trial. Objectives: The primary objective of this study is to evaluate the hypothesis that endovascular thrombectomy is superior to standard medical management in achieving more favorable outcomes according to the modified Rankin Scale scores at 90 days in subjects presenting with acute ischemic stroke related to a distal medium vessel occlusion within 24 hours from symptom onset (defined as time last know well, TLKW). Secondary objectives include the assessment of the cost-effectiveness of endovascular thrombectomy in the medium vessel occlusion (MeVO) population as well as its impact on health-related quality of life. Study design: The study is a prospective, multicenter, investigational, randomized, controlled, open-label study with blinded endpoint evaluation (PROBE design) and an adaptive design with population enrichment. Study population: Subjects presenting with acute ischemic stroke within 24 hours from TLKW and whose strokes are attributable to a distal medium vascular occlusion defined as co/non-dominant M2 segment or M3 segment of the MCA, the ACA (A1, A2, or A3 segments), or the PCA (P1, P2 or P3 segments) with evidence of salvageable brain tissue on perfusion imaging, M2 segment vessel diameter should not exceed 2.0 mm. Primary outcome: Shift in distribution of all levels of the 90-day the modified Rankin Scale with levels 5-6 combined (mRS; 0, 1, 2, 3, 4, 5-6) as assessed by structured assessment.

Conditions

Acute Ischemic Stroke; Endovascular Thrombectomy

Keywords

Medium Vessel Occlusion; Stroke Due To Medium Vessel Occlusion; Endovascular Treatment; Standard Medical Management

Outcome Measures

Primary Outcomes (1)

• The 90-day modified Rankin Scale (mRS)

  Shift in distribution of all levels of the 90-day modified Rankin Scale with levels 5-6 combined (mRS; 0, 1, 2, 3, 4, 5-6) as assessed by structured assessment.

  90 (± 14 days) after procedure

Secondary Outcomes (4)

• Modified Rankin Scale (mRS)

  90 (± 14 days) after procedure

• Independent Outcome

  90 (± 14 days) after procedure

• Excellent Outcome

  90 (± 14 days) after procedure

• Good Functional Outcomes

  90 (± 14 days) after procedure

Other Outcomes (2)

• Mortality

  90 (± 14 days) after procedure

• Symptomatic intracranial hemorrhage (SICH)

  24 hours (-2/+12H) after procedure

Study Arms (2)

Endovascular treatment+ standard medical management

EXPERIMENTAL

For the subjects randomized to endovascular treatment (EVT), treatment initiation is defined as the date and time of arterial puncture. Ideally, femoral artery puncture will occur within 30 minutes of randomization and no longer than 60 minutes after the completion of the qualifying imaging. Treatment initiation (arterial puncture) must occur before 24 hours since the subject was last known well. Date and time of arterial puncture, revascularization, and procedure end will be recorded. It is expected that the interventional procedure will be completed within two (2) hours of arterial access. If an appropriate thrombus or residual stenosis is identified, the choice of EVT strategy will be made by the treating neurointerventionalist. All mechanical thrombectomy devices for EVT, which are approved by CFDA for this purpose, are allowed in the trial.

Procedure: endovascular treatment

Standard medical management

ACTIVE COMPARATOR

Standard medical management

Other: Standard medical management

Interventions

endovascular treatment PROCEDURE

For the subjects randomized to endovascular treatment (EVT) treatment initiation is defined as the date and time of arterial puncture. Ideally, femoral artery puncture will occur within 30 minutes of randomization and no longer than 60 minutes after the completion of the qualifying imaging. Treatment initiation (arterial puncture) must occur before 24 hours since the subject was last known well.Date and time of arterial puncture, revascularization, and procedure end will be recorded. It is expected that the interventional procedure will be completed within two (2) hours of arterial access. If an appropriate thrombus or residual stenosis is identified, the choice of EVT strategy will be made by the treating neurointerventionalist. All mechanical thrombectomy devices for EVT, which are approved by CFDA for this purpose, are allowed in the trial.

Endovascular treatment+ standard medical management

Standard medical management OTHER

Standard medical management

Standard medical management

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Age ≥18 years (no upper age limit).
• Evidence of a primary (e.g., not secondary to EVT of proximal vessel occlusion) distal medium vascular occlusion defined as occlusion of the co/non-dominant M2 segment\* or M3 segment of the MCA, the ACA (A1, A2, or A3 segments), or the PCA (P1, P2 or P3 segments) resulting in significant clinical deficits and expected to be treatable by endovascular thrombectomy.
• \* Co/non-dominant M2 segment vessel diameter should not exceed 2.0 mm. Co-dominant supplying 50% of the MCA territory vs non-dominant supplying \<50% of the MCA territory.
• Premorbid mRS ≤ 2.
• Baseline National Institutes of Health Stroke Scale (NIHSS) score ≥6 at the time of randomization.
• Time from onset (or time last seen well) to randomization\<24 hours.
• For patients with more than 6 hours of onset (or time last seen well), Clinical-Imaging mismatch assessment defined as any of the following scenarios (A or B):
• A. Non-contrast CT of the head or Brain MRI DWI lesion with \<50% involvement of the vascular territory corresponding to the clinical manifestation:
• B. Target Mismatch Profile on CT perfusion or MRI (Mismatch Volume \>10cc and mismatch Ratio \>1.4 ).
• Informed consent obtained from patient or acceptable patient surrogate.

You may not qualify if:

• Any sign of intracranial hemorrhage on baseline CT/MR (SDH/SAH/ICH).
• Rapidly improving symptoms, particularly if in the judgment of the managing clinician that the improvement is likely to result in the patient having an NIHSS score of \<6 at randomization.
• Significant ischemic changes in a territory other than the occluded site that in the opinion of the investigator could reduce the benefit of endovascular treatment.
• Contra indication to imaging with MR or CT with contrast agents.
• Any terminal illness such that patient would not be expected to survive more than 1 year.
• Recent past history or clinical presentation of ICH, subarachnoid hemorrhage (SAH), arterio-venous (AV) malformation, aneurysm, or cerebral neoplasm other than meningioma.
• Any imaging findings suggestive of futile recanalization in the judgment of the local investigator.
• seizures at stroke onset if it precludes obtaining an accurate baseline NIHSS.
• Baseline blood glucose of \<50 mg/dL (2.78 mmol) or \>400 mg/dL (22.20 mmol).
• Known history of hereditary or acquired hemorrhagic diathesis and/or platelet count \<50×109/L.
• Known renal failure as defined as serum creatinine levels \> 260umol/l（3.0 mg/dL）.
• Presumed septic embolus or suspicion of bacterial endocarditis.
• Any other condition that, in the opinion of the investigator could impose hazards to the patient or affect the participation of the patient in the study if an endovascular procedure was performed.
• History of drug or alcohol use or dependence that, in the opinion of the site investigator, would interfere with adherence to study requirements.
• Subjects with occlusions in multiple vascular territories (e.g., bilateral or multi-territorial anterior circulation, or anterior/posterior circulation)

Sponsors & Collaborators

• The First Affiliated Hospital of University of Science and Technology of China: lead

Study Sites (1)

The First Affiliated Hospital of University of Science and Technology of China

Hefei, Anhui, 230001, China

RECRUITING

Related Publications (1)

• Jing X, Nogueira RG, Nguyen TN, Tao C, Zhu Y, Li R, Sun J, Wang L, Zhang C, Liu T, Song J, Saver JL, Hu W. Endovascular treatment in acute intracranial distal medium vessel occlusion stroke: Study protocol and rationale. Int J Stroke. 2025 Jul;20(6):763-768. doi: 10.1177/17474930251332753. Epub 2025 Mar 25.

  PMID: 40134089 DERIVED

MeSH Terms

Conditions

Ischemic Stroke

Condition Hierarchy (Ancestors)

Stroke; Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Vascular Diseases; Cardiovascular Diseases

Study Officials

• Wei Hu, MD, PhD

  The First Affiliated Hospital of University of Science and Technology of China

  STUDY CHAIR

Central Study Contacts

Wei Hu, MD, PhD

CONTACT

+86 055162284313; andinghu@ustc.edu.cn

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Purpose: TREATMENT
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Professor

Study Record Dates

• First Submitted: November 10, 2023
• First Posted: November 27, 2023
• Study Start: December 14, 2023
• Primary Completion: December 1, 2025
• Study Completion: March 1, 2026
• Last Updated: September 5, 2024

Record last verified: 2024-08

Data Sharing

• IPD Sharing: Will not share

Locations

CN (1)