Key Considerations When Incorporating Stroke Trial Data Into Clinical Practice: J Mocco, MD, MS

WATCH TIME: 5 minutes

"It's my hope that when people see this data, they say, number one, I have to seriously consider the literature to determine whether it makes sense to treat a given patient rather than automatically assuming it’s beneficial. And number two, we run a significant risk if the community selectively enrolls patients in randomized trials based on inherent biases rather than consistently including all eligible patients."

Two recent prospective, randomized trials (ESCAPE-MeVO, NCT05151172; DISTAL; NCT05029414) assessing thrombectomy for medium and distal vessel occlusion strokes were recently published in The New England Journal of Medicine (NEJM). All told, the procedure, which involves using a clot-removal device through a catheter to restore blood flow in patients who had ischemic stroke patients, showed no additional clinical benefit compared with standard medical management. These findings, presented at the 2025 International Stroke Conference (ISC), held February 5-7, in Los Angeles, California, are expected to generate significant discussion among stroke specialists.^1,2

In an editorial for NEJM, J. Mocco, MD, MS, further examined the trials and their clinical implications. He acknowledged the proven benefits of thrombectomy for large vessel occlusions but noted growing acceptance for its use in smaller strokes. However, Mocco raised concerns about the new trials, especially regarding patient selection, as both studies included older patients with higher baseline disabilities and milder deficits. He also pointed out that technical factors could have influenced the results. Mocco concluded in the editorial that thrombectomy for distal vessel occlusions should no longer be viewed as a default treatment.³

During ISC 2025, Mocco, vice chair of the department of neurosurgery and director of the Cerebrovascular Center at Mount Sinai, sat down with NeurologyLive^® to discuss how clinicians should adapt their approach when considering older patients for thrombectomy in light of the recent trial findings. He also explored how the inclusion of patients with lower NIH Stroke Scale scores might influence the interpretation of trial data and emphasized the need for strategies to minimize bias in patient selection during randomized trials. Mocco explained how these points raise important considerations for how stroke specialists might refine their clinical decision-making moving forward.

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REFERENCES
1. Goyal M, et al. Endovascular treatment to improve outcomes for medium vessel occlusions: The ESCAPE-MeVO trial. Presented at: ISC 2025; February 5-7; Los Angeles, CA. LB4.
2. Goyal M, Ospel JM, Ganesh A, et al. Endovascular Treatment of Stroke Due to Medium-Vessel Occlusion. NEJM. Published February 5, 2025.
3. HEADS UP Re: NEJM Editorial About 2 New Randomized Trials Evaluating Mechanical Removal of Certain Clot-Related Strokes. Mount Sinai Health System. News Release. Published February 8, 2025. Accessed February 10, 2025. https://www.newswise.com/articles/heads-up-re-nejm-editorial-about-2-new-randomized-trials-evaluating-mechanical-removal-of-certain-clot-related-strokestorial-about-2-new-randomized-trials-evaluating-mechanical-removal-of-certain-clot-related-strokes