Comparative Study

. 2025 Jun 1;17(e2):e356-e364.

doi: 10.1136/jnis-2024-022467.

Endovascular therapy versus medical management in isolated anterior cerebral artery acute ischemic stroke: a multinational multicenter propensity score-weighted study

Hamza Adel Salim^#^{1

2}, Benjamin Pulli^#³, Vivek Yedavalli^#⁴, Fathi Milhem⁵, Basel Musmar⁶, Nimer Adeeb⁷, Dhairya A Lakhani⁸, Muhammed Amir Essibayi⁹, Jeremy Josef Heit³, Tobias D Faizy¹⁰, Kareem El Naamani⁶, Nils Henninger¹¹, Sri Hari Sundararajan¹², Anna Luisa Kuhn¹³, Jane Khalife¹⁴, Sherief Ghozy¹⁵, Luca Scarcia¹⁶, Leonard Ll Yeo¹⁷, Benjamin Yq Tan^{17

18}, Robert W Regenhardt⁵, Nicole M Cancelliere¹⁹, Aymeric Rouchaud²⁰, Jens Fiehler²¹, Sunil A Sheth²², Ajit S Puri¹³, Christian Dyzmann²³, Marco Colasurdo²⁴, Leonardo Renieri²⁵, João Pedro Filipe²⁶, Pablo Harker²⁷, Răzvan Alexandru Radu²⁸, Mohamad Abdalkader²⁹, Piers Klein²⁹, Thomas R Marotta¹⁹, Julian Spears¹⁹, Takahiro Ota³⁰, Ashkan Mowla³¹, Pascal Jabbour⁶, Arundhati Biswas³², Frédéric Clarençon³³, James E Siegler¹⁴, Thanh N Nguyen²⁹, Ricardo Varela³⁴, Amanda Baker⁹, David Altschul⁹, Nestor Gonzalez³⁵, Markus A Möhlenbruch³⁶, Vincent Costalat²⁸, Benjamin Gory^{37

38}, Paul Stracke³⁹, Constantin Hecker⁴⁰, Gaultier Marnat⁴¹, Hamza Shaikh¹⁴, Christoph J Griessenauer⁴⁰, David S Liebeskind⁴², Alessandro Pedicelli⁴³, Andrea Maria Alexandre⁴³, Illario Tancredi⁴⁴, Erwah Kalsoum¹⁶, Boris Lubicz⁴⁵, Aman B Patel⁵, Vitor Mendes Pereira¹⁹, Max Wintermark², Adrien Guenego⁴⁵, Adam A Dmytriw^{46

19}; MAD-MT Investigators

Collaborators, Affiliations

Collaborators

MAD-MT Investigators:
Abdelaziz Amllay, Achala Vagal, Adrien Ter Schiphorst, Ajith J Thomas, Anil Gopinathan, Anne Dusart, Carolina Capirossi, Charbel Mounayer, Charlotte Weyland, Cheng-Yang Hsieh, Christopher J Stapleton, Erwah Kalsoum, Flavio Bellante, Géraud Forestier, Hamza Shaikh, Hugo H Cuellar-Saenz, Iacopo Valente, M D Igor Sibon, James D Rabinov, Jérôme Berge, Jessica Jesser, Juan Carlos Martinez-Gutierrez, Kevin Premat, Lina Chervak, Lukas Meyer, Mahmoud Elhorany, Miguel Quintero-Consuegra, Mohammad Ali Aziz-Sultan, Monika Killer-Oberpfalzer, Peter T Kan, Priyank Khandelwal, Ramanathan Kadirvel, Robert Fahed, Sergio Salazar-Marioni, Shogo Dofuku, M D Simona Nedelcu, Stavropoula I Tjoumakaris, Suzana Saleme, Yasmin Aziz, Xavier Barreau

Affiliations

¹ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA hamza.sleeem@gmail.com admytriw@mgh.harvard.edu.
² Department of Neuroradiology, MD Anderson Medical Center, Houston, Texas, USA.
³ Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, California, USA.
⁴ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA.
⁵ Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA.
⁶ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁷ Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Baton Rouge, Louisiana, USA.
⁸ Department of Radiology, West Virginia University, Morgantown, West Virginia, USA.
⁹ Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Albert Einstein College of Medicine, Bronx, New York, USA.
¹⁰ Department of Radiology, Neuroendovascular Program, University Medical Center, Münster, Germany.
¹¹ Department of Neurology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA.
¹² Department of Endovascular Neurosurgery and Neuroradiology NJMS, NJMS, Newark, New Jersey, USA.
¹³ Department of Radiology, Division of Neurointerventional Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA.
¹⁴ Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, New Jersey, USA.
¹⁵ Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, Minnesota, USA.
¹⁶ Department of Neuroradiology, Henri Mondor Hospital, Creteil, France.
¹⁷ Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹⁸ Division of Neurology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹⁹ Divisions of Therapeutic Neuroradiology and Neurosurgery, Neurovascular Centre, St. Michael's Hospital, Toronto, Ontario, Canada.
²⁰ Neuroradiology Department, University Hospital of Limoges, Limoges, France.
²¹ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
²² Department of Neurology, UTHealth McGovern Medical School, Houston, Texas, USA.
²³ Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Germany.
²⁴ Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA.
²⁵ Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy.
²⁶ Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
²⁷ Department of Neurology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA.
²⁸ Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
²⁹ Departments of Radiology & Neurology, Boston Medical Center, Boston, Massachusetts, USA.
³⁰ Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
³¹ Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, California, USA.
³² Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA.
³³ Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France.
³⁴ Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
³⁵ Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.
³⁶ Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.
³⁷ INSERM U1254, IADI, Université de Lorraine, Lorraine, France.
³⁸ Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France.
³⁹ Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany.
⁴⁰ Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria.
⁴¹ Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
⁴² UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, California, USA.
⁴³ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
⁴⁴ Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
⁴⁵ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.
⁴⁶ Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA hamza.sleeem@gmail.com admytriw@mgh.harvard.edu.

^# Contributed equally.

PMID: 39613322
PMCID: PMC12129695 (available on 2026-06-01)
DOI: 10.1136/jnis-2024-022467

Comparative Study

Endovascular therapy versus medical management in isolated anterior cerebral artery acute ischemic stroke: a multinational multicenter propensity score-weighted study

Hamza Adel Salim et al. J Neurointerv Surg. 2025.

. 2025 Jun 1;17(e2):e356-e364.

doi: 10.1136/jnis-2024-022467.

Authors

Collaborators

MAD-MT Investigators:
Abdelaziz Amllay, Achala Vagal, Adrien Ter Schiphorst, Ajith J Thomas, Anil Gopinathan, Anne Dusart, Carolina Capirossi, Charbel Mounayer, Charlotte Weyland, Cheng-Yang Hsieh, Christopher J Stapleton, Erwah Kalsoum, Flavio Bellante, Géraud Forestier, Hamza Shaikh, Hugo H Cuellar-Saenz, Iacopo Valente, M D Igor Sibon, James D Rabinov, Jérôme Berge, Jessica Jesser, Juan Carlos Martinez-Gutierrez, Kevin Premat, Lina Chervak, Lukas Meyer, Mahmoud Elhorany, Miguel Quintero-Consuegra, Mohammad Ali Aziz-Sultan, Monika Killer-Oberpfalzer, Peter T Kan, Priyank Khandelwal, Ramanathan Kadirvel, Robert Fahed, Sergio Salazar-Marioni, Shogo Dofuku, M D Simona Nedelcu, Stavropoula I Tjoumakaris, Suzana Saleme, Yasmin Aziz, Xavier Barreau

Affiliations

¹ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA hamza.sleeem@gmail.com admytriw@mgh.harvard.edu.
² Department of Neuroradiology, MD Anderson Medical Center, Houston, Texas, USA.
³ Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, California, USA.
⁴ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA.
⁵ Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA.
⁶ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁷ Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Baton Rouge, Louisiana, USA.
⁸ Department of Radiology, West Virginia University, Morgantown, West Virginia, USA.
⁹ Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Albert Einstein College of Medicine, Bronx, New York, USA.
¹⁰ Department of Radiology, Neuroendovascular Program, University Medical Center, Münster, Germany.
¹¹ Department of Neurology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA.
¹² Department of Endovascular Neurosurgery and Neuroradiology NJMS, NJMS, Newark, New Jersey, USA.
¹³ Department of Radiology, Division of Neurointerventional Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA.
¹⁴ Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, New Jersey, USA.
¹⁵ Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, Minnesota, USA.
¹⁶ Department of Neuroradiology, Henri Mondor Hospital, Creteil, France.
¹⁷ Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹⁸ Division of Neurology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹⁹ Divisions of Therapeutic Neuroradiology and Neurosurgery, Neurovascular Centre, St. Michael's Hospital, Toronto, Ontario, Canada.
²⁰ Neuroradiology Department, University Hospital of Limoges, Limoges, France.
²¹ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
²² Department of Neurology, UTHealth McGovern Medical School, Houston, Texas, USA.
²³ Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Germany.
²⁴ Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA.
²⁵ Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy.
²⁶ Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
²⁷ Department of Neurology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA.
²⁸ Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
²⁹ Departments of Radiology & Neurology, Boston Medical Center, Boston, Massachusetts, USA.
³⁰ Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
³¹ Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, California, USA.
³² Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA.
³³ Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France.
³⁴ Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
³⁵ Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.
³⁶ Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.
³⁷ INSERM U1254, IADI, Université de Lorraine, Lorraine, France.
³⁸ Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France.
³⁹ Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany.
⁴⁰ Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria.
⁴¹ Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
⁴² UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, California, USA.
⁴³ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
⁴⁴ Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
⁴⁵ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.
⁴⁶ Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA hamza.sleeem@gmail.com admytriw@mgh.harvard.edu.

^# Contributed equally.

PMID: 39613322
PMCID: PMC12129695 (available on 2026-06-01)
DOI: 10.1136/jnis-2024-022467

Abstract

Background: Isolated anterior cerebral artery occlusions (ACAo) in patients with acute ischemic stroke present significant challenges due to their rarity. The efficacy and safety of endovascular therapy (EVT) in comparison with best medical therapy (BMT) for ACAo remains unclear. This study aimed to assess the outcomes of these treatments.

Methods: This multinational, multicenter study analyzed data from the MAD-MT registry. Data were collected retrospectively from 37 sites across North America, Asia, and Europe. Inverse probability of treatment weighting (IPTW) was applied to balance confounding variables. The primary outcome was functional independence (modified Rankin Scale (mRS) scores of 0-2) at 90 days. Secondary outcomes included excellent outcomes (mRS 0-1), mortality at 90 days, and NIH Stroke Scale (NIHSS) score on day 1 post treatment.

Results: Of the 108 patients, 36 received BMT and 72 underwent EVT. The median age was 75 years, and 56% were male. At 90 days, 40% of patients achieved mRS 0-2, with no significant difference between EVT and BMT (38% vs 45%, p=0.46). Procedural success (mTICI 2b-3) was 91% in the EVT group, with a sICH rate of 2.9%. IPTW-adjusted analysis showed no significant difference between EVT and BMT for functional independence (OR 1.17, 95% CI 0.23 to 6.02, p=0.85), mortality (25% vs 21%, p=0.71) or day 1 NIHSS scores (Beta 2.2, 95% CI -0.51 to 4.8, p=0.11).

Conclusions: EVT showed high procedural success but did not significantly improve functional outcomes or mortality compared with BMT in patients with ACAo. Further randomized trials are needed to clarify EVT's role in ACAo.

Keywords: Stroke.

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Conflict of interest statement

Competing interests: RWR serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation. AG reports consultancy for Rapid Medical and Phenox, not directly related to the present work. FC reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading) and Artedrone (Board); all not directly related to the present work. NH received support from NINDS NS131756, NINR NR020231, and NINDS NS113844 during the conduct of the study. All unrelated to the present work. DSL is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, Rapid Medical. LLLY reports advisory work for AstraZeneca, substantial support from NMRC Singapore and is a medical advisor for See-mode, Cortiro and Sunbird Bio, with equity in Ceroflo. All unrelated to the present work. CJG reports a proctoring agreement with Medtronic and research funding by Penumbra. GM reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt, Sim and Cure (consulting), Medtronic, Johnson & Johnson, Penumbra, Bracco, and Phenox (paid lectures), all not directly related to the present work. ASP is a consultant for Medtronic Neurovascular, Stryker Neurovascular, Balt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc and Arsenal Medical, he received research grants from NIH, Microvention, Cerenovus, Medtronic Neurovascular and Stryker Neurovascular, and holds stocks in InNeuroCo, Agile, Perfuze, Galaxy and NTI. Dr Tjoumakaris is a consultant for Medtronic and Microvention (funds paid to institution, not personally). PJ is a consultant for Medtronic, Microvention and Cerus. BP reports consultancy Microvention, Stryker, Q’apel, and Nuvascular, all not directly related to the present work. JES has served as a consultant for AstraZeneca, and has received funding from the National Institutes of Health (R61NS135583), Viz.ai, Philips, and Medtronic. TNN reports Associate Editor of Stroke; advisory for Aruna Bio, Brainomix.

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Endovascular therapy versus medical management in isolated anterior cerebral artery acute ischemic stroke: a multinational multicenter propensity score-weighted study

Collaborators

Affiliations

Endovascular therapy versus medical management in isolated anterior cerebral artery acute ischemic stroke: a multinational multicenter propensity score-weighted study

Authors

Collaborators

Affiliations

Abstract

Conflict of interest statement

References

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Medical