This meta-analysis aims to compare the efficacy and safety of endovascular therapy (EVT) with the best medical treatment (BMT) in patients with Distal Medium Vessel Occlusions (DMVOs).

DMVOs represent a significant subset of Acute Ischemic Stroke (AIS), with unique treatment challenges due to vessel size and location. While EVT shows promise, its efficacy compared to BMT remains unclear.

PubMed, Cochrane Central, and ScienceDirect were searched from inception till May 2025. Categorical data were pooled as risk ratios (RR) using the Review Manager software under random effects model. The excellent functional outcome was defined as modified Rankin Scale (mRS) score of 0-1 whereas functional independence was defined as mRS score of 0-2. Neurological improvement is defined as a decrease of four or more points in the National Institutes of Health Stroke Scale (NIHSS) score. Alternatively, neurological deterioration is defined as an NIHSS score increase of ≥4 points 24 hours after admission.

Thirty-seven studies pooling a total of 9,505 patients were included. The excellent functional outcome was comparable between both the EVT and BMT arms (RR= 1.04;95%CI:[0.96, 1.13]; p= 0.34; I²= 59%). Similarly, the functional independence showed no significant difference between the two groups (RR= 1.00;95%CI:[0.94, 1.06]; p= 0.99; I²= 64%). The 90-day mortality (RR= 1.21;95%CI:[0.97, 1.52]; p= 0.09; I²= 46%) and neurological deterioration (RR= 1.39;95%CI:[0.65, 2.95]; p= 0.40; I²= 82%) were also comparable between the two arms. EVT showed a statistically significant increase in neurological improvement (RR= 1.38;95%CI:[1.05, 1.82]; p= 0.02; I²= 53%), although it was associated with a high risk of symptomatic intracranial hemorrhage (sICH) (RR= 1.56;95%CI:[1.15, 2.13]; p= 0.005; I²= 39%).

EVT was associated with a significant increase in the early neurological improvement although the risk of sICH was high. Other safety and efficacy outcomes including excellent functional outcome, functional independence, all-cause mortality and neurological deterioration were comparable.