What considerations guide your decision to perform endovascular therapy in stroke involving acute M2 or M3 occlusions?

When deciding whether to intervene in distal occlusions, I first assess the severity of the neurological deficits, particularly focusing on cortical signs such as aphasia, neglect, or visual field deficits. Based on criteria from prior LVO RCTs, I typically use an NIHSS threshold of 6 or greater. However, this can be adjusted depending on the clinical context and the specific territory. For example, an NIHSS threshold of 6 may be appropriate for an M2 occlusion due to the significant deficits associated with this territory. In contrast, A2 or P2 occlusions might justify a lower NIHSS threshold given the generally lower deficit burden in these regions.