The Evolving Debate Around DEVO and MEVO in Stroke Care

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In January 2026, the American Heart Association and American Stroke Association released updated guidelines for the management of acute ischemic stroke, highlighting the latest best practices in stroke care. Notably, these updates include guidance specific to pediatric patients, reflecting the unique challenges and considerations involved in treating children. Developed through extensive research and expert consensus, the recommendations aim to streamline and optimize rapid, evidence-based interventions across a variety of clinical settings.

To explore the practical impact of these updates, NeurologyLive® hosted a conversation with Beth Cavanaugh, MD, pediatric stroke neurologist and director of the Pediatric Stroke Program at Le Bonheur Children's Hospital, and Andrei Alexandrov, MD, professor and chair of the Department of Neurology at the University of Arizona College of Medicine–Phoenix. During the discussion, the clinicians covered several topics, including the pediatric considerations and the need for collaboration among pediatric specialists and adult stroke programs.

In this episode, Alexandrov and Cavanaugh discuss the evolving debate around distal and medium vessel occlusions (DEVO/MEVO) and what it may mean for clinical decision-making. Their conversation touches on the role of advanced imaging, multidisciplinary collaboration, and emerging evidence that continues to shape how clinicians evaluate and manage stroke in modern practice.

This transcript is edited for clarity. Click here to view more of our stroke coverage.

Alexandrov, MD: This is an interesting debate. First of all, being less supportive of intervening on more distal and medium vessel occlusions should not be taken as no need for vascular imaging. That's one thing that I avoid folks to overinterpret saying, “Oh yeah, mild stroke, likely just occlusion, I'm not going to do vascular imaging.” No, no, no. Hyperacute multimodal imaging should remain the same - CTE, CTA at the very least, ideally CTP that is also now supported by guidelines.

And then the second ,thing before you call it distal or MEVO and not even alert the vascular team for that particular patient, at least talk about imaging with a stroke neurologist if not a neuroendovascular specalist. Let them look at the perfusion deficit location, what kind of deficit the patient has, and then ask, is there a technical solution for that level of occlusion? Science is evolving and, by the time the guidelines are published, even though there are 2026, the inclusion of clinical trials will have started in 2024. So we have evidence that’s emerging now that will allow you to navigate that MEVO part a little bit better.

Cavanaugh, MD: I think it's definitely a discussion that is that is ongoing because, like many rare diseases are, we just have less patients who are presenting in lower numbers. So things like performing randomized clinical trials have always been difficult when there are small numbers and rare populations. But it's an ongoing conversation we have, and we hope to learn more from how the adults are choosing which patients are going to benefit from interventions.