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Introduction The role of mechanical thrombectomy (MT) for medium vessel occlusions (MeVOs), particularly M2 segment occlusions, remains debated. Recent trials, including ESCAPE-MeVO and DISTAL, failed to demonstrate any benefit over best medical treatment alone.Aim of Study To compare 90-day functional outcomes between patients with M1 and M2 occlusions treated with endovascular thrombectomy (EVT) using propensity score matching.Method We analyzed 171 consecutive patients from the multicenter German Stroke Registry who underwent EVT for M1 or M2 occlusions. Propensity score matching and multivariable logistic regression were performed. The primary endpoint was functional independence (mRS 0–2) at 90 days.Results M2 occlusions were associated with significantly better outcomes compared to M1 occlusions (OR = 2.07; 95% CI: 1.28–3.34; p = 0.003). Older age and higher NIHSS were linked to poorer outcomes (age OR = 0.95; 95% CI: 0.94–0.96; p < 0.001; NIHSS OR = 0.91; 95% CI: 0.88–0.93; p < 0.001), while higher ASPECTS showed a non-significant trend toward better outcomes.Conclusion Despite recent randomized trials questioning the benefit of EVT for M2 occlusions, our study suggests a potential advantage for EVT in this subgroup. However, limitations in both our observational design and recent trials—such as heterogeneous patient selection, lack of detailed occlusion stratification, and procedural variability—highlight the need for more refined, targeted studies to determine the true benefit of thrombectomy in distal occlusions.Conflict of Interest No