This session on atherosclerosis and vascular mechanisms in stroke offered a comprehensive and clinically relevant overview of how atherosclerotic disease interact, shaping both stroke risk and recurrence. The presentations combined advanced imaging, biomarker research, and clinical data to refine our understanding of stroke aetiology and prevention.

Lucas Fache – Leuven, Belgium

Dr. Fache opened the session with an insightful presentation on intracranial artery calcification (IAC) and its clinical relevance. Using data from a large multicentre cohort, he demonstrated that IAC is highly prevalent, present in over 90% of patients with TIA or ischaemic stroke. Importantly, both the volume and morphology of calcifications were associated with stroke aetiology.

Patients with large-artery atherosclerosis showed higher calcification burden and more intimal-dominant patterns. Moreover, increasing IAC volume was linked to a higher prevalence of extracranial carotid stenosis and a significantly increased risk of recurrent stroke. These findings position IAC as a potential imaging biomarker for risk stratification and secondary prevention.

Haiwei Li – Guangzhou, China

Dr. Li presented real-world data on the effectiveness of immediate angioplasty or stenting in patients with acute ischaemic stroke due to severe intracranial atherosclerotic stenosis. The study addressed a clinically challenging subgroup where optimal management remains uncertain.

The findings suggested that early endovascular intervention may improve functional outcomes in selected patients, highlighting the importance of tailored treatment strategies in intracranial atherosclerosis. However, patient selection and procedural risks remain key considerations.

Fei Han – Beijing, China

Dr. Han explored the relationship between large artery phenotypes and cerebral small vessel disease (cSVD), focusing on vascular function. The study demonstrated that arterial abnormalities such as dolichoectasia and increased vessel diameter are associated with impaired cerebrovascular reactivity and altered blood–brain barrier permeability.

Importantly, reduced cerebrovascular reactivity partially mediated the progression of small vessel disease, suggesting that large artery pathology may act as a driver of downstream microvascular damage. This work highlights the interconnected nature of vascular pathology across different vessel sizes.

Elias Johansson – Gothenburg, Sweden

Dr. Johansson addressed stroke risk in patients with retinal artery occlusion (RAO) associated with symptomatic carotid stenosis. The analysis showed that patients presenting with retinal events (RAO or amaurosis fugax) have a lower risk of recurrent stroke compared to those with cerebral events.

Interestingly, the mechanism behind this lower risk remains unclear, despite evidence of embolic origin in RAO. These findings may have implications for risk stratification and timing of carotid interventions.

Gian Marco De Marchis – St. Gallen, Switzerland

Professor De Marchis presented interim results from the AGELESS study, focusing on lipid biomarkers and carotid plaque vulnerability. The data showed that LDL cholesterol and ApoB were strongly associated with symptomatic carotid disease and intraplaque haemorrhage, while lipoprotein(a) was not.

These findings suggest differential roles of lipid fractions in plaque instability and may inform more targeted preventive strategies in atherosclerotic stroke.

Anna Kopczak – Munich, Germany

Dr. Kopczak demonstrated the clinical utility of routine carotid MRI for detecting intraplaque haemorrhage (IPH). The study showed high interrater reliability across scanners and field strengths, supporting its feasibility in daily practice.

Importantly, the presence of IPH helped reclassify stroke aetiology in a subset of patients with previously cryptogenic stroke, reinforcing its value as a diagnostic and potentially prognostic marker.

Marc Delgado-Romeu – Barcelona, Spain

Dr. Delgado-Romeu focused on inflammation as a driver of plaque progression. Using FDG-PET imaging, the study showed that increased metabolic activity within carotid plaques was associated with a higher risk of progression and stroke.

Although based on interim data, these findings support the role of inflammation imaging as a tool for identifying high-risk plaques and guiding preventive strategies.

Juul Bierens – Maastricht, Netherlands

Dr. Bierens introduced spectral photon-counting CT, an emerging imaging technology that allows detailed characterisation of carotid plaque composition and stenosis.

This technique offers improved spatial resolution and tissue differentiation, with the potential to enhance detection of high-risk plaque features and refine patient selection for intervention.

Conclusion

This session highlighted the growing importance of integrated vascular imaging and biomarker-driven approaches in stroke care. From calcification and inflammation to plaque composition and vascular function, the studies emphasised that stroke is not a single-vessel disease but a complex, systemic process.

Advances in imaging and phenotyping are paving the way toward more precise risk stratification, personalised treatment, and improved prevention of recurrent stroke, underscoring the need for continued research and clinical integration.

The joint ESO–ESMINT scientific session on the opening evening of ESOC 2026 in Maastricht turned to the unresolved frontiers of endovascular stroke care. Chaired by Natalia Perez De La Ossa (Badalona, Spain) and Christian Taschner (Freiburg, Germany), the 90-minute programme worked outwards from the established core of large vessel occlusion thrombectomy to five areas where the evidence is still being built: extracranial carotid disease, medium and distal vessel occlusions, adjunctive intra-arterial thrombolysis, rescue stenting after failed reperfusion, and intravascular imaging.

EVT in isolated extracranial carotid artery occlusion

Christian Nolte (Berlin, Germany) opened the session with the case for endovascular treatment in patients with isolated cervical ICA occlusion — a scenario that affects a meaningful share of ischaemic stroke patients but has been largely excluded from the major thrombectomy trials. He emphasised that procedural complexity, and patient outcome, varies with the location of the occluded internal carotid artery segment. Drawing on observational data from several studies, including ETIICA and a post hoc analysis of the SELECT2 trial, his central message was that “one size does not fit all”: the benefit of EVT is more likely in occlusions of the C2–C6 segments rather than C1 (patients with a more likely embolic aetiology than atherosclerotic), in patients with a higher baseline NIHSS (a value of 15 has been proposed as a potential cutoff, a value above 15 being associated in the observational data with a favourable mRS shift). A persistent challenge remains in pinpointing the exact location of the occlusion on vascular imaging. Ongoing randomised trials such as ETICA, EVT-i ICAO and INTERNAL will give us more depth in understanding and finding the best solutions for this group of patients.

Who (if anyone) to treat in medium and distal vessel occlusion?

Marios Psychogios (Basel, Switzerland) addressed the post-DISTAL, post-ESCAPE-MeVO landscape, in which routine thrombectomy for medium vessel occlusions has not shown overall benefit. Even though recent guidelines limit the recommendations for treating patients with MeVO, Prof. Psychogios was certain that this debate is far from closed, and pointed to two new randomised trials: Oriental-MeVO, recently presented at ISC 2026, which showed improved outcomes in patients with medium vessel occlusion and moderate or high clinical severity treated with endovascular therapy; and DISTALS trial, evaluating Tigertriever 13, a stent retriever specifically designed  for distal vessel occlusion.

He then revisited the DISTAL data and identified subgroups of patients who might still benefit from thrombectomy — those with NIHSS >9 or with a larger perfusion deficit. He further pointed to limitations of the study, such as substantial heterogeneity in centre experience translating into heterogeneity in procedural outcomes, older-generation devices that weer used during the recruitment period. He also suggested that the trials might have been overly restrictive in their selection — a “reverse cherry-picking” phenomenon that may have biased the results. Other concerns he raised included overly complex inclusion criteria based on vessel occlusion definitions, potentially under-reported ICAD cases and slow time to randomisation.

His message to the audience was that the road towards routine thrombectomy in patients with medium and distal vessel occlusion is a difficult one, but that the field should keep faith that we will reach this point in the future. Until there are new data from ongoing RCT, we should still take into consideration treating patients with MDVO, if they are better selected and if the community is adapting its technique and uses newer devices.

Intra-arterial thrombolysis post successful reperfusion

Georgios Tsivgoulis (Athens, Greece) offered a comprehensive and up-to-date review of the data on adjunctive intra-arterial thrombolysis after successful endovascular reperfusion, weighing the positive signals from RCTs such as CHOICE, ANGEL-TNK and PEARL against the neutral primary results of POST-TNK and POST-UK. The rationale across these studies is that thrombolysis might address the “no-reflow” phenomenon observed in roughly a quarter of patients despite successful recanalization. He presented the key results of all RCTs published to date, including CHOICE-2 (2026), summarising the positive findings across the field.

He then turned to meta-analyses of the available RCTs, which show that intra-arterial thrombolysis is overall associated with reduced disability, a higher chance of an excellent functional outcome and a favourable mRS shift. The findings were most consistent in the meta-analysis that excluded Urokinase studies and demonstrated a clear benefit for anterior circulation stroke when intra-arterial Alteplase was used at the consistent dose of 0.225 mg/kg — one quarter of the standard intravenous dose. The benefit from intra-arterial Tenecteplase was less consistent, owing to dose heterogeneity across trials (one quarter or one half of the i.v. dose), but still, pooled analysis show improved functional outcomes. No clear benefit has been demonstrated in posterior circulation stroke, where the data remain limited and underpowered. These findings support the concept that targeting microcirculatory reperfusion — the “no-reflow” phenomenon — is a key determinant of clinical recovery beyond large-vessel recanalization.

When thrombectomy fails: acute intracranial stenting as a bail-out strategy

Marc Ribo (Barcelona, Spain) addressed a current hot topic: the role of acute intracranial stenting as a bail-out strategy when recanalization is not achieved after multiple thrombectomy passes. The impact of the first-pass effect on outcome is well established, and any level of recanalization is better than none, so the goal should always be to push for the highest possible reperfusion. Data from the RESISTANT International Registry show a steady increase in the number of patients treated with acute intracranial stenting over recent years.

Based on observational data, a higher number of passes before stenting is associated with worse outcomes. He argued that we should identify as early as possible which patients ought to be stented from the first passes, with a proposed cut-off of 3 retrieval attempts. He also encouraged the development and use of prediction models to identify patients unlikely to recanalize with routine techniques.

In closing, Ribo proposed a staged approach to achieving complete or near-complete recanalization (mTICI 2C/3): up to three passes of conventional thrombectomy, followed, if needed, by staged rescue treatment, consisting in intravenous or intra-arterial agents (a potential impactful proposed technique is SAIL – stent retriever assisted lysis with Tirofiban), then angioplasty, and finally stenting. RCT data to define the optimal approach are still awaited; until then, individual clinical judgement should guide decision-making.

Optical coherence tomography in acute ischaemic stroke

The session closed with a forward-looking talk from Vania Anagnostakou (Worcester, United States) on intravascular optical coherence tomography in the neurointerventional field. Originally developed for interventional cardiology, the technique is now being translated to the neurovascular field. This imaging modality uses near-infrared light to generate high-resolution images by measuring depth-resolved reflections and can visualise tissue microstructure and composition. A dedicated neurovascular OCT probe has been designed and can be delivered intravascularly through a microcatheter, making it very easy to use.

The technique offers micron-resolution imaging (down to 10 microns) of thrombus composition, underlying intracranial atherosclerosis, vasospasm, dissection flaps, post-thrombectomy vessel injury and stent placement. In large vessel occlusion strokes, it can help identify the length and type of clot (red or white) and thus helping in planning the thrombectomy procedure. She closed with a clear message that OCT can play an increasingly important role in the future management of patients with neurovascular disease.

This session on optimising pre- and interhospital stroke management provided a powerful start to ESOC 2026. The presentations highlighted the evolving role of rapid stroke recognition technologies, mobile stroke units, telestroke networks, and simulation-based training, combining scientific insight with practical, system-level applications.

Dr Maren Ranhoff Hov – Oslo University Hospital, Norway

Dr. Maren Ranhoff Hov opened the session with a presentation on emerging technologies for rapid stroke recognition, highlighting the persistent gap between urban and rural stroke care. She emphasized that limited access to specialized centers in rural areas contributes to worse outcomes.

She presented promising solutions, including remotely controlled CT systems, which substantially reduced assessment times and improved access to reperfusion therapies. Mobile Stroke Units were described as a cornerstone of advanced prehospital care.

Looking ahead, she highlighted the potential of lightweight, low-radiation CT technologies, as well as additional tools such as transcranial ultrasound and cerebral oxygenation monitoring in the prehospital setting.

She concluded by underscoring that the true impact of these innovations depends on their effective integration into healthcare systems, supported by training, simulation, and coordinated teamwork.

Professor Guillaume Turc – Sainte-Anne Hospital, Paris, France

Professor Guillaume Turc focused his presentation on the challenges and preliminary results of the ASPHALT randomized control trial, which established the first Mobile Stroke Unit (MSU) program in France.

He detailed the significant administrative obstacles faced in France compared to other European countries. Specifically, the French X-ray protection agency required the MSU to be shielded to the same standards as a stationary hospital room. Furthermore, radiation safety tests were required before the unit could be authorized, yet these tests could not be performed until after the vehicle was fully built.

The Paris MSU operates between 8 a.m. and 6 p.m., targeting suspected stroke patients within a six-hour symptom window. The onboard team is highly specialized, featuring a practitioner trained in both neurology and emergency medicine. Professor Turc reported that the MSU achieved a response time, which was significantly faster than traditional hospital-based care. However, he noted that patient recruitment for the trial was slower than anticipated.

Professor Turc discussed how the trial’s primary outcome was designed as a cost-benefit analysis at the request of French health economists to determine if the system was cost-effective for the French healthcare model.

Dr. Pierre Seners – Hôpital Fondation A. de Rothschild, Paris, France

Dr. Pierre Seners focused his presentation on the development of telestroke networks and the critical challenges associated with inter-hospital transfers. He highlighted that because more than half of stroke patients worldwide require transfer to specialized centers for advanced care, the “door-in-door-out” (DIDO) time is just as vital as in-hospital treatment times.

He advocated for a systematic approach involving all stakeholders to identify bottlenecks and implement data-driven changes. Dr Seners pointed to the success of AI automatic LVO detection software on CT scans, which can significantly reduce the time needed to identify patients requiring urgent transfer.

He highlighted efficient models, where ambulances are dispatched the moment a patient is accepted, and “no-wait” policies that eliminate delays while waiting for transfer decisions. He discussed a model where, instead of transferring the patient, a “flying team” (interventionalist and assistant) is sent to the primary stroke center to perform procedures on-site.

To save critical minutes, he suggested protocols that allow patients to go directly to the angiography suite upon arrival at a comprehensive center, avoiding redundant diagnostic steps.

Dr. Seners concluded by emphasising the importance of team culture, noting that sharing performance data and celebrating successes – such as achieving fast timeliness metrics – is essential for maintaining a highly efficient stroke network.

Professor Silke Walter – Saarland University, Germany

Prof. Silke Walter provided a comprehensive overview of clinical trial evidence in prehospital stroke management, focusing on strategies to accelerate diagnosis and treatment before hospital arrival.

She discussed key trials, including RACECAT, which showed no difference in outcomes between direct transport to comprehensive versus primary stroke centers in suspected LVO, highlighting the complexity of triage decisions. Evidence from MSU trials such as B-PROUD and BEST-MSU demonstrated substantial reductions in treatment times and improved functional outcomes. She also reviewed studies on prehospital thrombolysis, including Tenecteplase versus Alteplase trials, confirming feasibility, and INTERACT-4, which suggested potential benefits of early blood pressure control in selected patients.

She concluded that despite some neutral or heterogeneous trial results, the overarching evidence consistently supports the benefit of faster prehospital identification and treatment, while emphasising the need for continued research and effective implementation in real-world systems.

Professor Waltraud Pfeilschifter – Klinikum Lüneburg, Germany

Professor Waltraud Pfeilschifter focused her presentation on simulation-based training for acute stroke pathways. She argued that while new technologies are vital, the way teams interact and communicate is a subject for specialized training that is now reflected in updated clinical guidelines.

She cited studies indicating that simulation training significantly improves patient outcomes and team interaction. Professor Pfeilschifter shared her personal experience implementing these programs, recommending multidisciplinary teams of five to ten people – including nurses and paramedics – to keep the training manageable and practical.

She noted that simulation training is a key driver in reducing treatment delays and emphasized that even highly experienced teams benefit from regular simulation.

The Catalan welcome was out in full force when I arrived at Sant Pau for my 2 week stay. My visit came as the perfect break from the dreary beginnings of Irish to the sunshine of Barcelona. The purpose of my visit however was not to escape Seasonal Affective Disorder, but to become au fait with the laboratory skills required for one of the projects of my PhD. This opportunity was possible thanks to the generous invitation of the team at the Institut Research de Sant Pau (Dr Nuria Puig Grifol, Dr Sonia Benitez Gonzalez and Dr Pol Camps Renon) and the ESO Department to Department Visit Grant.

As a clinician, this was my first foray into lab work and experiments since secondary school. Any unease was quickly banished by the expert guidance I received form the staff in Sant Pau. I was adopted under the wing of the wonderful research lab team and guided step-by-step through each process of the ELISA technique and the analysis of results. I was then provided with the opportunity to complete an experiment all by myself which I saw as a real achievement in my short visit. Following this positive experience, I feel well prepared to begin my lab work in Dublin, and I am very grateful to the team for their guidance.

Whilst the majority of my trip was focused on learning, I did have opportunity to sample Barcelona’s sights in the evenings, both on my days off, and from the lab which has an impressive view of the Sagrada Familia. Highlights included a complementary visit to the Recinte Modernista de Sant Pau, the old Hospital Sant Pau which has been converted into museum which is considered a masterpiece of Catalan Modernism architecture. No trip to Barcelona is complete without seeing Antoni Gaudí’s work, and visits to La Pedrera and Cas Batlló were also possible during my time. The cultural educational opportunities did not stop there, as I learnt about La Castanyera, Tió de Nadal and got to eat my fair share of tapas!

I will remember my time in Barcelona fondly, and I am very grateful to ESO for the opportunity to learn not just about ELISA, but about the great work the team in Sant Pau do, and about Catalan culture. I could not have asked for a better experience, and a lot of this is down to Nuria, Sonia, Pol and their team for being so welcoming and understanding.

Ischaemic stroke is typically considered a disease of older age. Yet approximately 10% of strokes occur in adults between 18 and 55 years [1]. While acute management in these patients largely follows the same principles as in older individuals, determining the underlying cause often presents a much greater challenge.

In contrast to older patients, where vascular risk factors such as hypertension, diabetes, or atherosclerosis frequently explain the event, stroke in younger adults is far more likely to result from uncommon or non-classical mechanisms [2]. This difference has direct clinical implications. In many young patients, the traditional diagnostic framework fails to identify the cause of stroke.

 

The usual suspects in young stroke

Cardioembolism represents one of the leading mechanisms of stroke in younger adults. While atrial fibrillation is the most common source of cardioembolic stroke in older populations, it accounts for only a small proportion of strokes in younger patients. Instead, a patent foramen ovale is often the most relevant cardiac finding. Approximately 50% of patients aged 60 years or younger with an embolic stroke of undetermined source have a PFO, compared with 25% of the general population. It has been estimated that approximately 10% of all ischaemic strokes in young and middle-aged adults can be attributed to paradoxical embolism through a PFO [3].

The second most common mechanism is cervical artery dissection, which accounts for up to 15–25% of strokes in adults under 50 years of age. Dissections of the carotid or vertebral arteries often occur spontaneously and may initially present with relatively subtle symptoms such as unilateral neck pain or headache [4].

Beyond conventional vascular risk factors and cardiac sources of embolism, clinicians must also consider prothrombotic disorders in young stroke patients. Antiphospholipid syndrome (APS) represents one of the most clearly established risk factors for arterial thrombotic events in younger individuals [5]. In contrast, the contribution of inherited thrombophilias, such as factor V-mutations, to arterial stroke risk remains controversial and routine testing is generally not advised [6]. However, the clinical relevance may be greater in the presence of a PFO: the combination of these mutations with PFO has been associated with a 4- to 5-fold increased risk of cerebral ischaemia, likely through facilitation of paradoxical embolism [7].

Inflammatory and infectious vasculopathies

Primary angiitis of the central nervous system (PACNS), although rare, illustrates the potential consequences of delayed diagnosis. Patients may initially present with headache, cognitive changes, or focal neurological deficits, and the clinical picture can mimic more common stroke mechanisms. Because PACNS requires prompt immunosuppressive treatment, failure to recognise the disease early may significantly worsen long-term outcomes [8].

Importantly, PACNS is not the only inflammatory condition that may affect the cerebral vasculature. Central nervous system involvement can also occur in systemic vasculitides such as giant cell arteritis, Takayasu arteritis, polyarteritis nodosa, or ANCA-associated vasculitides. In addition, infectious vasculopathies, e.g., caused by varicella–zoster virus, HIV, or syphilis, must be carefully excluded before immunosuppressive therapy is initiated [9].

Rare but important differential diagnoses
Additional rare conditions can also present with stroke in young adults. These include reversible cerebral vasoconstriction syndrome (RCVS), which typically manifests with thunderclap headaches and transient multifocal vasoconstriction of the cerebral arteries [10]. Other important differential diagnoses include Moyamoya angiopathy, characterised by progressive stenosis of the intracranial carotid circulation with the development of fragile collateral vessels [11].

Genetic and metabolic disorders must also be considered: monogenic disorders account for up to 7% of strokes in young adults [12]. Prominent examples include CADASIL, the most common monogenic cause of cerebral small vessel disease, typically presenting with migraine with aura, recurrent subcortical strokes, and progressive cognitive decline [13]. Fabry disease is particularly important to diagnose given the availability of enzyme replacement therapy. Mitochondrial disorders such as MELAS should also be considered, as stroke-like episodes may clinically mimic ischaemic stroke despite a distinct, non-vascular pathophysiology [14]. Although individually rare, these conditions become particularly relevant when stroke occurs in young individuals without conventional vascular risk factors.

Conclusion
These observations underline a key principle in the management of juvenile stroke: while acute treatment pathways may be similar across age groups, the search for an underlying cause must be tailored to the patient’s age and clinical context. Identifying the specific mechanism is crucial not only to understand why the event occurred, but also to guide targeted strategies for secondary prevention.

References

1. Nedeltchev, K. Ischaemic Stroke in Young Adults: Predictors of Outcome and Recurrence. J. Neurol. Neurosurg. Psychiatry 2005, 76, 191–195, doi:10.1136/jnnp.2004.040543.
2. Schöberl, F.; Ringleb, P.A.; Wakili, R.; Poli, S.; Wollenweber, F.A.; Kellert, L. Juvenile Stroke: A Practice-Oriented Overview. Dtsch. Arztebl. Int. 2017, doi:10.3238/arztebl.2017.0527.
3. Kent, D.M.; Wang, A.Y. Patent Foramen Ovale and Stroke. JAMA 2025, 334, 1463, doi:10.1001/jama.2025.10946.
4. Keser, Z.; Chiang, C.-C.; Benson, J.C.; Pezzini, A.; Lanzino, G. Cervical Artery Dissections: Etiopathogenesis and Management. Vasc. Health Risk Manag. 2022, Volume 18, 685–700, doi:10.2147/VHRM.S362844.
5. Garcia, D.; Erkan, D. Diagnosis and Management of the Antiphospholipid Syndrome. New England Journal of Medicine 2018, 378, 2010–2021, doi:10.1056/NEJMra1705454.
6. Chiasakul, T.; De Jesus, E.; Tong, J.; Chen, Y.; Crowther, M.; Garcia, D.; Chai‐Adisaksopha, C.; Messé, S.R.; Cuker, A. Inherited Thrombophilia and the Risk of Arterial Ischemic Stroke: A Systematic Review and Meta‐Analysis. J. Am. Heart Assoc. 2019, 8, doi:10.1161/JAHA.119.012877.
7. Saver, J.L. Cryptogenic Stroke. New England Journal of Medicine 2016, 374, 2065–2074, doi:10.1056/NEJMcp1503946.
8. Salvarani, C.; Brown, R.D.; Christianson, T.; Miller, D. V.; Giannini, C.; Huston, J.; Hunder, G.G. An Update of the Mayo Clinic Cohort of Patients With Adult Primary Central Nervous System Vasculitis. Medicine 2015, 94, e738, doi:10.1097/MD.0000000000000738.
9. Kraemer, M.; Berlit, P. Systemic, Secondary and Infectious Causes for Cerebral Vasculitis: Clinical Experience with 16 New European Cases. Rheumatol. Int. 2010, 30, 1471–1476, doi:10.1007/s00296-009-1172-4.
10. Singhal, A.B. Reversible Cerebral Vasoconstriction Syndrome: A Review of Pathogenesis, Clinical Presentation, and Treatment. International Journal of Stroke 2023, 18, 1151–1160, doi:10.1177/17474930231181250.
11. Scott, R.M.; Smith, E.R. Moyamoya Disease and Moyamoya Syndrome. New England Journal of Medicine 2009, 360, 1226–1237, doi:10.1056/NEJMra0804622.
12. Ekker, M.S.; Boot, E.M.; Singhal, A.B.; Tan, K.S.; Debette, S.; Tuladhar, A.M.; de Leeuw, F.-E. Epidemiology, Aetiology, and Management of Ischaemic Stroke in Young Adults. Lancet Neurol. 2018, 17, 790–801, doi:10.1016/S1474-4422(18)30233-3.
13. Chabriat, H.; Joutel, A.; Dichgans, M.; Tournier-Lasserve, E.; Bousser, M.-G. CADASIL. Lancet Neurol. 2009, 8, 643–653, doi:10.1016/S1474-4422(09)70127-9.
14. Tetsuka, S.; Ogawa, T.; Hashimoto, R.; Kato, H. Clinical Features, Pathogenesis, and Management of Stroke-like Episodes Due to MELAS. Metab. Brain Dis. 2021, 36, 2181–2193, doi:10.1007/s11011-021-00772-x.

The increasing demand for neurointerventional specialists has led to a growing acceptance of neurologists into dedicated neurointerventional training programs. In this blog piece we present two perspectives of training pathways for neurologists in the delivery of endovascular thrombectomy: Romania and Turkey.

Dr Mihai Ionescu:

Training in neurointervention is carried out according to national authorities and follows country-specific training pathways. Consequently, training duration, procedural requirements and eligible trainee backgrounds vary considerably across Europe. To promote standardisation and high-quality training, the European Society of Minimally Invasive Neurological Therapy (ESMINT), European Society of Neuroradiology (ESNR) and the European Union of Medical Specialists (UEMS) have previously published¹ guidelines outlining recommended training requirements in interventional neuroradiology.

Since 2023, Romania has implemented a dedicated subspecialty neurointerventional training program that accepts trainees from diverse medical backgrounds including radiology, neurology, neurosurgery and pediatric neurology. We believe this model may be informative for healthcare systems currently facing shortages of neurointerventionalists and low endovascular treatment rates.

I would strongly recommend clinical fellowships such as the European Stroke Organisation Department-to-Department Visit Programme^2,3 or the ESMINT fellowships⁴  which currently provide valuable exposure for neurologists in high-volume European centers.

Dr Ionescu personal archive photographs from the 2020 ESO Department-to-Department Visit Programme at the Centre Hospitalier Universitaire Dupuytren, Interventional Neuroradiology Department, Limoges, France which subsequently led to Fellowship Training and completion of a University Diploma in Interventional Neuroradiology in Limoges.

Dr Atilla Odezmir:

Under the umbrella of the Turkish Cerebrovascular Diseases Society (Türkiye Beyin Damar Hastalıkları Derneği), a structured “Interventional Neurology” diploma (board certification) program for neurologists was initiated in 2012. As of 2026, the number of board-certified “Interventional Neurologists” trained through this one year program who actively perform mechanical thrombectomy and endovascular secondary prevention procedures for ischemic stroke is 65. Among them, 16 are women interventional neurologists. In response to the landmark randomised endovascular therapy trials published in 2015, a two-step training model was adopted, aiming to prepare interventional neurologists not only for mechanical thrombectomy but also for comprehensive stroke center organisation and the development of regional stroke systems of care.^2,3

Standardised accreditation and competency-based assessment are central to ensuring patient safety and consistent quality across centers.^2,3 The programmes have been award winning and supported by the Turkish government.

This has changed the face of stroke care in Turkey – as of 2026, 29 comprehensive stroke centers across the country are led by interventional neurologists, and mechanical thrombectomy is routinely performed in these centers.

Our accredited training centers under the Turkish Cerebrovascular Diseases Society are prepared to host and train visiting interventional neurologists from abroad.

In collaboration with the European Stroke Organisation, we are ready to welcome neurologists from across Europe to provide both structured mechanical thrombectomy training and capacity-building support for European countries with unmet needs for thrombectomy services: esoinfo@eso-stroke.org

1. Sasiadek M, Kocer N, Szikora I, et al. Standards for European training requirements in interventional neuroradiology guidelines by the Division of Neuroradiology/Section of Radiology European Union of Medical Specialists (UEMS), in cooperation with the Division of Interventional Radiology/UEMS, the European Society of Neuroradiology (ESNR), and the European Society of Minimally Invasive Neurological Therapy (ESMINT). J NeuroIntervent Surg. 2020;12(3):326. doi:10.1136/neurintsurg-2019-015537

2. Mehmet Akif Topçuoğlu, Atilla Ozcan Ozdemir. Acute stroke management in Turkey: Current situation and future projection. European Stroke Journal 2023;8: 16-20.

3. Atilla Ozcan Ozdemir, Semih Giray, Erdem Gürkaş. Training standards for neurointerventional procedures regarding endovascular treatment and secondary endovascular protection of acute ischemic stroke. Turkish Cerebrovascular Disease Journal. 2023;29 (3):106-114

Simulation is an increasingly valuable tool in stroke education. It provides a safe and structured environment to train practical skills, improve decision-making, strengthen teamwork, and rehearse time-critical scenarios in acute stroke care. For junior clinicians as well as more experienced professionals seeking a refresher, simulation helps translate knowledge into action.

At ESOC 2026 in Maastricht (6–8 May 2026), the ESO Simulation Education Committee will host four Hands-on Simulation Workshops on Thursday, 7 May 2026. We will simulate two acute stroke cases in a simulated emergency department environment with you actively role-playing the physician part. These small-group sessions are designed to provide practical, case-based learning with direct faculty feedback, and places are limited. Workshops can be booked separately during ESOC registration on a first-come, first-served basis.

Here is what to expect from each workshop:

Workshop A | 08:30–10:00 – Simulation Workshop on Code Stroke: From Diagnosis to Early Treatment

A practical workshop on acute stroke diagnosis, early treatment, door-to-treatment times, and crew resource management in the hyperacute setting. Particularly suited to participants looking for a structured overview of the code stroke pathway, either as a starting point for simulation-based training or as a focused refresher of core principles.

Workshop B | 13:15–14:45 – Simulation Workshop on the Management of the Deteriorating Patient After Reperfusion Therapy

Focused on the acutely deteriorating patient after reperfusion therapy, with emphasis on decision-making, communication, shared mental models, and interprofessional learning. Especially relevant for participants interested in teamwork and crisis management in a high-pressure scenario.

Workshop C | 15:00–16:30 – Simulation Workshop on the Management of Complex Acute Stroke Cases

Dedicated to challenging stroke presentations, including complications, frailty, and contraindications to treatment. Particularly suitable for participants with prior experience in acute stroke care who want to deepen their approach to complex cases and nuanced treatment decisions.

Workshop D | 17:00–18:30 – Simulation Workshop on Tele-Stroke Management in the Acute Stroke Setting (Joint Session of the ESO Stroke Simulation Committee and the ESO Telestroke Committee)

This workshop explores simulation training in a telestroke environment, including remote assessment, communication, NIHSS scoring, workflow optimisation, and complication management using telemedicine equipment in a controlled simulated setting. Especially relevant for participants interested in understanding the operational principles of tele-stroke services and gaining initial experience within such an environment.

As each workshop takes place in a different time slot, participants are welcome to register for more than one session and build a progressive learning experience across the day.

Whether you are early in your stroke career or looking to refresh essential practical skills, these workshops offer a unique opportunity to learn by doing.

Places are limited! Book your workshop during ESOC registration and join us in Maastricht, Thursday 7 May 2026: #VoiceOfStroke.

The 27th webinar of the European Stroke Organization’s educational series was hosted by Dr. Marieta Peycheva and Dr. Ellis van Etten. With the title “Intravenous thrombolysis in patients with relative and absolute contraindications: how far should we go?”, it features Dr. Thomas Meinel (Inselspital, Bern University Hospital, Switzerland) and Dr. Odysseas Kargiotis (University of Patras, Greece) discussing the boundaries of intravenous thrombolysis (IVT) in some complex situations.

The first part of the discussion regarded patients on direct oral anticoagulants (DOACs), highlighting a case where a patient with high rivaroxaban levels was treated with IVT without complications. Although 2021 ESO guidelines are restrictive regarding DOACs, recent observational data and the 2026 American guidelines suggest that high plasma levels might not always preclude treatment with an individualized risk-benefit analysis. While idarucizumab is a common and safe reversal agent for dabigatran, the use of andexanet alfa as reversal of rivaroxaban/apixaban is not recommended before IVT primarily due to a documented increase in thrombotic events. Ongoing RCTs will clarify the safety and efficacy of IVT in this scenario and results are expected 2028.

The dilemma of minor strokes is another key topic, exemplified by a case where IVT treatment for a mild disabling deficit (left hemiparesis with impaired gait, NIHSS 4) resulted in a fatal brainstem hematoma. Although underpowered and yielding non-statistically significant results, the PRISMS trial demonstrated a trend that alteplase may not benefit minor non-disabling strokes, suggesting that IVT should be avoided in these particular cases. The definition of “disabling” remains inherently subjective and requires careful clinical judgment. However, in patients with large vessel occlusions (LVO) and mild symptoms, some evidence suggests IVT may still be beneficial.

Regarding post-operative patients, guidelines generally suggest waiting 14 days after major surgery, yet the experts emphasize that individual circumstances, such as a non-traumatic spinal puncture, might allow for earlier intervention and communication with the surgeon might be helpful for decision-making.

Patients with a history of stroke were also addressed. Non-randomized data and meta-analyses indicate that previous ischemic strokes generally do not significantly increase haemorrhage risk, though clinical outcomes are often poorer due to pre-existing disabilities. However, strokes occurring within the prior two weeks signal a higher risk for symptomatic haemorrhage, requiring careful consideration of timing and lesion size. In patients with a history of haemorrhagic stroke, the underlying cause is the primary risk predictor. In this context, the two speakers challenge the strict use of microbleed counts: to contraindicate IVT, physicians should rather look for the presence of potential Cerebral Amyloid Angiopathy (CAA)-related symptoms than simply consider exceeding a threshold of ten microbleeds.

For patients with unknown stroke onset times, the consensus is that advanced imaging such as CT perfusion or MRI is mandatory to identify salvageable tissue, as treating without such data beyond standard windows is risky.

In other special scenarios, IVT is considered reasonably safe during pregnancy for disabling deficits but requires caution in cases of recent large myocardial infarctions or long-bone fractures due to systemic bleeding risks. Finally, the presenters stress the importance of individualized care and involving patients and families in decision-making for borderline cases, noting that legal requirements for informed consent vary significantly across different countries.