The joint ESO-ESMINT session focused on addressing the current challenges in the field of stroke endovascular treatment and brought forward valuable insights.

Professor Jens Fiehler highlighted the hurdles and limitations in the process of approving new devices for neurointerventions. Since the first documented thrombectomy in 2008, advancements in skill have enabled expanded indications for treatment and improved patient outcomes. When selecting the optimal technical approach, multiple variables must be considered (e.g., anatomical factors, use of a balloon guide catheter, or aspiration pump). Additionally, procedural success is influenced by the treating physician’s experience and preferred technique. As a result, the integration of new devices or techniques into routine practice is inherently complex. Theoretically, demonstrating a 6% improvement in treatment outcomes with a new device would require enrolling approximately 1,500–1,700 participants, which is not feasible. In-silico modeling may offer a viable alternative to evaluate new devices and establish their safety and efficacy.

Dr. Helena I. De Sousa Guerreiro discussed various complications associated with rescue stenting. Mechanical thrombectomy fails in about 20% of cases, with underlying intracranial atherosclerotic disease (ICAD) observed in 5–10% of these. Among ICAD cases, re-occlusion rates are high—occurring in 36% of cases intraprocedurally and approximately 50% postprocedurally. Recent publications have demonstrated the benefits of rescue stenting, mainly due to improved recanalization rates. However, rescue stenting carries risks such as symptomatic intracranial hemorrhage (up to 17%, often due to vessel perforation), re-occlusion, in-stent restenosis, stent deployment failure, distal embolization, and vessel dissection. Recommended strategies to mitigate these complications include early implementation of rescue stenting, appropriate antiplatelet management, careful patient selection, technical optimization, and comprehensive post-treatment care—including blood pressure control and drug resistance testing.

Dr. Julien Allard focused his presentation on optimizing antiplatelet therapy. Through a comprehensive review of available antiplatelet agents and their mechanisms of action, he provided guidance on selecting the most appropriate medication tailored to individual patient needs. He also introduced their institution’s local protocol for antiplatelet management. Key considerations in choosing the right medication include the route of administration, pharmacodynamics, hemorrhagic risk assessment, and platelet function restoration.

Dr. Anne Christine Januel addressed the current challenges in improving access to stroke care across Europe. Ideally, patients would receive treatment directly at a comprehensive stroke center by an experienced team. In practice, however, no single model fits all contexts. Consequently, various approaches have been implemented to enhance timely access to care, including “drip and ship,” “drive/fly a doctor,” “direct to angio,” and the use of AI tools to accelerate in-hospital workflows. Dr. Januel presented examples of infrastructure improvements following the implementation of these models. Scientific societies play a critical role in supporting such efforts by providing regulatory guidance and education. In this regard, ongoing ESMINT initiatives include skills courses, internships at high-volume centers, e-fellowships, and remote proctorships.

Continuing the theme, Dr. Violoza Inoa concluded the session with an overview of the success and feedback from fellowship programs and educational courses for physicians from low- and middle-income countries. Participants reported a significant positive impact on their clinical practice, including increased confidence in thrombectomy techniques, improved patient selection and treatment indication, and a subsequent rise in the number of procedures performed independently. Dr. Inoa emphasized the importance of sustained efforts to enhance stroke care infrastructure through tailored educational programs and ongoing local support.

Prof. Joanna Wardlaw and Dr. Markus Kneihsl chaired this session regarding an often overlooked topic in cerebrovascular disease. Overall, the session has been rich of delivered contents with a lot of interaction and questions from the floor.

Silja Raty, Finland

“Patients with Covert brain infarcts-which diagnostic workup is needed?”

The first talk tackled the diagnostic workup in patients with covert brain infarcts (CBI), a frequent occurrence in clinical practice. A wide investigation in a basically asymptomatic patient may be time and resource consuming, on the other hand, there is a non-trascurable risk of subsequent stroke in such population. Currently, two guidelines (American Heart Association and European Stroke Association) have been published and provide hints on how to manage the diagnostic workup. First of all, is important to know whether infarction was really symptomatic (few or underrated symptoms from the patient), so the clinical history is fundamental to move the next steps. Besides, implementation of primary prevention strategies is mandatory, particularly hypertension, glucose and lipid control. This is particularly relevant since most CBI are caused by small vessel disease. Moreover, CBI have been associated with intracranial artery stenosis, so it may be worth to investigate the vascular status with extra and intracranial vessel study. Radiologist and clinicians should also strive to identify the phenotype of CBI (embolic vs non embolic), since this may predict the subsequent risk of hemispheric stroke. This is why the vascular surgery guideline suggest to consider endarterectomy in patients with carotid stenosis and CBI ipsilateral to the stenosis. Finally, CBI are associated also with AF, thus cardiac investigations such as heart rate monitoring and echocardiography are recommended. Regarding PFO, there are data that show no clear association with CBI. Ongoing studies may provide valuable insights on this topic, so far, further investigations should performed on individual basis.

Aristeidis Katsanos, Canada

“Does the pattern of covert brain infarcts indicate etiology and influence prognosis?”

Suabanalysis of randomized controlled studies or observational studies may provide meaningful data to answer to this question. Data from the Northern Manhattan Study (NOMAS) show that 18% of people enrolled had at least one CBI. Intracranial artery stenosis may be causative, so it should be promptly investigated. We also know that phenotype of CBI may provide valuable hints on their etiology: AF caused CBI are different from those caused by atherosclerosis, as showed by dedicated studies (Swiss-AF, COMPASS MIND). Furthermore, small vessel disease features such as lacunar infarcts seem ot have a different distribution between AF and atherosclerosis: while AF is associated either with absence of lacunar infarcts or presence of multiple lacunes; atherosclerosis is usually associated with presence of a single lacunar infarct. In the COMPASS study, incident CBIs were mostly cortical, and around a third located in the cerebellum. PACIFIC-Stroke also performed a suba-analysis regarding incident CBI and found no clear relationship between the location of CBI when etiology of stroke was considered. However, cortical CBI were more prevalent in AF, while chronic cavitated lesions more prevalent in atherosclerosis and small vessel disease. Finally, in patients with ischemic stroke, the burden of pre-existing CBI is associated with increased stroke severity, mainly in the basal ganglia. In conclusion, some phenotypical imaging characteristics of CBI may guide etiological investigations.

Maria Hernandez Perez, Spain

“Silent” periinterventional brain infarcts: do they matter?

Silent periinterventional infarcts may be a complication of every surgical intervention, this is relevant given the high number of patients who undergo surgery every year. Actually, there is an overall risk of increase of around 33%. MRI with diffusion sequences is the reference standard for diagnosis, since it can detect recent infarct and provide a temporal link with surgery. Such infarcts are usually very small (around 0.2 ml of volume) and do have clinical consequences such as cognitive impairment and postoperative delirium. From observational data there is evidence that higher small vessel disease burden associated with higher risk of having a periinterventional brain infarct. Moving to carotid surgery, it is well established that in carotid surgery or stenting there is a three-fold increased risk increased risk of perioperative infarct. In patients with aneurysm coiling CBIs are frequent (67%), and the risk of severe stroke, disability, and cognitive impairment is related to the number of perioperative infarcts, therefore careful selection of patients eligible for treatment is needed. There is a lack of evidence regarding the long-term impact of periinterventional brain infarcts. In conclusion, it is likely that procedural, operator and patient factor may contribute to periinterventional infarcts, which are frequent and virtually present in every type of surgery. More studies are needed to understand mechanisms and consequences of this type of brain infarct.

Markus Kneihsl, Austria

Atrial fibrillation and covert brain infarcts

CBI is the most frequent incidental finding in clinical practice for a stroke physician. CBI in people with stroke/TIA and CBI in people without TIA/stroke should be likely managed in a different way. Subanalysis of ELAN trial provided valuable information regarding the first group. For example, people with covert brain infarcts may benefit from early anticoagulation since it seems the risk of recurrence is increased with the late anticoagulation. Additionally, the phenotype of CBI has also an impact, since non-lacunar CBIs seem to have a higher risk of stroke recurrence and may benefit of early anticoagulation, while such risk does not seem higher CBIs of non-embolic origin. Cerebellar lesions: some insights come from studies of microbleeds that showed a different pattern distribution (cortical vs deep) in patients with microbleeds, suggesting a different type of origin: deep cerebellar infarcts may recognize a small vessel disease origin, while cortical cerebellar infarct may be associated with AF, and the latter may benefit from anticoagulation. Further analysis may improve our understanding of the link between AF and covert brain infarcts.

Thomas Meinel-Switzerland

Setting up a dedicated referral pathway and clinic for covert cerebrovascular disease

The last talk was about a dedicated outpatient clinic for management of CBI. The risk of stroke at one year in patients with CBI is 2.4%, and from observational studies we know that around 8% of all MRIs show a CBI as incidental finding. Not all patients should be referred to a dedicated CBI clinic, for example patients with dementia or terminal cancer, or those with previous stroke/TIA should not. The phenotype of the potential ischemic lesion needs to be accurately differentiated from other origins of lesion, and suspect lesions should be graded according to the probability to be ischemic. For example, cavitatory lesions have high potential to be ischemic, whereas unspecific lesions or dilated perivascular spaces are not. In parallel, Dr. Meinel suggested that neuroradiologist should closely collaborate with stroke physicians to ensure harmonization of protocols and pathways of care. Some examples from the outpatient clinic from Dr. Meinel’s Hospital are: understanding the clinical implications of CBI with talks and seminars, urgent referral pathways for acute ischemic lesions, a list in PACS to refer suspect CBI accidentally found in patients, and the use of smartphrases in the reports to contact the CBI outpatients clinic in case of suspect lesions. Also, double check if patient has a previous brain imaging stored to narrow down the timepoint at which CBI had occurred. In case of a referral, the use of a simple structured and reproducible

questionnaire may help, and asking about previous surgical procedures, particularly cardioaortic, is mandatory. In cases of a real CBI, given that there have been no symptoms and, patient preferences are a very important point to consider: someone may just want to ignore o prefer a referral to GP rather than start an extensive diagnostic work-up and possibly start a therapy. Neurological exam should look for covert deficits and gait abnormalities, diagnostic work-up should encompass labs, cardiac and neck/head vessels exams, blood pressure monitoring and possibly targeted therapy. Mood and cognitive problems are often neglected in such patients, so they should not be overlooked. ESO guidelines on diagnosis and management covert small vessel disease are available, but they do not cover cortical CBI. For the future, a network of dedicated CBI clinics is the key to generate better evidence for this condition.

After a wonderful three days of first-rate science, gathering of the stroke community, and an energetic ESOC party at the Finlandia hall last evening, we rounded out our scientific program with an interesting plenary session this morning. After the presentation of awards to the emerging leaders programme and the prize winners, we kicked off with some evidence for pre-hospital stroke management.

Performed in Australia, the MSU-TELEMED trial demonstrated the safety and efficacy of telemedicine in mobile stroke units. Based on these results the team plan to deploy two mobile stroke units with one neurologist who will be aboard in one vehicle and communicating with the other via telemedicine. This will both enhance the productivity of the units and be cost-saving.

Next, the MAP-STROKE study. This is a pre-hospital triage tool developed using a Bayesian predictive modelling algorithm which can advise the EMS whether they should bypass the local centre and instead transfer the patient to a comprehensive stroke centre. The researchers sampled data from Get With The Guidelines in the USA and simulated an impact study estimating the use of the MAP STROKE tool in these data. The results suggested that use of MAP-STROKE would be associated with a 2.1% increase in the likelihood of achieving a mRS of 0-2 when compared to transporting the patient to the nearest hospital. The improvement was driven by a reduced time to reperfusion in those eligible for thrombectomy. However, this approach also caused a delay of on average 14 minutes in time to thrombolysis in those eligible for tPA. A geographical subgroup analysis suggested that the benefit was more marked in rural areas. As these results are derived from simulated data and may be optimistic, the team are now  planning to integrate MAP STROKE into an online application and conduct an RCT testing its use. We will watch this space.

Moving to secondary prevention and anti-inflammatory therapies, the results of two studies featuring colchicine, a repurposed gout anti-inflammatory medication, were presented. Firstly, in a secondary analysis of the CONVINCE trial, participants with non-severe non-cardioembolic stroke, randomised to 0.5mg colchicine daily or usual care, had CRP levels measured in blood at baseline, 28 days and annually at their local hospital. This pre-specified secondary analysis stratified patients by their achieved CRP level on treatment: ‘low’ <2mg/L or ‘high’ ≥2mg/L and compared the rates of MACE events across these categories. Those with low CRP levels < 2mg/L on colchicine had a significantly lower rate of MACE compared to those with CRP >2mg/l and the control arm, suggesting that lower is better for CRP in secondary prevention.

Then, the results of the Co-VASC-ICH  feasibility phase-2 trial performed in Canada were presented. This study aimed to assess if a trial investigating colchicine to reduce MACE in patients intracranial haemorrhage (ICH) was feasible. The investigators achieved their aim, recruiting 100 participants presenting with ICH within 24 hours. They now plan to continue with phase-3 trial CoVASC-ICH-2. Colchicine appeared to be well tolerated in this study, an extended release preparation of colchicine was used, and was sometimes administered via NG tube. There were no differences in MACE, death or dependency between treatment arms, but this was a feasibility study and not powered to estimate differences between these outcomes. We wish our colleagues well with the phase 3 trial and look forward to the results of CoVASC-ICH-2 with interest.

The STATICH trial is the most recent trial to investigate an important question, to which we still do not have a definitive answer. Should we restart antithrombotic treatment in patients after intracranial haemorrhage?  Participants in this study were stratified into two trials- one for those with an indication for antiplatelet and another for those with indication for anticoagulation. Recruitment to this trial was slow and there were a low number of events. Unfortunately these results are underpowered. The primary outcome was recurrent spontaneous ICH within 2 years. A similar number of events occurred irrespective of treatment assigned.  The investigators plan to collaborate on an individual participant data meta-analyses with similar trials and we hope these analyses provide some more information on this important unanswered question.

Next the results of the TENCRAOS trial. Patients presenting with central retinal artery occlusion were randomised to receive tenecteplase 0.25mg (within 4.5 hours of symptom onset) or ASA 300mg. The primary outcome was measured using logMAR at 30 days (and was approximately equivalent to being able to read an extra 3 lines on the Snellen chart). Participants were on average 71 years old, and the trial workflow relied on an ophthalmologist making the diagnosis of CRAO, then referring the patient to the stroke team for randomisation and treatment. Impressively, most of the patients in this trial were recruited and treated within 3 hours, highlighting the coordination and strong team work by recruiting sites. However, the results showed no difference in the primary outcome and importantly, there were numerically more adverse events and one fatal ICH in the TNK group.

Next, we move to the theme of neuroprotection. We listened to the results of an interesting study examining the effect of edaravone, a neuroprotectant that is already used in stroke care in China and Japan, which is thought to reduce oxidative stress. Investigators randomized 614 patients to treatment with edaravone for 28 days or placebo. More patients treated with edaravone (65%) achieved the primary outcome (a favourable mRS of 0-2) compared to control (47%), which was a significant difference. Paradoxically, the NIHSS score was similar in both treatment groups. There were also numerically more deaths and adverse events in the edaravone treatment arm. We look forward with interest to see if these results can be replicated, as effective neuroprotection strategies would be a powerful addition to our battery of stroke treatments.

We lack robust randomised trial data to guide us on the best approach to treatment of patients with tandem occlusions in the anterior circulation. The CERES-TANDEM Study is an important observational study which collated global real-world data and reported the functional outcomes of patients who received emergent stenting at time of EVT, compared to no stenting.  The results demonstrated that there was a higher odds of an excellent functional outcome (defined as mRS 0-1) with emergent stenting and this was not associated with an increased risk of haemorrhage.

After that, we moved to blood pressure control during EVT. Patients in this trial were randomized between two different approaches to control BP during EVT: either standard care (no intervention if SBP remained between 140-180 during EVT) compared with an individualized targeted titration of BP every 2.5 minutes to achieve a MAP of ±10% of the patients baseline BP. This intervention required the support of anaesthesiology,  but most EVT procedures were done under conscious sedation. The primary outcome was a favourable mRS 0-2 at 90 days. Of 433 randomized patients, the mean age was 69, baseline NIHSS 15, and ASPECTS 8. There was no difference in the mRS at 90 days with intensive BP management during EVT.

Finally, pivoting back to neuroprotection, the results of the IRIS trial were presented. This study sought to investigate the efficacy of IL-6 inhibitor tocilizumab as a neuroprotectant when given at the same time as EVT. Patients were recruited from 6 comprehensive stroke centres in China, were on average 69 years old, had a baseline NIHSS of 16 and ASPECTS of 8-9. The baseline infarct core volume measured by DWI was 15ml. The primary outcome was ischaemic core growth in millilitres measured from baseline to 72 hours. The results showed that the change in infarct volume was 8.8ml in the treatment group compared with 27ml in the placebo group, which was a statistically significant difference. More studies with a clinical endpoint are needed to investigate this promising strategy further.

And that concludes the science presented at this year’s ESOC. Now, we look towards Maastricht 2026. The organising committee aim to make 2026 the most sustainable ESO conference yet, and to that end, we will all be given the use of a bicycle throughout our time there. This was met with enthusiastic applause by the delegates! So, Moi Moi to Helsinki, thank you to ESO and the organising committees for an energising and collaborative few days, and see you all next year!

The second day of the ESOC 2025 brought scientific inquiry to life, thanks to the remarkable contributions of our presenters, that showcased an exceptional standard of scientific work reflecting depth, innovation, and clinical relevance that define the forefront of stroke research. All the posters showcased excellent work, making the selection truly challenging but here are some of the most interesting ones.

In the acute ischemic stroke management section, Thomas Meinel and his collaborators presented the data for the DO-IT trial regarding Intravenous Thrombolysis in patients with recent intake of direct oral anticoagulants. The authors observed that IVT in patients with DOAC treatment didn’t significantly increase the risk of sICH and presented a better functional outcome. At the same time, the authors observed that among IVT patients, higher DOAC plasma levels or recent intake of DOAC medication was not associated with higher bleeding risk. In the same section Lina Palaiodimou et al. made a systematic review and meta-analysis regarding the use of Tenecteplase for acute ischaemic stroke in the extended time window. The authors concluded that evidence from the RCTs included suggest that TNK improves the likelihood of an excellent functional outcome and reduces disability at 3 months in patients treated in extended window, without significant safety concerns. Pinckaers et al. presented data from the Select2 trial regarding the Effect of time form last known well to randomization on EVT outcomes across witnessed, wake-up and unwitnessed strokes. The authors observed that there were no statistically significant heterogeneity in EVT effect estimates between wake-up, witnessed and unwitnessed strokes.

In the intracerebral hemorrhage section Kaindl et al. presented data about frequency and outcome and outcome effects of antagonizing anticoagulant-related intracerebral hemorrhage. From the total of 1469 ICH associated with oral anticoagulants, more than 500 patients received antagonization therapies, The authors concluded that the use of antagonization did not significantly reduce odds of early neurological deterioration, but it was associated with reduced mortality and better functional outcomes at 90 days

In the Pre-hospital service organisation, QoL, Recovery, Rehabilitation & Outcome section, Carmen Montalvo Olmedo presented a poster regarding socioeconomic deprivation among patients with stroke treated with EVT in Catalonia, in which they observed that socioeconomic deprivation is associated with worse functional outcome and the differences are driven mainly by within-center disparities between provincial region and center disparities in the metropolitan region. In the same section Karisik et al. presented data regarding the impact of dysphagia on early psychosocial consequences after acute ischemic stroke and observed that post-stroke dysphagia has severe psychosocial consequences including increased dependency in daily living and a higher risk of being unable to return to work.

In the Digital transformation, AI & Robotics, Diagnosis and Imaging, Biomarkers & Pathophysiology, Etiology section, had some interesting posters, full of promising studies. Alexander Nelde and his colleagues presented a poster about AI for prediction of Atrial Fibrilation in the Stroke Unit and observed that alteration of heart rate variability are the strongest predictors of AF in patients with acute ischemic stroke. At the same time, they observed that the model used may enable AF risk stratification immediately after admission to the stroke unit and support the decision on prolonged cardiac monitoring. Felix Nagele and his colleagues presented data regarding linking vascular risk factors with the topology of enlarged perivascular spaces in the Hamburg city health study and observed that among individuals aged between 45-74 years a multivariate low-dimensional association between vascular risk factors and perivascular space enlargement burden, predominantly in the anterior circulation was found  and that this relationship was mediated by white matter microstructural injury.

The Risk Factors, Primary & Secondary prevention section was full of very interesting studies. A poster that caught my attention was presented by Ramon Luengo-Fernandez and his colleagues and touched a important topic regarding the Economic Burden of Stroke in 37 European countries and showed that stroke costs European countries more than their combined foreign aid expenditure (96 bn euro vs 71 bn euro), 51 bn euros of this total cost being spent on health and health related social care. Gabriele Prandin et al. evaluated the impact of inflammation biomarkers in mechanical thrombectomy outcomes and observed that the 24-hours-neutrophil-to-lymphocyte ratio (NLR)is a powerful predictor of stroke outcomes post MT, with a threshold of 4.30 strongly associated with poor prognosis. Xiao et al. evaluated the possibility that Statin prevents Radiation-Induced Carotid Artery Stenosis after Radiotherpy for head and neck malignant tumors and observed that statin treatment was associated with lower risk of RICS in these patients, regardless of baseline LDL-C levels.

In the Late Abstract section, Menglu Ouyang and his colleagues from the OPTIMIST trial published the data regarding Acceptability and fesability of low-intensity post-thrombolysis monitoring after acute ischemic stroke and observed that low-intensity monitoring was found acceptable, feasible and health professionals recognised the advantages of intervention such as reduced disturbances to the patients, fewer time constrains, free-up ICU beds and reduced nurse workload. The authors observed that the time saved was redirected toward patient education and other nursing duties. Koji Tanaka and his colleagues from the ANNEXA-I trial evaluate the usage of Non-Contrast Computed Tomography (NCCT) markers of hematoma expansion and response to Andexanet in FXa inhibitor- associated intracranial hemorrhage and observed that NCCT markers of hematoma expansion (HE) were associated with HE in patients with FXa associated ICH and the efficacy of Andexanet was largely consistent regardless of the NCCT markers. The authors observed that the Blend sign may help identifying patients that obtain greater benefit from Andexanet.

This year’s poster walk featured a diverse range of topics and impressive contributions and collaborations. A showcase of high-quality research and fresh perspectives in stroke care.

More Conference Highlights

The evening session on day 2 of ESOC 2025 here in Helsinki, Finland on “Intravenous Thrombolysis in Acute Ischemic Stroke: Expanding Indications and Evidence” was chaired by Melinda Roaldsen from Tromsø, Norway and Bart Van Der Worp (Utrecht, Netherlands).

Gaspard Gerschenfeld (Paris, France) kicked off the session with “TIME TO TREATMENT WITH INTRAVENOUS TENECTEPLASE BEFORE THROMBECTOMY AND FUNCTIONAL OUTCOMES IN ACUTE ISCHEMIC STROKE”. He points out that the benefit of intravenous thrombolysis (IVT) with alteplase plus thrombectomy vs thrombectomy alone has been shown to be time dependent and up to now, there is little data on tenecteplase. The study aimed to determine whether the potential benefit associated with tenecteplase plus thrombectomy vs thrombectomy alone decreased with treatment time. In a retrospective pooled analysis of patients with anterior circulation large vessel occlusion stroke with known symptom onset and no contraindication to IVT treated with either Tenecteplase before thrombectomy (TETRIS registry) or thrombectomy alone (ETIS registry), the study assessed the influence of the expected symptom onset-to-thrombolysis time (OTT) on the association between treatment and better functional outcome (lower mRS scores at 3 months). In a total of 1,890 patients between 2015-2024, median expected OTT was 144 vs. 149 minutes . Overall, tenecteplase before thrombectomy was associated with better 3-month functional outcome (weighted common OR 1.53 ; P < 0.0001). Tenecteplase before thrombectomy remained significantly associated with better 3-month functional outcome up to an expected OTT of 190 minutes.

Overall there was no significant interaction of OTT with treatment effect. He concludes that compared to MT alone, tenecteplase before MT in routine clinical care is associated with better 3-month functional outcomes without significant interaction between the expected OTT and treatment effect. Next, Aravind Ganesh (Calgary, Canada) presented “OUTCOMES AFTER MINOR ISCHEMIC STROKE IN ELDERLY PATIENTS TREATED WITH INTRAVENOUS THROMBOLYSIS VERSUS STANDARD OF CARE IN THE TEMPO-2 TRIAL”. This post-hoc analysis of the TEMPO-2 trial analyzed 884 patients regarding outcomes and adverse events in patients assigned to tenecteplase (TNK) vs. non-thrombolytic standard of care aged >80 years and ≤80 years. Among the 884 patients in the ITT-analysis, 208 (23.5%) were >80 years old. Patients >80 years fared worse with TNK on the mRS responder analysis (54% with TNK vs 69% control, aRR:0.80). There was no significant difference in patients ≤80 years (77% vs 77%, aRR:1.01). In both age groups, patients assigned to TNK were more likely to achieve NIHSS 0 at 5-days/discharge (aRR ≤80 years: 1.14,1.05-1.24, >80 years: 1.22,1.07-1.40) and recanalisation of arterial occlusions (aRR ≤80: 2.05,1.59-2.64, >80 years: 2.81,2.23-3.53). Serious adverse events (SAEs) were more frequent with TNK among patients >80 years (RR:2.29), but were not accounted by hemorrhagic outcomes (e.g. symptomatic intracranial hemorrhage in one patient). He concludes that elderly patients with minor stroke and occlusion or perfusion lesion assigned to TNK were more likely to achieve recanalisation of occlusions and short-term neurological recovery, as were younger patients. However, patients >80 years assigned to TNK had worse 90-day outcomes with more frequent SAEs, but this was not driven by sICH and might perhaps be driven by stroke progression or stroke recurrence. All in all, these results argue against the use of TNK in mild strokes in elderly patients.

Thomas Payne from Parkville, Australia presented “MATERNAL AND FOETAL SAFETY OUTCOMES OF THROMBOLYTICS FOR ISCHAEMIC STROKE IN PREGNANCY: A SYSTEMATIC REVIEW AND AGGREGATED CASE SERIES”. He emphasises that the safety of intravenous thrombolytics (IVT) in pregnancy is largely unknown and guidelines recommend a benefit-risk evaluation. In a systematic review, 121 studies were included on thrombolytics for stroke and non-stroke indications during pregnancy with the aim to provide maternal and fetal safety outcomes. A total of 214 patients were included who were treated with thrombolytics during pregnancy, of whom 83 had an ischemic stroke. The rate of miscarriage/stillbirth in women receiving thrombolysis was higher than in the general population. All in all, 31 cases of fetal death were reported in women treated with thrombolysis. After thorough analysis, there were six cases (19%) in which fetal death was deemed likely to be causally related to thrombolytics. He concludes that miscarriage/stillbirth rates are higher in the thrombolysis population compared to the non-stroke population and further data are urgently needed to draw conclusions.

Cristina Del Valle Vargas (Badalona, Spain) presented “USE OF INTRAVENOUS THROMBOLYSIS IN EXTENDED TIME WINDOW, WITH OR WITHOUT THROMBECTOMY, FOR ACUTE ISCHEMIC STROKE: A MULTICENTER STUDY IN CATALONIA”. She points out that IVT in the extended time window guided by advanced imaging relies on low-moderate evidence. Data on IVT combined with mechanical thrombectomy (MT) in this context remain scarce. This study aimed to analyse the use of IVT in the extended time window and assessed its clinical benefit compared to the conventional window (<4.5h) using real-world data. In a prospective multicenter registry of stroke patients in Catalonia (CICAT), 7,143 patients were analysed for good functional outcome. A total of 539 patients received IVT in the extended time window (414 IVT, 125 IVT+MT). For IVT alone, good outcome (extended 41.6% vs. conventional 46.4%, p=0.064), mortality (both 12.9%), and sICH (3.4% vs. 2.7%, p=0.430) were comparable. For IVT+MT, good outcome (extended 40.7% vs. conventional 44.8%, p=0.352) and sICH (6.4% vs. 4.4%, p=0.287) were similar, but mortality was higher in the extended time window (25.0% vs. 16.6%, p=0.02). Age, diabetes, baseline mRS, NIHSS and ASPECTS, but not time-window group, were independently associated with poor outcome. She concludes that IVT in the extended time window without MT is a widely accepted policy in Catalunya, accounting for 7.5% of all IVT-patients. The data seem reassuring and are mostly in line with pivotal studies. More evidence is needed regarding the safety of IVT in the extended time window when MT is planned.

“Intravenous thrombolysis prior to endovascular treatment in posterior circulation occlusions; a patient pooled analysis of four randomised controlled trials” was presented by Robrecht Knapen (Maastricht, Netherlands) on behalf of the VERITAS collaboration. The benefit of IVT before endovascular treatment (EVT) in the posterior circulation remains uncertain. This study aimed to assess the impact of IVT before EVT on treatment outcomes in patients with vertebrobasilar occlusion and included data from four RCTs within the

VERITAS collaboration (BEST, BASICS, ATTENTION, and BAOCHE trial). Out of 988 patients, 556 patients were allocated for EVT and analysed. No significant differences were observed between patients treated with or without IVT prior to EVT in terms of mRS 0-3 at 3 months (47% vs 44%), mRS 0-2 (39% vs 32%), mortality (33% vs 38%), and sICH rates (6.3% vs 4.9%). Also, subgroup analyses did not reveal any differences. He concludes that the findings suggest that bridging IVT over EVT alone was safe but not associated with improved outcomes and might imply a shared regime with a careful patient selection e.g. opting for IVT in transferred patients with a presumed treatment delay or patients with distinctive characteristics favoring bridging-IVT.

Lina Palaiodimou (Athens, Greece) presented “INTRAVENOUS THROMBOLYSIS IN PATIENTS WITH ACUTE ISCHAEMIC STROKE TAKING TICAGRELOR AS MONOTHERAPY OR COMBINATION WITH OTHER ANTIPLATELET DRUG.”

The safety of ticagrelor pretreatment in acute ischemic stroke (AIS) patients receiving intravenous thrombolysis (IVT) is uncertain and largely based on case reports. This study evaluated safety and efficacy outcomes of IVT in AIS patients pretreated with ticagrelor and used data from the SITS-International Stroke Thrombolysis Registry. Patients on single (SAPT) or dual (DAPT) antiplatelet therapy with ticagrelor were compared to patients with aspirin SAPT or other DAPT.

A total of 45 ticagrelor (8 SAPT, 37 DAPT with aspirin) and 42,058 other antiplatelet pretreated AIS patients who received IVT were included. Also, 37 ticagrelor-DAPT patients were matched with 137 patients receiving any other-DAPT. Patients with ticagrelor-DAPT had a trend for higher proportions of sICH (16.2% vs. 5.8%, p=0.051) and parenchymal hemorrhage (27.0% vs 13.1%, p=0.050) but similar 3-month excellent functional outcome (40.5% vs. 48.9, p=0.367) and death (21.6% vs. 17.5%, p=0.568) compared to other-DAPT. She concludes that the observational data show a numerically higher risk of sICH and parenchymal hemorrhage after IVT in the ticagrelor-DAPT patients, but without a detrimental effect on 3-month clinical outcomes compared to any other-DAPT. Additional larger prospective studies are warranted to determine the safety of IVT in AIS patients pretreated with ticagrelor, especially using tenecteplase because the rate of its use compared to alteplase was low in this study.

Elise K. Kristensen (Tromsø, Norway) presented “FUNCTIONAL OUTCOMES OF THROMBOLYSIS VERSUS NO THROMBOLYSIS IN PATIENTS WITH MILD ISCHEMIC STROKE. A COMPARATIVE EFFECTIVENESS STUDY”. This study evaluated the effectiveness and safety of intravenous thrombolysis (IVT) in mild acute ischemic stroke (NIHSS score ≤5). A total of 1,736 IVT-treated patients were matched with 1,736 controls not treated with IVT. At 90 days follow-up, 68.4% of IVT-treated patients and 61.2% of controls had excellent functional outcome (mRS 0-1; OR 1.39, 95% CI 1.20-1.60, p<0.001). IVT was associated with a higher probability of achieving mRS scores 0-2 (OR 1.57, 95% CI 1.29-1.91, p<0.001) and overall lower mRS scores (OR 1.41, 95% CI 1.25-1.59, p<0.001). No significant differences in mortality were observed. In the IVT group, sICH occurred in 3.7% within 24 hours after treatment. She concludes that IVT was associated with favorable functional outcomes at 90 days in patients with mild acute ischemic stroke.

Nishita Singh (Winnipeg, Canada) completed the session with “IMPACT AND PREDICTORS OF SERIOUS ADVERSE EVENTS IN ALTEPLASE COMPARED TO TENECTEPLASE TRIAL: A SECONDARY ANALYSIS”. In this secondary analysis of the AcT trial, SAEs were recorded within 24 hours of treatment and classified by organ system using the Medical Dictionary for Regulatory Activities (MedDRA). The study focused on predictors of SAEs and their impact on mRS at 90 days and quality of life. Of all 1,577 enrolled patients, 219 (13.9%) had SAEs in the study. Patients with SAEs had higher NIHSS (median 11 vs. 9, p<0.01) and higher thrombectomy rates (29.2% vs. 50.2%, p<0.01) than those without SAEs. SAEs had a reasonable effect on mRS-shift with an aOR of 4.43 (95%CI 3.05-6.43) for any SAE. Nervous system disorders were the most common SAE type (58%), including stroke worsening (26.7%) and intracranial hemorrhage (25%). No significant differences were observed in SAE distribution by organ class or SAE term between tenecteplase and alteplase. Baseline NIHSS, large vessel occlusion, ASPECTS score and cerebral atrophy were significant predictors of SAE occurrence. She concludes that there were no differences in SAE incidence and type between tenecteplase and alteplase, which is very reassuring for clinical practice. SAEs were associated with worse functional outcomes regardless of intravenous thrombolytic type.

This evening session of day 2 gave a real breath of fresh air on the hottest research topics on intravenous thrombolysis in acute ischemic stroke. All presenters and the audience will now prepare for the final session of day 2, the vibrant ESOC party held at Finlandia Hall in Helsinki, Finland.

At this year’s Presidential Symposium Award & Large Clinical Studies session, the presentations demonstrated the evolving landscape of stroke research. With studies ranging from artificial intelligence in clinical decision-making to mobile health interventions and post-stroke dementia risk, the session showed ambition, innovation, and practical insight. Here’s what stood out.

One of the most talked-about studies was the GOLDEN BRIDGE II trial, which explored the use of an artificial intelligence-based clinical decision support system (AI-CDSS) to improve outcomes in patients with acute ischaemic stroke. The AI tool integrated data from hospital records, imaging, and clinician input to help guide treatment decisions around stroke etiology and secondary prevention. Over 21,000 patients from 77 hospitals were included, making this a substantial trial. The findings were promising: patients managed with the help of AI-CDSS had significantly better outcomes, with a 30% relative reduction in new vascular events after one year. However, because the randomisation was done at the hospital level rather than the patient level, variations in care between hospitals could have influenced the results. Nonetheless, the trial represents a strong case for the future role of AI in stroke care.

Another trial investigated a rather different approach to stroke prevention — a non-invasive treatment known as enhanced external counterpulsation (EECP). This method was tested in patients with severe intracranial arterial stenosis, a group at high risk for recurrent strokes. Patients received daily one-hour sessions of EECP, and researchers monitored changes in cerebral vasodilatory reserve (CVR) over six months using imaging techniques. The results suggested that EECP improved CVR and reduced the risk of further strokes. Though still considered early-stage evidence, it’s a compelling proof of concept that invites further exploration in larger trials.

A separate study based in Ghana tackled the challenge of blood pressure control in stroke survivors. The trial introduced a nurse-led, mobile health intervention that included home blood pressure monitoring, regular educational calls, and medication reminders. Over a 12-month period, patients receiving the intervention were significantly more likely to achieve blood pressure targets compared to those receiving usual care. This is an encouraging example of how relatively simple, scalable interventions — especially when delivered through mobile technology — can make a meaningful difference.

The long-term consequences of stroke were the focus of a five-year prospective cohort study examining the risk factors for post-stroke dementia. Researchers followed over 700 patients, conducting baseline MRI scans and cognitive assessments. They found that just under 9% developed dementia over the follow-up period. Those who did were more likely to have metabolic syndrome, low HDL cholesterol, small vessel disease, and atrial fibrillation. Interestingly, the risk of dementia appeared to increase over time rather than immediately after stroke. Female sex and receiving reperfusion therapy were associated with a lower risk.

Falls are a major concern for stroke survivors living in the community, and the FAST trial was the first to demonstrate that a tailored, home-based intervention could significantly reduce fall rates. The programme combined home safety adjustments, exercise integrated into daily routines, and support for community mobility. Participants in the intervention group had a one-third reduction in falls compared to those receiving usual care. The findings point to the value of personalised, practical support in stroke recovery — a relatively low-tech but high-impact approach that could be widely adopted.

Finally, the ESTREL trial addressed whether dopamine could enhance motor recovery after stroke. Patients were given either levodopa/carbidopa or a placebo over a five-week period, with motor function assessed using standardised tools. Despite the theoretical basis for dopamine’s role in neuroplasticity, the trial found no benefit. This negative result is valuable in its own right, helping to refine therapeutic focus and guide future research.

Altogether, these studies paint a rich picture of current directions in stroke research. From high-tech innovations to community-based interventions, the common thread is a growing emphasis on personalisation, prevention, and evidence-based care.