In 2024-2026, I had the honour of being selected as one of three participants of the first ESO Emerging Leader Programme cohort. This opportunity has provided me with a strong platform for both professional growth and personal development, enabling me to deepen my understanding of stroke care challenges across Europe, strengthen my leadership skills, and learn directly from leading European stroke physicians. Throughout the programme, I have expanded my academic and professional activities, developed valuable networks for scientific collaboration, and applied these experiences to support ongoing improvements in stroke care in Lithuania.

A central benefit of the programme has been the mentorship and collaborative opportunities it enabled. Among all things, my mentor Prof. Alastair Webb played an important role in supporting my final research project, helping to secure funding through the Lithuanian Research Council. This funding allowed me to establish a research team at Vilnius University and build on my Emerging Leaders final project – strengthening stroke care quality monitoring at Vilnius University Hospital and contributing to the development and evaluation of a national Stroke Learning Health System in Lithuania.

Despite substantial advances in stroke care, quality improvement efforts worldwide still rely heavily on manual data collection, retrospective audits, and infrequent feedback cycles. These approaches are resource-intensive, slow to respond to emerging problems, and prone to reporting bias. At the same time, widespread adoption of electronic health records (EHRs) and national digital health infrastructures creates new opportunities to embed continuous learning directly into routine care. Lithuania, a small Baltic country with 11 accredited stroke centres, has systematically monitored stroke care performance since 2014. In addition, at Vilnius University Hospital, we developed fully automated data extraction using in-house EHRs, which enabled dashboards for near-real-time quality monitoring, providing a strong foundation for developing a Learning Health System (LHS) for stroke care. In 2024, the Lithuanian government decide to invest in a data exchange and monitoring platform for medical clusters, creating an opportunity to scale a similar model to the national level.

Therefore, my Emerging Leader Programme final research project aimed to describe, design, scale, and implement a national LHS for stroke care in Lithuania that transforms routinely collected clinical data into continuous measurement-learning-improvement cycles across the entire stroke care pathway. This was a part of a broader project initiated by the Lithuanian government, in which experts from most major Lithuanian stroke centres and other stakeholders have been involved, building on the available national digital infrastructure.

Lithuania’s centralised Digital Health Platform integrates national referrals, discharge summaries, e-prescriptions, mortality data, selected laboratory results, and imaging data. In addition, data from other health-related and administrative registries are available for secondary use through the National Data Lake, governed by the State Data Agency. With the engagement of relevant stakeholders, we attempted to identify key performance indicators (KPIs) for the Lithuanian Stroke Database and define the core variables that must be captured from participating hospitals’ EHRs. Stroke centres that did not record the required variables needed to adapt their EHR workflows and data structures to ensure systematic capture at the point of care and extraction from primary data sources. Finally, near-real-time dashboards would enable benchmarking across sites, analyses, and timely feedback loops to support clinical governance, transparency, and evidence-informed decision-making.

We have described the Lithuanian digital health architecture and the secondary data reuse pathway in two original scientific articles. Through a multi-stage Delphi process involving clinicians, Emergency Medical Services, a stroke non-governmental organisation, and policymakers, we established a Lithuanian Stroke Database, comprising 53 KPIs covering prehospital care, acute treatment, early rehabilitation, secondary prevention, and long-term outcomes. The process has been described, and the KPIs have been published as an original article. We have updated Vilnius University Hospital EHRs to be suitable for data extraction for variables that have not been included in our previous in-hospital model. As a side quest, structured data was supplemented with a large language model (LLM) to convert unstructured VUH clinical documentation into structured, registry-ready datasets. This approach enabled automated export of a hospital dataset to international registries (e.g., RES-Q) through an API without manual data entry. Preliminary validation suggests performance comparable to, or exceeding, that of trained clinical staff – an abstract detailing it has been presented at ESOC 2026, where it won the Best Poster Award, and an original article is in progress. Stroke-related variables are automatically extracted from hospital EHRs and, together with data from other hospitals, will be used to measure standardised KPIs at a national level. Data contribution from all Lithuanian stroke centres is anticipated by September 2026. The next stage will be to ensure that all the data is of satisfactory quality.

Lithuania’s national LHS for stroke care could potentially demonstrate how a mature digital health ecosystem can transform routine clinical data into continuous learning and improvement. The system is expected to reduce administrative burden, minimise reporting bias, and enable rapid responses to quality gaps. The platform could hopefully support research, registry-based clinical trials, and boost international collaboration.

Participating in the ESO Emerging Leader Programme has been a very important experience in my professional journey. It has helped me grow as a leader, academic, and clinician. The mentorship of Prof. Alastair Webb, the different learning opportunities, and the connections I built with leading European stroke physicians have greatly broadened my perspective. The programme also allowed me to become part of a growing network of future stroke leaders and created opportunities for collaboration in research, international projects, and future funding.

Most of all, the programme has helped me see more clearly how I can apply these experiences to improving stroke care in Lithuania. It has supported my goal of building my own research team at Vilnius University and strengthened my motivation to continue working at the intersection of stroke care and digital health innovation. I am leaving the programme with greater confidence, a stronger professional network, and a clearer sense of how I want to contribute to the field in the years ahead.

Are you an early-career stroke professional looking to develop your leadership skills, expand your international network and drive change in your own country? Applications for the ESO Emerging Leaders Programme are now open until 31 August 2026.
Learn more and apply now.

On 12 July 2026, PeerVoice hosted the CE-Accredited symposium “Assessing the Potential of Factor XIa Inhibition for Secondary Stroke Prevention: Supporting Our Cross-Specialty Colleagues in Improving Patient Outcomes” at the ISTH Congress in Paris. As factor XIa (FXIa) inhibitors are being investigated as a potential strategy for secondary stroke prevention, haematologists have an important role in understanding the emerging evidence and its implications for thrombosis, bleeding, and antithrombotic management. The on-demand version of this session is endorsed by ESO and is now available to watch free of charge. To access the program, please click here.

This educational activity explored whether FXIa inhibition could improve prevention of recurrent stroke without increasing bleeding risk. Jeffrey Weitz, MD, OC, FRCP(C); Charlotte Cordonnier, MD, PhD; and Mike Sharma, MD, MSc, FRCPC, discussed the biological rationale, phase 3 evidence, and potential clinical implications of this emerging approach.

Why Target Factor XIa?

Charlotte Cordonnier highlighted the continuing unmet need in secondary stroke prevention. Recurrent stroke remains a substantial risk despite current treatment, while more intensive antithrombotic approaches can increase haemorrhage. FXIa is therefore of interest because it appears to contribute more to pathological thrombosis than to physiological haemostasis, raising the possibility of preventing thrombosis while preserving normal clotting.

Evidence From OCEANIC-STROKE

Mike Sharma reviewed the phase 3 OCEANIC-STROKE trial, which randomised 12,327 patients with recent non-cardioembolic ischaemic stroke or high-risk transient ischaemic attack (TIA) to the investigational FXIa inhibitor asundexian or placebo alongside antiplatelet therapy. Asundexian significantly reduced recurrent ischaemic stroke, with a hazard ratio of 0.74, and effects were consistent across prespecified patient subgroups. Importantly, this benefit was achieved without a significant increase in bleeding.

International Society on Thrombosis and Hemostasis (ISTH) major bleeding occurred in 1.9% of patients receiving asundexian versus 1.7% receiving placebo. Rates of clinically relevant non-major bleeding, intracranial haemorrhage, and minor bleeding were comparable between treatment groups, supporting the hypothesis that selective FXIa inhibition may reduce thrombosis while preserving haemostasis.

Looking Towards Clinical Practice

Jeffrey Weitz led the panel in a discussion that emphasised that any future integration of FXIa inhibitors into practice will require multidisciplinary collaboration, particularly around antithrombotic therapy, bleeding assessment, and peri-procedural management.

The ongoing LIBREXIA-STROKE trial evaluating milvexian will provide further evidence. For now, FXIa inhibitors remain investigational, but the findings discussed during the activity suggest a potentially important new direction for secondary stroke prevention.

Watch on demand

To date, evidence supporting late-window intravenous thrombolysis (IVT) comes from the 2019 individual patient meta-analysis by Campbell et al.¹, which pooled 414 patients. Patients presenting 4.5-9 hours after stroke onset were selected using perfusion imaging demonstrating salvageable brain tissue. IVT showed a benefit (mRS 0-1 at 90 days; aOR 1.86 [1.15-2.99]), despite an increased risk of symptomatic intra-cerebral haemorrhage. However, most patients were treated before endovascular thrombectomy (EVT) became standard practice. Recent randomised trials tried to help define which patients may- or may not- still benefit from IVT beyond the conventional therapeutic window.

LVO – When thrombectomy is available

The TIMELESS² and TNK-PLUS³ trials evaluated late-window IVT in patients with large vessel occlusion (LVO), including M2 occlusions in TIMELESS. Most patients underwent EVT (100% of patients in TNK-PLUS and 77% in TIMELESS). Neither trial demonstrated a functional benefit of IVT administered within 4.5-24 hours after symptom onset. In TIMELESS, IVT did not improve the distribution of functional outcomes (ordinal mRS shift: aOR 1.13, 95% CI [0.82-1.57]), while in TNK-PLUS, there was no significant increase in the proportion of patients achieving mRS 0-2 at 90 days (aRR 1.01, 95% CI [0.83-1.24]). No significant increase in sICH was observed. In both trials, patients were selected using perfusion imaging, and were required to have evidence of salvageable brain tissue with an ischemic core <70 ml.

LVO – When thrombectomy is not available

In settings where EVT is unavailable, the potential role of late-window IVT has also been investigated. The HOPE⁴ and TRACE-III⁵ trials evaluated IVT in patients with proximal vessel occlusion who could not undergo EVT, treating patients within 4.5-24 hours after symptom onset. In both trials, eligibility required evidence of salvageable brain based on perfusion imaging with an ischemic core <70ml. Both studies demonstrated that late-window IVT improved the likelihood of an excellent functional outcome compared with standard medical therapy (TRACE-III RR 1.37 [1.04-1.81]; HOPE aRR 1.52 [1.14-2.02]). The incidence of sICH was numerically higher in the IVT group in both trials, but the difference was statistically significant only in the HOPE trial (aRR 7.34 [1.54-34.84]).

Non-LVO

In contrast, the OPTION trial⁶, focused on patients with non-LVO who were not candidates for EVT. Selected using perfusion imaging (ischemic core volume <50ml with salvageable tissue), IVT administered 4.5-24 hours showed an improved excellent functional outcome (RR 1.28 [95% CI, 1.04-1.57]), although this benefit came at the cost of an increased risk of symptomatic haemorrhagic transformation (RR 2.85 [1.16-5.54]).

Posterior circulation ischemic stroke

Most randomised trials have focused on anterior circulation ischaemic stroke. The TRACE-5⁷ and EXPECTS⁸ trials evaluated IVT in Chinese patients with a posterior circulation stroke (pc-ASPECTS ≥6-7). Both studies reported improved functional outcomes with late-window IVT without increase in sICH. However, the clinical context differed between trials. In EXPECTS, patients considered eligible for EVT were excluded, although 22% of patients had LVO. In contrast, TRACE-5 included patients with basilar artery occlusion, with EVT planned in 56% of patients.

To conclude, IVT beyond 4.5 hours requires highly selected patients, guided by EVT availability, advanced imaging, and vascular territory. Ongoing studies will further define which patients are most likely to benefit and future guidelines will help refine patient selection and treatment strategies.

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1. Kleinig TJ, Fatar M, et al. Extending thrombolysis to 4·5-9 h and wake-up stroke using perfusion imaging: a systematic review and meta-analysis of individual patient data. Lancet. 2019;394:139–147.
2. Albers GW, Jumaa M, Purdon B, Zaidi SF, Streib C, Shuaib A, Sangha N, Kim M, Froehler MT, Schwartz NE, et al. Tenecteplase for Stroke at 4.5 to 24 Hours with Perfusion-Imaging Selection. N Engl J Med. 2024;390:701–711.
3. Xiong Y, Che F, Wang H, Hao M, Nguyen TN, Fisher M, Jin A, Cao Z, Wang Z, Yao X, et al. Intravenous Tenecteplase Prior to Endovascular Treatment for Ischemic Stroke at 4.5 to 24 Hours: The TNK-PLUS Randomized Clinical Trial. JAMA. 2026;335:1849–1858.
4. Zhou Y, He Y, Campbell BCV, Liebeskind DS, Yuan C, Chen H, Zhang Y, Yi T, Luo Z, Zhang Z, et al. Alteplase for Acute Ischemic Stroke at 4.5 to 24 Hours: The HOPE Randomized Clinical Trial. JAMA. 2025;334:788–797.
5. Xiong Y, Campbell BCV, Schwamm LH, Meng X, Jin A, Parsons MW, Fisher M, Jiang Y, Che F, Wang L, et al. Tenecteplase for Ischemic Stroke at 4.5 to 24 Hours without Thrombectomy. N Engl J Med. 2024;391:203–212.
6. Ma G, Mo R, Zuo Y, Ma Q, Zhao G, Yao X, Liang J, Zhou L, He Y, Long F, et al. Tenecteplase for Acute Non-Large Vessel Occlusion 4.5 to 24 Hours After Ischemic Stroke: The OPTION Randomized Clinical Trial. JAMA. 2026;335:1137–1147.
7. Xiong Y, Alemseged F, Cao Z, Schwamm LH, Zhang S, Parsons MW, Fisher M, Hao Y, Jin A, Yin J, et al. Tenecteplase versus standard medical treatment for basilar artery occlusion within 24 h (TRACE-5): a multicentre, prospective, randomised, open-label, blinded-endpoint, superiority, phase 3 trial. Lancet. 2026;407:763–772.
8. Yan S, Zhou Y, Lansberg MG, Liebeskind DS, Yuan C, Yu H, Chen F, Chen H, Zhang B, Mao L, et al. Alteplase for Posterior Circulation Ischemic Stroke at 4.5 to 24 Hours. N Engl J Med. 2025;392:1288–1296.

When I joined the ESO Emerging Leader Programme in 2024, I set out to address an important gap in stroke and cerebrovascular care in Bulgaria: the limited awareness and under-recognition of cerebral amyloid angiopathy (CAA). Three years later, the programme has helped transform this idea into a growing national initiative while providing invaluable opportunities for learning, collaboration, and professional development.

CAA is a common cerebral small vessel disease and a major cause of lobar intracerebral haemorrhage and cognitive decline. Despite its clinical importance, Bulgaria lacked a dedicated registry, referral pathways, and coordinated expertise in this field. My project, “Virtual Hospital for Patients with Cerebral Amyloid Angiopathy in Bulgaria,” aimed to establish the foundations for a national system supporting the diagnosis, management, and research of CAA.

One of the first steps was conducting a nationwide survey among Bulgarian healthcare professionals to assess current knowledge and clinical practice. The results revealed significant challenges in awareness, diagnostic confidence, and access to specialised investigations, highlighting the need for a coordinated national approach.

Building on these findings, we established a multidisciplinary expert network bringing together neurologists and neuroradiologists to discuss complex cases and provide recommendations for diagnostic evaluation and management. We also began developing the first national CAA registry in Bulgaria, creating a foundation for future research and improved patient care.

The ESO Emerging Leader Programme played a crucial role in shaping this project. Participation in the ESO Edinburgh Stroke Research Workshop helped refine the initial concept, while the ESO Focused Workshop on CAA and a Department-to-Department observership at the Carlo Besta Neurological Institute in Milan provided valuable clinical and research experience. These opportunities allowed me to learn from leading European experts and gain insight into multidisciplinary approaches for rare cerebrovascular diseases.

Beyond the project itself, the programme offered numerous opportunities for leadership development and international collaboration. Through ESO working groups, webinars, guideline activities, and interactions with fellow Emerging Leaders, I developed new skills in scientific communication, networking, and collaborative research. Some of the most rewarding outcomes have been the lasting professional relationships and multinational collaborations that continue beyond the programme.

One of the biggest challenges was building awareness for CAA to many healthcare professionals in Bulgaria. Establishing new pathways and networks required engagement across multiple institutions and specialties. However, this challenge also became one of the most fulfilling aspects of the project, demonstrating how collaboration can drive meaningful change.

Looking ahead, the next steps include expanding the national registry, strengthening multidisciplinary consultations, and further integrating Bulgaria into international research initiatives focused on cerebral small vessel diseases. My ultimate goal is to improve the recognition and management of CAA while ensuring that patients have access to specialised expertise and evidence-based care.

I am deeply grateful to the European Stroke Organisation, the Emerging Leader Programme, and my mentor, Professor Anna Bersano, for their guidance and support throughout this journey. The experience has reinforced my belief that progress in healthcare is built through collaboration, education, and a shared commitment to improving patient outcomes.

Are you an early-career stroke professional looking to develop your leadership skills, expand your international network and drive change in your own country? Applications for the ESO Emerging Leaders Programme are now open until 31 August 2026.
Learn more and apply now.

The ESO EAST Steering Committee organised the 12^th ESO EAST Workshop, with support from the ESO Head Office. The 12th ESO EAST Workshop was held on 5 May 2026 in Maastricht, the Netherlands, traditionally organised a day before the European Stroke Organisation Conference.  It followed the Joint Stroke Action Plan for Europe National Coordinators (SAP-E NC) & ESO EAST Meeting and gathered ESO EAST Country Representatives, the ESO EAST Steering Committee, ANGELS Initiative representatives, the RES-Q team, ESO Head Office representatives, invited guests, and industry partners.

The programme focused on key developments in stroke care across the ESO EAST region, with mainly sessions structured around an introductory presentation followed by country experiences and discussion.

The first session, chaired by Dmytro Lebedynets and Alexandras Vilionskis, addressed mechanical thrombectomy issues in the region, focusing on training and implementation. An introductory presentation by Dmytro Lebedynets, based on the ESO EAST survey, provided an overview of current practices and challenges, followed by country presentations illustrating different stages of development and service organisation.

This was followed by the RES-Q registry session, chaired by Cristina Tiu and Robert Mikulik. Robert Mikulik opened the session with an overview of new developments in the RES-Q registry, with a particular focus on intracerebral hemorrhage (ICH) and quality monitoring. Country contributions highlighted experiences with implementing ICH guidelines in clinical practice.

The session on emerging leaders in stroke, chaired by Alexander Tsiskaridze and Hrvoje Budinčević, presented selected projects reflecting ongoing innovation in the region. Presentations by Marieta Peycheva and Rytis Masiliūnas demonstrated approaches to improving stroke care through digital solutions (virtual hospitals) and national system-level initiatives.

The final session, chaired by Zuzana Gvodinova and Michal Karlinski, focused on neurorehabilitation. Michal Karlinski introduced the session with results from the ESO EAST survey, followed by country presentations addressing current practice and remaining gaps in achieving optimal standards of care in neurorehabilitation.

Discussions were conducted in an amicable, constructive atmosphere, continuing the long-standing tradition of collaboration within the ESO EAST community.

Learn more about ESO EAST

In November 2025, I had the honour of visiting St. George’s Hospital in London as part of the ESO Department-to-Department (D2D) programme. For four weeks, I worked in the Hyper Acute Stroke Unit (HASU) and had the opportunity to observe its daily workflow, participate in clinical discussions, and learn from a highly organised multidisciplinary team.

The HASU has 20 beds, and every morning the team – including neurologists or geriatricians, residents, nurses, physiotherapists, nutritionists, and speech therapists – meets for a structured pre-ward round discussion. Each member documents important clinical, laboratory, and radiological information for all patients. After this meeting, doctors review updated imaging and laboratory results, while a neuro-radiologist joins the team on Mondays to discuss CT and MRI findings. During the ward round, patients are examined, results are reviewed at the bedside, and family members are informed about the treatment plan. After the round, the team discusses new information and finalises the plan for investigations and treatment.

What impressed me most was the high level of involvement of junior doctors and residents in every stage of patient care. Each team member has a clearly defined role, from the emergency department through discharge, which ensures smooth coordination and efficient workflow. The thrombolysis call system is another strength of the unit. When the on-call team receives the alert, two residents and one stroke nurse arrive in the Emergency Department within 10 minutes. Their actions follow clear protocols and are supervised by the on-call neurologist, contributing to a rapid door-to-needle time

After returning to Georgia, I delivered a presentation to my department about the HASU model, which does not currently exist in our healthcare system. I explained how the unit is organised, how daily work is structured, and how thrombolysis is managed in a timely manner. I emphasised that neurologists and geriatricians are directly involved in interpreting neuroimaging and making important treatment decisions, while in my country, we are more dependent on the radiology team for these evaluations. I also discussed differences in acute stroke management, secondary prevention strategies, and ongoing stroke research at St. George’s Hospital. My colleagues asked many questions, which showed their interest and
eagerness to improve stroke care.

Overall, this experience strengthened my clinical skills and deepened my understanding of stroke care organisation. It inspired me to apply some of these practices in my home institution, particularly regarding structured teamwork, efficient thrombolysis, and multidisciplinary collaboration. I am grateful to ESO for this opportunity and to the entire HASU team for their openness and support. I would like to especially thank my supervisor and Head of Department, Dr Anthony Pereira, for guidance and encouragement during my stay.