As part of the ESO TF4UKR Department-to-Department Visiting Programme, I had the privilege of completing a ten-day internship at the Stroke Center of Karolinska University Hospital in Stockholm this summer.

First and foremost, I would like to express my heartfelt gratitude to Professor Mazya and his team for the warm welcome, hospitality, patience, enthusiasm, humour, and genuine human attitude — as well as for answering all my questions and for generously sharing their time.

I was deeply impressed by the work of the department — above all, by its logistics, clear division of responsibilities, and system-based organisation. The level of practicality stood out: clear algorithms, tables, and reminders — everything readily available and thoughtfully designed. Workspaces are organised in a way that allows clinicians to be both comfortable and maximally efficient. The technical and material resources are equally impressive — state-of-the-art CT scanners and a cath lab that truly feels like a spacecraft.

Continuous education, meetings, case discussions, team-based decision-making, and multidisciplinary consultations are an integral part of daily routine. The professionalism of the nursing staff is exceptional. However, the most important aspect is how people work. Almost silently. Quickly. Without unnecessary words. Everyone knows their role, performs it precisely, and is able to “read the room”. This approach results in remarkably short door-to-needle and door-to-groin times and, ultimately, better patient outcomes.

I also observed a higher average age of treated patients, milder or well-compensated comorbidities, and a seemingly lower incidence of severe strokes — a reflection of long-terminational investment in primary prevention and the active, healthy lifestyle of the population.

Yes, this is about funding and national health policy. But even more, it is about systems — systems that are built over years, often from within, slowly and sometimes painfully, through difficult and unpopular decisions, persistence, and the courage to defend what is right. And, above all, it is about people — the people who carry these systems every single day. I am deeply grateful to everyone involved in my internship experience for a renewed sense of inspiration to grow, improve, and implement what I have learned in my own clinical practice.

(And to Stockholm as well — a city I truly fell in love with.)

This year’s presidential Symposium Awards and Large Clinical Studies Session, chaired by Götz Thomalla (Hamburg, Germany) and Guillaume Turc (Paris, France), highlighted the expanding horizons of stroke research. After the presentation of ESO Awards, the Honorary Member Awards, the ESO Emerging Leaders and the Angel Awards, seven studies were presented.

Amrou Sarraj presented the results of the individual patient-data meta-analysis on the endovascular treatment (EVT) for large ischemic stroke from the “Analysis of Mechanical Thrombectomy for Large core ischemic Stroke (ATLAS)” collaboration. This meta-analysis included six randomized clinical trials and sought to evaluate the safety and efficacy of EVT versus best medical care among patients with large ischemic core. A total of 944 patients undergoing EVT and 942 receiving medical management were included. ATLAS meta-analysis demonstrates benefit of EVT in wide-spectrum of patients with large core strokes (Number needed to treat – NNT of 4 for improving 1-point or more on modified Rankin Scale – mRS). Consistent improvements were also detected in functional independence, independent ambulation and mortality.

Maarten Uyttenboogaart presented the Carotid Artery Stenting during Endovascular treatment of Stroke (CASES) trial. This is a phase III international multicenter randomized clinical trial with open label treatment and blinded outcome assessment (PROBE) with non-inferiority design, conducted in 26 EVT centers in the Netherlands and Belgium, aiming to investigate if the immediate carotid artery stenting (CAS) during EVT is non-inferior to a deferred treatment strategy for patients with acute ischemic stroke due to tandem lesions. Overall, non-inferiority was not met, since the distribution of mRS scores at 90 days between the two groups did not differ significantly. However, CAS during EVT improved recanalization rates and increased the patency of the carotid artery at 24 hours and 90 days. Moreover, CAS during EVT was safe and did not increase the rate of symptomatic ICH and mortality rate.

 

LATE-MT was presented by Jianmin Kiu. This is a randomized controlled clinical trial aiming to investigate the effectiveness of EVT treatment in the time window of 24-72 hours of onset, in acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO) of the anterior circulation, with an NIHSS score ≥6 points and favorable CT perfusion profile (infarct core volume <50 ml, mismatch ratio ≥1.8 and mismatch volume ≥1.5 ml). The results of this trial showed that EVT in the time window of 24-72 hours after onset improved 90-day functional outcome. However, this resulted in increased mortality and higher rates of symptomatic intracerebral hemorrhage (sICH) compared with standard medical care, suggesting that more selective patient targeting for EVT in the very late time window may yield better outcomes.

The MILD-MT trial aiming to investigate the safety and effectiveness of EVT for patients with mild ischemic stroke caused by acute anterior LVO through perfusion imaging screening was presented by Wenhuo Chen. This multicenter prospective randomized controlled clinical trial, conducted in China, included 144 patients in the group of combined EVT plus best medical management (BMM) and 156 in the group of BMM alone. The trial was positive, achieving the primary efficacy endpoint with higher rates of mRS score 0-1 in the group of EVT+BMM. Moreover, the trial supported the perfusion-based selection of patients with mismatch≥50 ml.

Craig Anderson presented the CRAFT trial, a multicenter, prospective, randomized, open, blinded outcome assessed (PROBE) clinical trial, aiming to determine the safety and effectiveness of more intensive blood pressure (BP) lowering in patients with atrial fibrillation (AF). In this trial each group included 838 patients, who received home BP monitoring to guide treatment. Overall, in patients with AF, the intensive home BP guided strategy (target SBP<120 mmHg) did not reduce major cardiovascular events compared with standard treatment (target SBP<135 mmHg). However, the detected heterogeneity of treatment across prespecified subgroups, with apparent benefits of intensive treatment in males, younger people, and in those on oral anticoagulant suggests an individualized approach to BP-lowering treatment targets in patients with AF.

Elizabeth Lightbody presented the COMMITS trial, a multicenter randomized controlled trial aiming to evaluate the effect of motivational interviewing (MI) compared with Attention Control (AC) and Usual Care (UC) on depressive symptoms post-stroke. A total of 1246 consecutive adult acute stroke patients across 18 sites were included. Motivational Interviewing was associated with a small but consistent reduction in depressive symptoms, without any significant functional, quality-of-life, or economic benefit. These effects were observed in a predominantly mild stroke population with low baseline psychological morbidity.

Jeffrey Saver presented the DISTALS trial, evaluating the safety and effectiveness of the Tigertriever 13 Revascularization Device in restoring blood flow in the neurovasculature in patients presenting within 24 hours of onset with an ischemic stroke with disabling neurological deficits due to a primary distal vessel occlusion (DMVO). This was a multicenter, prospective, randomized, blinded (endpoint), controlled study, conducted in 25 centers in US and Europe. Rates of sustained reperfusion at 24h were significantly higher, whereas no symptomatic ICH occurred in the EVT group using Tigertriever 13.

The second Large Clinical Trial session delivered compelling new evidence across a broad spectrum of topics, including primary prevention, acute stroke management, reperfusion therapy, and post-stroke care, leaving the audience of more than 4,000 participants eager for the upcoming sessions of the 12th European Stroke Organisation Conference 2026 in Maastricht.

The closing session of ESOC 2026, chaired by Urs Fischer and Else Sandset, concluded three days of high-level scientific exchange in Maastricht with the presentation of ESOC awards and a series of major late-breaking clinical trial results spanning acute stroke treatment, secondary prevention, cerebral venous thrombosis, and stroke imaging.

Craig Anderson presented secondary cognitive and imaging outcomes from the TRIDENT trial, a multinational, double-blind, placebo-controlled trial of a triple low-dose antihypertensive pill after intracerebral haemorrhage, recently published in the New England Journal of Medicine. Over a mean follow-up of 3 years, no significant difference was observed between the triple-pill and placebo groups in cognitive outcomes or MRI markers of cerebral small vessel disease, suggesting that longer follow-up or larger dedicated studies may be needed to detect potential cognitive benefits of sustained blood pressure lowering after ICH.

Mikael Mazighi presented the GREEN trial, evaluating intravenous glenzocimab as an adjunct to mechanical thrombectomy in large vessel occlusion stroke. The trial was terminated early for futility after enrolling 102 patients, with no benefit on the 90-day mRS ordinal shift and a numerical trend toward worse outcomes in the treatment arm.

The GALLOP-2 trial, presented by Hao Wang and Yiu Ming Bonaventure Ip, evaluated short-course adjunctive semaglutide in patients with anterior circulation large vessel occlusion treated with endovascular thrombectomy without prior thrombolysis. Semaglutide was associated with improved 90-day functional outcomes and a favourable mRS distribution shift compared with standard therapy, supporting further investigation of GLP-1 receptor agonists as neuroprotective agents in acute ischaemic stroke.

Diana Aguiar de Sousa presented the 24-month results of the EXCOA-CVT cluster-randomised trial, conducted across 43 centres in 21 countries, comparing 3–6 versus 12 months of anticoagulation after cerebral venous thrombosis. Consistent with the 12-month results, no evidence emerged that prolonging anticoagulation provides additional clinical benefit, supporting an individualised approach to treatment duration in clinical practice.

Marios Psychogios presented the SPINNERS trial, a multicentre non-inferiority study evaluating syngo DynaCT Sine Spin flat-detector CT versus multi-detector CT for intracranial haemorrhage detection in 251 stroke patients across 13 hospitals. Overall non-inferiority was not met, but sensitivity exceeded 96% in patients with NIHSS ≥10 and in high-volume centres, suggesting a potential role for FDCT in One-Stop Management and Direct-to-Angio workflows in selected patients.

Yilong Wang presented the TAPIS trial, simultaneously published in The Lancet, a double-blind, placebo-controlled trial of early ticagrelor-aspirin dual antiplatelet therapy combined with intravenous thrombolysis in 1,382 patients with moderate ischaemic stroke across 60 hospitals in China. Early DAPT significantly improved the rate of excellent functional outcome at 90 days (68.7% vs 62.0%; RR 1.11; p=0.0089) without a meaningful increase in symptomatic intracranial haemorrhage, representing an important advance in acute stroke care pending validation in broader populations.

Guoyong Zeng and Jeffrey L. Saver presented the INSTANT trial, simultaneously published in JAMA, evaluating intravenous tirofiban after tenecteplase in 359 patients with acute ischaemic stroke without large vessel occlusion who had an insufficient clinical response to thrombolysis. The unadjusted primary outcome favoured tirofiban (mRS 0–1: 63.8% vs 52.2%; p=0.03), though the adjusted analysis did not reach significance, and tirofiban did not increase haemorrhagic risk, suggesting a promising rescue strategy warranting confirmation in larger trials.

Xiang Luo presented the ATTRACTION trial, evaluating adjunct tirofiban after successful endovascular recanalization in 1,380 patients with anterior circulation large vessel occlusion stroke across 82 centres in China. Tirofiban significantly improved functional independence at 90 days (49.3% vs 43.3%; adjusted RR 1.15; p=0.009) without a significant increase in symptomatic intracranial haemorrhage or mortality, though external validation in broader international populations is warranted.

Elena Zapata-Arriaza presented the ATILA trial, a Spanish multicentre randomised trial comparing low-dose intravenous tirofiban versus intravenous aspirin as periprocedural antiplatelet therapy in 240 patients with tandem lesion stroke undergoing mechanical thrombectomy plus emergent carotid stenting. Tirofiban significantly reduced acute in-stent reocclusion at 24 hours (7.2% vs 16.8%; aOR 0.345; p=0.015) and intra-stent aggregation, without a statistically significant increase in symptomatic intracranial haemorrhage, supporting its use in this challenging and underrepresented patient population.

The closing session of ESOC 2026 delivered an exceptional and rich programme of late-breaking results, reflecting the breadth of global stroke research. The convergence of positive findings from TAPIS, ATTRACTION, INSTANT, and ATILA – all pointing toward early antiplatelet strategies in selected populations – alongside the nuanced results of SPINNERS and GALLOP-2, underscores the importance of patient selection and treatment context. ESOC 2026 concluded with a shared commitment to advancing stroke care through rigorous science and international collaboration.

Walking through the poster exhibition at the 12th European Stroke Organisation Conference in Maastricht was an exciting experience. Here are four studies that stopped me in my tracks.

Air pollution and stroke outcomes

Fiona Huber and colleagues tackled a cutting-edge topic with their poster, “LONG-TERM EXPOSURE TO AIR POLLUTION (PM2.5 AND NO2) AND ITS ASSOCIATION WITH CLINICAL OUTCOMES AFTER ACUTE ISCHAEMIC STROKE.” Air pollution is an established stroke risk factor, and this Swiss research group examined its impact on 1,446 acute ischaemic stroke patients hospitalised between 2015 and 2022. Average annual exposure to PM2.5 and NO2 was estimated using geocoded residential addresses. Higher PM2.5 exposure was associated with greater stroke severity at admission (higher median NIHSS, p=0.008), more cardioembolic aetiology (p<0.001), and more ICA/MCA tandem occlusions (p<0.001). Interestingly, patients with higher PM2.5 exposure also presented with shorter prehospital delays, longer acute care stays, fewer EVT complications, and better adjusted 3-month functional recovery (mRS 0–2: OR 1.052; 95% CI: 1.001–1.106). Higher NO2 exposure, by contrast, was linked to poorer excellent outcomes (mRS 0–1: OR 0.975; 95% CI: 0.951–1.000) and more recurrent strokes (p=0.005). These findings reinforce the need for greater awareness, among patients, clinicians, and researchers alike, of how air quality affects both stroke risk and recovery, including countries with potentially lower pollution exposure levels.

Sexual health after stroke

Monica Serrano and her Spanish colleagues drew attention to an often-overlooked post-stroke deficit with their poster, “SEXUAL HEALTH IMPAIRMENT AMONG POST-STROKE PATIENTS: AN OBSERVATIONAL STUDY.” From a prospective cohort of up to 340 eligible patients, 35 were ultimately included. Participants were contacted six months after their stroke to assess sexual activity, function, and body image, and to explore links with mood and quality of life. Before the stroke, 91.4% reported a satisfactory sex life; afterwards, 71% resumed sexual activity. No significant differences between sexes were found in mRS scores, quality of life, or depression and anxiety prevalence. However, nearly half of participants (48.6%) reported sexual dysfunction, with women more affected than men. The low response rate (10.9%) underscores the sensitivity of this topic, and the impressive high prevalence of this deficit highlights the urgent need for tailored assessment tools and counselling services within stroke care pathways.

Ultrasound in the hybrid Mobile Stroke Unit

Radim Licenik and colleagues presented an innovative contribution from the pre-hospital setting: “USE OF POINT-OF-CARE AND INTERVENTIONAL ULTRASOUND MODULES DEVELOPED FOR HYBRID MOBILE STROKE UNITS.” Hybrid Mobile Stroke Units (h-MSUs) are specialised ambulances designed to respond not only to stroke but to a broader range of neurological emergencies. Equipped with mobile CT scanners, ultrasound, X-ray, ECG, EEG, and advanced point-of-care laboratory equipment, they can deliver neurointensive care in pre-hospital settings. The Czech MSU team, in collaboration with the World Organisation of Neurosonology POCUS/FoCUS working group, developed a multimodule POCUS programme applicable across healthcare settings. The MSU-POCUS module integrates cardiac, medical, neurological, vascular, and interventional modalities, and was deployed during a trial in the Zlín-Valmez region of Czechia from October to December 2023. The results confirm that MSU-POCUS is a feasible, safe, and efficient tool that adds meaningful diagnostic capability to standard pre-hospital care.

Sex and socioeconomic disparities among stroke patients in Tanzania

Finally, Joshua Ngimbwa from Tanzania passionately presented compelling work with the e-poster “SEX AND SOCIOECONOMIC DIFFERENCES IN RISK FACTORS, CLINICAL PRESENTATION, AND THIRTY-DAY OUTCOMES OF STROKE PATIENTS AT TERTIARY HOSPITALS IN TANZANIA.” Low- and middle-income countries largely contribute to the global stroke burden in terms of incidence, mortality, and disability-adjusted life years (DALYs). While sex differences and socioeconomic status are well-documented determinants of stroke outcomes in high-income settings, evidence from Tanzania remains limited and inconsistent, despite recent national efforts to establish stroke units and a stroke registry. This ongoing multicentre prospective cohort study aims to evaluate sex- and socioeconomic-related differences in vascular risk factors, clinical presentation, and 30-day outcomes among adults admitted with neuroimaging-confirmed stroke to three major tertiary hospitals. Socioeconomic status is measured using a standardised composite index adapted from the Demographic and Health Survey wealth scale, with a target sample of 630 participants over one year. This work has the potential to inform more equitable, context-specific stroke care strategies in sub-Saharan Africa, and we look forward to seeing the final results.

The teaching course “Stroke Beyond the Brain: Systemic and Hematologic Drivers of Cerebrovascular Events” showed how often stroke reflects a systemic, hematologic, or immune-mediated disorder rather than an isolated cerebrovascular event. Chaired by Xabier Urra (Barcelona, Spain) and Natalia Perez de la Ossa (Badalona, Spain), the session brought together clinically relevant perspectives on thrombophilia, vasculitis, antiphospholipid syndrome, and thrombotic microangiopathy.

The speaker pointed out a strong reminder that precision stroke medicine often begins with recognizing systemic red flags. The most consistent themes across the course were broad differential diagnosis, thoughtful laboratory testing, and urgent multidisciplinary treatment when APS, vasculitis, or TMA/TTP is suspected.

1.Hematologic disease and hypercoagulability

Annette Fromm (Bergen, Norway) provided a concise overview of hematologic disorders associated with prothrombotic states and hyperviscosity, emphasizing that both mechanisms often overlap in clinical practice. Particularly helpful was the structured review of inherited thrombophilia set against the broader background of venous thrombosis and possible arterial ischemic risk.

She summarized that acquired hematologic conditions such as sickle cell disease, cancer, myeloproliferative disorders, and multiple myeloma also contribute substantially to stroke risk. The talk made clear that these risks are usually shaped by a combination of patient-related, disease-related, and therapy-related factors.

2.Autoimmune disease and stroke

Hubert de Boysson (Caen, France) framed systemic vasculitis as an important diagnostic model for stroke medicine, spanning small-, medium-, and large-vessel vasculitides. One of the most practical aspects was the focus on work-up and disease activity. A strong point was the recognition that autoimmune stroke mechanisms are often mixed rather than isolated, with inflammatory disease coexisting with atherosclerosis or small-vessel disease. Clinical examples such as anterior ischemic optic neuropathy and ANCA-associated vasculitis illustrated how careful phenotyping remains essential.

3.Antiphospholipid syndrome

David Werring (London, United Kingdom) highlighted the clinical complexity of antiphospholipid syndrome (APS) in patients with ischemic stroke and TIA. APS appears to be particularly relevant in younger patients with cryptogenic stroke, although the relationship between antiphospholipid antibodies and ischemic stroke remains difficult to quantify because antibody findings may be transient or not clearly causal.

A major practical highlight was the discussion of who should be tested: younger adults with unexplained ischemic stroke, patients with prior venous thrombosis, pregnancy-related stroke or pregnancy loss, and those with hematologic abnormalities such as thrombocytopenia or anemia. Equally important was the caution that acute-phase testing can be misleading, making repeat confirmation after 12 weeks essential in many cases.

The most debated part of the lecture concerned treatment. Evidence for antithrombotic management remains limited and practice varies considerably. The session finally underscored the need for rapid recognition of catastrophic APS and for multidisciplinary management in refractory cases.

4. Thrombotic microangiopathy

Arthur Liesz (Munich, Germany) presented thrombotic microangiopathy (TMA) as an important and time-critical stroke differential diagnosis. A central take-home message was that frequent CNS involvement means stroke physicians should think of TTP early when neurologic symptoms occur in the setting of thrombocytopenia and hemolysis.

The diagnostic part of the talk was especially practical, with emphasis on ADAMTS13 testing, the PLASMIC score, and the need to start plasma exchange as early as possible. The treatment section highlighted how outcomes in acquired TTP have improved markedly with plasma exchange, corticosteroids, rituximab, and caplacizumab, while complement-mediated TMA has opened an additional therapeutic perspective with eculizumab.

This joint session with the Society of Vascular and Interventional Neurology was chaired by Götz Thomalla (Hamburg, Germany) and Thanh N. Nguyen (Boston, United States), bringing together leading experts to explore the evolving role of imaging in acute stroke, from classical concepts such as core and penumbra to emerging technologies and future perspectives.

Leptomeningeal collaterals: from physiology to therapeutic target

Marilyn Cipolla (Burlington, USA) opened the session by exploring the critical role of leptomeningeal collaterals in acute ischemic stroke. These vessels provide low but sufficient perfusion to sustain penumbral tissue viability until reperfusion can be achieved. Preclinical models demonstrated that induced hypertension could enhance collateral flow and reduce infarct core size. While randomized trials have shown early neurological improvement, long-term benefits remain uncertain.

Other promising strategies aimed at improving collaterals include:

• Sphenopalatine ganglion stimulation, showing modest increases in cerebral blood flow, particularly in cortical strokes;
• Remote ischemic conditioning, effective in experimental models but not confirmed in large preclinical trials;
• Head-down tilt positioning, associated with early neurological improvement and reduced infarct growth in experimental settings.

Overall, collaterals represent a promising avenue to extend the therapeutic window, although patient selection and optimal strategies remain to be defined.

Is the core–penumbra concept still relevant?

Tudor Jovin (Camden, USA) revisited the cornerstone concepts of ischemic core and penumbra in acute stroke. While these concepts have historically guided treatment decisions, especially in extended time windows, he argued that current imaging techniques inadequately capture the biological complexity of the ischemic tissue. Evidence from large core thrombectomy trials demonstrated substantial treatment benefits even in patients with minimal or no apparent mismatch.

Key insights include:

• No clear treatment effect modification based on mismatch status in thrombectomy studies;
• Similar treatment effect sizes in large-core and small-core patients;
• Imaging “core” can overestimate irreversible injury due to phenomena such as lesion reversal and “ghost infarcts”.

Importantly, penumbral salvage explains only a fraction of clinical benefit. Other mechanisms, such as edema reduction and preservation of the neurovascular unit, play a major role. He concluded that while the concept remains biologically relevant, it should be considered only one of several mechanisms underlying clinical benefit with reperfusion.

Photon-counting CT: a new era in stroke imaging

Linda Jacobi-Postma (Maastricht, Netherlands) presented photon-counting CT as a transformative innovation in neuroimaging. Compared to conventional CT, this technology offers: Higher spatial resolution, reduced electronic noise, improved contrast-to-noise ratio, lower radiation and contrast dose, intrinsic spectral imaging capabilities.

In stroke imaging, photon-counting CT improves:

• Detection of early ischemic changes and small infarcts;
• Visualization of posterior fossa and brainstem lesions;
• Identification of distal and medium vessel occlusions;
• Characterization of plaque composition and vessel pathology.

It also enables advanced applications of photon-counting CT such as material decomposition (e.g., distinguishing hemorrhage from iodine) and improved post-interventional imaging.

Despite its promising characteristics, optimization of acquisition parameters and clinical integration remain ongoing challenges. Nonetheless, this technology may represent not just an incremental improvement, but a paradigm shift in CT imaging.

Artificial intelligence in acute stroke imaging: from promise to proof

Sunil Sheth (Houston, USA) addressed the rapidly expanding role of artificial intelligence (AI) in stroke workflows. AI-based tools are now widely implemented for large vessel occlusion (LVO) detection, automated imaging analysis, workflow coordination and communication. However, he emphasized a critical point: performance accuracy alone is not sufficient. AI must demonstrate clinically meaningful impact. Using a stepped-wedge study design across multiple stroke centers, his group showed that AI implementation:

• Reduced workflow times (e.g., door-to-reperfusion metrics);
• Improved efficiency, particularly when actively used by clinicians.

Importantly, benefits were linked to user engagement, highlighting that technology alone is insufficient without proper integration into clinical practice. Looking ahead, AI may move beyond detection tasks toward predictive modeling, helping clinicians anticipate outcomes such as hemorrhage risk or long-term recovery.

Imaging in haemorrhagic stroke: current standards and future directions

Martina Goeldlin (Bern, Switzerland) focused on acute imaging in intracerebral hemorrhage (ICH), which accounts for approximately 15% of strokes. She emphasized that: rapid imaging is equally critical in ICH (“time is brain”) and CT remains the primary modality, though MRI can be used in selected centers

Key challenges include:

• Identifying underlying etiology (e.g., vascular malformations, small vessel disease, cerebral amyloid angiopathy);
• Avoiding delays in treatment caused by ischemic stroke–oriented workflows (e.g., direct-to-angio approaches).

Emerging imaging markers and scores, such as those for cerebral amyloid angiopathy, may improve risk stratification and guide management. Advanced imaging techniques and better integration of MRI may further refine diagnosis and prognosis in hemorrhagic stroke.

Take-home message

This session underscored a major shift in stroke imaging:

• Imaging is evolving from a diagnostic tool to a therapeutic guide;
• Traditional concepts like core–penumbra are being redefined in light of new evidence;
• Technologies such as photon-counting CT and AI are reshaping clinical workflows.

A more individualized, biology-driven approach to stroke care is emerging

As innovation accelerates, the challenge will be not only adopting new tools but rigorously validating their impact on patient outcomes.

I have thoroughly enjoyed attending ESOC this year in the beautiful city of Maastricht. The scientific programme offered incredible insights into the latest stroke research. Beyond the sessions, the historic charm of Maastricht provided a wonderful backdrop for networking and catching up with old friends and colleagues. The poster session on Day 2 included many interesting studies, reflecting a truly vibrant and scientifically prolific stroke community. I would like to highlight a couple of posters that caught my eye and sparked my interest.

One of my top picks from the Best Poster category was: “Effect of Intensive Blood Pressure Lowering on Perihematomal Edema in Acute Intracerebral Hemorrhage: Pooled Analysis of the Four INTERACT Trials” by Ren et al. This study was based on individual participant-level data from the four INTERACT trials assessing the effect of blood pressure lowering among patients with acute ICH. Oedema growth was defined as the volume increase from baseline to the 24-hour CT scan. A total of 2,549 participants were included, with haematoma and oedema volumes well-balanced at baseline. Adjusted for other baseline variables, strong evidence (p=0.004) was found for an association between intensive blood pressure lowering and 24-hour oedema growth. Participants randomized to intensive blood pressure lowering had 1.16 mL (95% CI 0.37 to 1.95) less mean growth within the first 24 hours. Additionally, there was strong evidence of time-dependence in the treatment effect (p for interaction = 0.009), with the upper bound of the confidence interval crossing the no-effect line 2.2 hours after onset.

From the Best Poster category, I would also like to highlight: ”Intravenous Thrombolysis in Acute Ischemic Stroke Patients on Direct Oral Anticoagulants Undergoing Endovascular Thrombectomy” by Matusevicius et al. The study aimed to investigate the risk-benefit of adding bridging therapy (intravenous thrombolysis plus endovascular therapy ) in acute ischaemic stroke patients on DOACs undergoing EVT. The study utilised data from the SITS international registry. Of the 1,991 patients on DOACs treated with EVT, 317 received intravenous thrombolysis. After propensity score matching, no difference in favourable outcome (modified Rankin Scale 0-2) at 3 months was found (71 [36.0%] versus 155 [35.1%], p=0.898). In addition, no difference in symptomatic haemorrhagic transformation was observed.

Focusing on the Acute Ischaemic Stroke Management category, the work of Ma et al. “Outcome of Direct Endovascular versus Bridging Therapy for Ischemic Stroke due to Medium Vessel Occlusion” deserves mention. The study presents data from patients in the multicentre Reperfusion therapy for acute ischemic STrOke due to large aRtEry occlusions (RESTORE) registry with CT-angiography-verified medium vessel occlusion (MeVO) who underwent endovascular therapy. Patients were treated either with bridging therapy (intravenous thrombolysis plus endovascular therapy ) or EVT alone. Among the 140 eligible patients, 41 received bridging therapy and 99 received EVT alone. Bridging therapy was associated with 156% higher odds of being in a more favourable modified Rankin Scale category after 3 months (cOR 2.56, 95% CI 1.23 to 5.35).

From the Recovery, Rehabilitation and Outcome category, I would like to showcase: “Death and dependency 90 days after in-hospital ischaemic stroke in Sweden: a nationwide register study” by Ben-Shabat et al. This study utilised data from the Swedish Stroke Registry (Riksstroke) spanning 2010 to 2019. The study aimed to compare outcomes between patients suffering from in-hospital ischaemic stroke (IHIS) and those with community-onset ischaemic stroke (COIS). Of the 198,864 stroke patients included, 11,420 (5.7%) were classified as IHIS. Patients in the IHIS group generally presented with a higher burden of comorbidity and greater stroke severity, with a median NIHSS of 7 compared to 3 in the COIS group. While a comparable number of IHIS and COIS patients received intravenous thrombolysis, the door-to-needle time was notably shorter for IHIS patients (80 minutes versus 125 minutes for COIS). Even after adjusting for comorbidities, stroke severity, and treatment, IHIS was associated with 162% higher odds of suffering death or dependency within 90 days (OR 2.62, 95% CI 2.48 to 2.76).

The teaching course on rare intracranial vasculopathies aimed to shed light on three cerebrovascular conditions that are often underrecognized and insufficiently considered in routine clinical practice, namely moyamoya disease, primary angiitis of the central nervous system (PACNS), and intracranial dissection. This 90-minute session was chaired by Stefan Kiechl (Innsbruck, Austria) and Jori Ruuskanen (Turku, Finland) and was highly interactive, with active participation from the audience, reflecting the growing interest in these disorders, which, also thanks to recent advances in diagnostic tools, are receiving increasing clinical attention.

Moyamoya angiopathy

Dominique Herve (Paris, France) opened the session with an insightful lecture on Moyamoya disease, a rare intracranial vasculopathy characterized by progressive stenosis of the intracranial segments of the cerebral afferent arteries and by the formation of an intricate network of fragile collateral vessels resembling a “puff of smoke” (“moyamoya” in Japanese), ultimately leading to an increased risk of both ischemic and hemorrhagic stroke. The lecture covered all major aspects of the disease, from diagnosis to therapeutic options. Starting from epidemiology, it was shown that the incidence of moyamoya disease is markedly higher in Asian countries than in European and American populations. Moreover, both the clinical and radiological features of the disease vary according to geographic origin, with systemic manifestations and atypical angiographic patterns being more frequently observed in patients from Western countries. Particular attention was devoted to emerging tools for the assessment of chronic cerebral hypoperfusion in these patients, such as SPECT imaging with a 99mTc tracer, which can rapidly identify patients who may benefit from early revascularization procedures. Regarding therapeutic options, although disease-modifying treatments are still unavailable, several surgical approaches capable of altering the natural history of the disease were discussed. In particular, according to the ESO guidelines by Bersano et al., revascularization procedures may be considered in patients presenting with ischemic or hemorrhagic manifestations in the presence of markers of cerebral hemodynamic impairment, as well as in patients with cerebral hemodynamic impairment associated with choroidal collaterals.

Primary Angiitis of the Central Nervous System (PACNS)

Next, Marialuisa Zedde (Reggio Emilia, Italy) delivered a lecture on primary angiitis of the central nervous system (PACNS), a highly complex disorder that remains challenging to recognize because of its broad spectrum of differential diagnoses. Particular emphasis was placed on the diagnostic difficulties posed by this rare condition. It was highlighted that the effective implementation of diagnostic and therapeutic recommendations requires a multidisciplinary approach involving vascular neurologists and neuroradiologists with specific expertise in PACNS and its mimics. Several diagnostic tools currently available for the evaluation of PACNS were discussed, and the recommendations provided in the latest ESO guidelines by Zedde et al. were illustrated. In particular, although brain MRI is abnormal in approximately 93% of patients, radiological findings are often nonspecific. Likewise, cerebrospinal fluid analysis, while mainly recommended to exclude alternative diagnoses, frequently yields either normal or nonspecific results in patients with PACNS. Considerable attention was devoted to the role of vascular imaging. Digital subtraction angiography (DSA) was presented as the current gold standard, given that MRA and CTA may fail to detect subtle abnormalities affecting distal vessels. Vessel wall imaging (VWI) was also discussed as a promising emerging technique; however, its current clinical application remains limited by insufficient pathological validation and by the difficulty in interpreting persistent vessel wall enhancement, which may remain detectable even after clinical resolution.

Intracranial Dissections
The final lecture, delivered by Vasileios-Arsenios Lioutas (Boston, United States), focused on intracranial dissections, with particular emphasis on the unique anatomical vulnerability of intracranial arteries. It was explained how these vessels are more prone to rupture and subarachnoid hemorrhage than extracranial arteries because of the absence of an external elastic lamina and the presence of a thinner tunica media. From a clinical perspective, intracranial dissections may present with either ischemic or hemorrhagic phenotypes, most commonly subarachnoid hemorrhage. Interestingly, clinical manifestations appear to vary according to the vascular territory involved, with ischemic presentations being more frequently associated with dissections of the anterior circulation and hemorrhagic manifestations predominating in posterior circulation involvement. Among the most important warning signs, the speaker highlighted the so-called “sentinel headache,” which may occur up to three days before a major cerebrovascular event and should therefore never be underestimated. Particular attention was also devoted to therapeutic management. Hemorrhagic presentations were described as true medical emergencies requiring immediate surgical or endovascular intervention, including both deconstructive and reconstructive techniques, in order to reduce the otherwise high mortality risk. Conversely, in non-hemorrhagic cases, antiplatelet therapy is generally preferred, although current evidence is largely extrapolated from studies on extracranial artery dissections. Intravenous thrombolysis, on the other hand, is usually discouraged because of the significantly increased risk of intracranial hemorrhage. Finally, long-term management was reported to rely on strict blood pressure control and serial vascular imaging, usually performed three to six months after the acute event, to assess vessel healing and the potential risk of recurrent dissection.

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.