Stroke: Vascular and Interventional Neurology

BackgroundTandem lesion strokes (TLS), defined by the coexistence of an intracranial large- or medium-vessel occlusion and a concomitant cervical internal carotid artery (ICA) stenosis or occlusion, represent a challenging subtype of acute ischemic stroke. Optimal endovascular management remains controversial, particularly regarding the role of emergent carotid artery stenting (eCAS) during mechanical thrombectomy. ObjectiveTo compare the safety and efficacy of emergent carotid artery stenting versus mechanical thrombectomy alone in patients with anterior circulation tandem lesion strokes treated at a comprehensive stroke center. MethodsWe conducted a retrospective observational cohort study of consecutive adults with anterior circulation TLS treated with endovascular therapy within 24 hours of symptom onset between January 2015 and July 2025. Patients were categorized into two groups according to treatment strategy: eCAS performed during thrombectomy or mechanical thrombectomy alone (MTa). Primary efficacy outcomes were ordinal shift in 90-day modified Rankin Scale (mRS), excellent outcome (mRS 0-1), and functional independence (mRS 0-2). Secondary efficacy outcome was successful recanalization (TICI [≥]2b). Primary safety outcomes included symptomatic intracranial hemorrhage (sICH), in-hospital mortality, and 90-day mortality. ResultsA total of 111 patients were included (mean age 71.2 {+/-} 12.6 years; 68.5% male), of whom 74 (67%) underwent eCAS and 37 (33%) received MTa. Patients treated with eCAS achieved higher rates of successful recanalization (97.3% vs 78.4%; OR 13.26, 95% CI 2.13-82.49; p = .006) and excellent functional outcomes at 90 days (41.9% vs 12.5%; OR 6.80, 95% CI 1.35-34.20; p = .020). There were no significant differences between groups in rates of sICH, early neurological deterioration, or mortality. Ordinal logistic regression showed a non-significant trend toward better functional outcomes with eCAS. ConclusionsIn this single-center experience, emergent eCAS during mechanical thrombectomy for TLS was associated with higher reperfusion rates and improved functional outcomes without increased hemorrhagic risk or mortality. These findings support eCAS as a feasible and safe strategy in selected patients and highlight the need for prospective randomized trials.

ObjectiveWe aimed to do an updated meta- analysis comparing outcomes of mechanical thrombectomy (MT) associated with standard medical treatment (SMT), compared to SMT alone, in adult patients with acute ischemic stroke (AIS) due to medium or distal vessel occlusion (MDVO). MethodologyWe systematically searched PubMed, LILACS, Scielo, Cochrane, and ClinicalTrials.gov databases. Randomized controlled trials (RCTs), retrospective cohort studies, and systematic reviews with meta-analysis comparing MT+SMT with SMT alone in adults with AIS due to MDVO, evaluating at least one of the outcomes of interest, were included. The evaluated outcomes were functional recovery (modified Rankin Scale [mRS] 0-1 and mRS 0-2) at 90 days, all-cause mortality at 90 days, and the occurrence of intracranial hemorrhage (ICH). Risk of bias was assessed using RoB 2, Newcastle-Ottawa, and AMSTAR 2 tools. Heterogeneity was assessed with Chi{superscript 2} and I{superscript 2}, and publication bias with funnel plots and Egger/Begg tests. ResultsTwelve studies (4 RCTs, 7 cohorts, 1 systematic review) were included. Meta-analyses showed no significant difference between MT+SMT and SMT alone for: mRS 0-1 (Excellent Recovery), mRS 0-2 (Good Recovery), mortality at 90 days, and Symptomatic Intracranial Hemorrhage. ConclusionCurrent evidence, combining RCTs and observational studies, does not support the routine use of MT over SMT alone for MDVO in terms of functional improvement at 90 days (mRS 0-1 or 0-2). Non-significant trends towards increased mortality and sICH risk with MT were observed, with considerable heterogeneity for sICH. KEY MESSAGESeveral randomized controlled trials (RCTs) have demonstrated the benefit of mechanical thrombectomy associated with standard medical treatment (SMT), in patients with IS caused by large vessel occlusion (LVO). There for the boundaries of MT began to be questioned, raising the possibility of performing it for medium and distal vessel occlusions (MDVO). As a result of this study, there was no evidence to support the use of MT over SMT alone for MDVO, therefore the therapeutic decisions should remain individualized and further research is crucial to define the exact role of the MT.

BackgroundThe optimal noninvasive screening strategy for detecting patent foramen ovale (PFO) in patients with cryptogenic stroke (CS) remains uncertain. Although transthoracic echocardiography (TTE) and transcranial Doppler (TCD) are widely used, whether combining both modalities improves diagnostic performance has not been fully established. MethodsAmong 432 consecutive CS patients, 399 underwent collaborative screening with both TTE and TCD bubble tests performed by a multidisciplinary Heart-Brain Team, followed by transesophageal echocardiography (TEE) as the reference standard. Bubble tests were conducted at rest and during the Valsalva maneuver (VM). Diagnostic performance, concordance between modalities, and incremental value were evaluated using receiver operating characteristic analysis, Cohens kappa statistics, and sequential logistic regression models. ResultsTEE confirmed PFO in 156 patients (39.1%). Both TTE and TCD demonstrated significantly higher diagnostic accuracy during VM than at rest, with no significant difference in area under the curve between modalities under VM. Sequential logistic regression showed a significant incremental increase in predictive value when TCD during VM was added to TTE during VM ({chi}{superscript 2} increase from 271.4 to 297.2; p<0.0001). Although overall agreement between TTE and TCD during VM was substantial ({kappa}=0.63), 54 patients (14%) showed discordant results, among whom 15 (28%) had TEE-confirmed PFO. Applying an "OR" rule (positive if either test was positive) significantly improved sensitivity compared with either modality alone, at the expense of modestly reduced specificity. ConclusionsDual screening with TTE and TCD during VM within a Heart-Brain Team framework significantly enhances sensitivity for PFO detection and reduces missed diagnoses in patients with CS. An "OR" rule interpretation represents a practical and clinically effective screening strategy.

BackgroundNeurointerventional therapy is a cornerstone in managing head and neck vascular disorders, with cerebral angiography serving as its fundamental diagnostic and therapeutic backbone. However, manual cerebral angiography is associated with several inherent limitations. While existing robotic-assisted systems have shown promise in mitigating some of these issues, they face challenges such as limited compatibility, lengthy setup times, and a lack of high-quality real-world evidence. MethodsThe ERASE trial is a multicenter, prospective, randomized controlled trial (RCT). A total of 450 eligible patients will be enrolled from six comprehensive stroke centers in China and randomized 1:1 to either the robotic-assisted group or the control group. Both groups use the Seldinger technique for femoral/radial artery access. Operators undergo standardized training on the robotic system, and all patients are followed up at baseline, end of surgery, 24 hours postoperatively, and 7 days post-discharge. ResultsThe primary efficacy outcome is the clinical success rate. The primary safety outcome is the incidence of perioperative/postoperative complications (e.g., vascular perforation, dissection, pseudoaneurysm), serious adverse events, and device malfunctions. Secondary outcomes include technical failure rate, overall procedural time, pre-puncture setup time, target vessel super-selective catheterization time, digital subtraction angiography fluoroscopy time, participant radiation doses and contrast agent volume. A key safety endpoint is the rate of new asymptomatic cerebral infarctions detected via postoperative brain MRI-diffusion-weighted imaging. ConclusionsAs the RCT focusing on the YDHB-NS01 Ver 2.0 system, the ERASE trial addresses critical unmet needs in neurointerventional practice and will generate high-quality evidence for robotic-assisted cerebral angiography. Trial registration number: ClinicalTrials.gov NCT07182188. Clinical Perspective1) What Is New? This multicenter RCT evaluates the YDHB-NS01 Ver 2.0 robotic-assisted system and provides rigorous evidence on its safety and efficacy compared with manual cerebral angiography, while validating targeted design enhancements addressing prior systems shortcomings 2) What Are the Clinical Implications? The study s findings could standardize the clinical application of robotic-assisted cerebral angiography and inspire further research on refining robotic interventional workflows to improve patient outcomes and provider safety.

BackgroundMechanical thrombectomy has become standard-of-care in the treatment of emergent large vessel occlusion. However, it is not yet known if social factors impact post-thrombectomy recovery. We studied the association between clinical and sociodemographic factors with 3-month functional outcomes post thrombectomy. MethodsIn this prospective cohort study, 291 patients who underwent mechanical thrombectomy at Montefiore-Einstein Hospital in NYC between 1/1/2021 and 4/1/2024 were analyzed. The cohort spanned multiple census tracts across New York City and surrounding areas and included a diverse patient population. The primary outcome was change in modified Rankin Scale ({Delta}mRS) from pre-stroke baseline to 90-180 days post-stroke. Ordinal logistic regression was used to assess the relationship between {Delta}mRS and social vulnerability, adjusting for age, sex, stroke severity, and procedural success. ResultsWorse functional outcomes were associated with older age (OR 1.03; p = 0.004), male sex (OR 1.85; p = 0.006), higher stroke severity (OR 1.71; p < 0.001), and lower reperfusion success (OR 2.22; p = 0.011). Social vulnerability was not significantly associated with long-term outcomes (OR 0.88; p = 0.550). ConclusionIn this cohort, functional outcomes after mechanical thrombectomy were influenced by clinical and procedural factors rather than sociodemographic vulnerability. While equitable outcomes were observed in the acute setting, ongoing research is needed to explore potential disparities across the broader stroke care continuum, including post-acute recovery.

PurposeIntracranial atherosclerotic disease-related large vessel occlusion (ICAD-LVO) presents distinct challenges, particularly regarding the high risk of reocclusion and the need for specific management strategies. While several prediction scores exist to differentiate ICAD-LVO from embolic LVO (EMB-LVO), their external validity remains unproven. We aimed to externally validate six established prediction scores for differentiating the two. MethodsWe analyzed data from a prospectively maintained, two-center stroke registry (June 2021-March 2025). Consecutive patients who underwent mechanical thrombectomy and had complete clinical and imaging data necessary for calculating six scores (ISAT, REMIT, ABC2D, ATHE, ICAS-LVO, and Score-ICAD) were included. LVO etiology was defined based on angiographic findings during endovascular treatment. The discriminative performance of each score was assessed using the area under the receiver operating characteristic curve (AUC). ResultsOf 1,288 screened admissions, 91 patients met the inclusion criteria (ICAD-LVO, n = 18; embolic occlusion, n = 73). The AUCs (95% confidence interval) for differentiating etiology were: ISAT, 0.870 (0.664-1.000; P = 0.064); REMIT, 0.793 (0.676-0.911; P <0.001); Score-ICAD, 0.707 (0.582-0.833; P = 0.013); ABC2D, 0.627 (0.504-0.751; P = 0.095); ATHE, 0.600 (0.451-0.749; P = 0.230); and ICAS-LVO, 0.465 (0.301-0.630; P = 0.650). ConclusionIn this external validation, REMIT demonstrated the most robust and statistically significant discrimination between ICAD-LVO and EMB-LVO. Overall, scores incorporating imaging features outperformed those relying on clinical variables. These findings support the concept that ICAD-LVO represents a distinct pathophysiological entity from embolic occlusion and that accurate mechanism inference requires comprehensive imaging assessment of intracranial atherosclerotic disease beyond the occlusion site.

BackgroundSuccessful recanalisation without functional independence is a frequent phenomenon following endovascular thrombectomy for large vessel occlusion stroke. AimTo demonstrate safety and efficacy of adjunct tirofiban therapy after endovascular thrombectomy in patients with anterior circulation large vessel occlusion stroke achieving successful recanalization defined as modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3. DesignThe study of adjunct tirofiban treatment after successful endovascular thrombectomy recanalisation (ATTRACTION) is a multicenter, prospective, double-blind, randomized trial enrolling 1360 patients in China. Eligible patients will be randomised 1:1 to either the tirofiban or placebo group. OutcomeThe primary efficacy outcomes is assessed as the proportion of participants with a modified Rankin Scale (mRS) score of 0-2 at 90 days, and the primary safety outcome is symptomatic intracranial haemorrhage within 48 hours from randomisation. ConclusionThis study will provide evidence on the efficacy and safety of sequential tirofiban therapy after successful recanalisation in patients with anterior circulation large vessel occlusion stroke. Trial registration numberNCT06265051 WHAT IS ALREADY KNOWN ON THIS TOPICSuccessful recanalization without functional independence is a frequent phenomenon following endovascular thrombectomy and previous small-sample, retrospective studies supported the administration of adjunct tirofiban therapy in patients after endovascular thrombectomy achieving successful recanalization. WHAT THIS STUDY ADDSThe ATTRACTION trial aims to access the efficacy and safety of adjunct tirofiban therapy and the protocol describes the rationale and design of the trial. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICYATTRACTION trial will inform whether tirofiban therapy after successful recanalisation by endovascular thrombectomy can improve patient outcomes.

BackgroundAmong patients with acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO) who undergo successful reperfusion following endovascular thrombectomy (EVT), only one-third are disability-free at 90 days, which may be related to persistent microvascular hypoperfusion after thrombectomy known as the "no-reflow phenomenon". Adenosine is administered to prevent percutaneous coronary intervention (PCI)-related no-reflow through microvasculature dilation and neutrophil-mediated inflammation modulation. However, its role in in the setting of AIS has not been clearly elucidated. ObjectiveTo evaluate the safety and efficacy of adjunctive intra-arterial adenosine following successful EVT in LVO patients. Methods and designIn this multicenter, open-label, randomized, phase 2 trial, we evaluated the safety and efficacy of adjunctive intra-arterial adenosine following successful EVT in AIS patients. Up to 160 eligible stroke patients with anterior intracranial large vessel occlusion presenting within 24 hours from symptom onset (time last known well) are planned to be consecutively randomized. The primary outcome was the shift in the distribution of mRS scores at 90 days. Safety outcomes included symptomatic intracranial hemorrhage (sICH) within 48 hours and mortality at 90 days. DiscussionsThis pivotal trial will provide first-hand data on the efficacy and safety of adjunctive intra-arterial adenosine following successful EVT in patients with acute ischemic stroke due to LVO. Trial registry numberChiCTR2400092051 (www.chictr.org.cn).

BackgroundMiddle meningeal artery embolization (MMAE) has emerged as an adjunct or alternative strategy for the management of chronic subdural hematoma (cSDH). Although accumulating studies suggest potential benefit, uncertainty remains regarding its safety profile, recurrence-prevention effect, and the reliability of adverse event reporting. This systematic review and meta-analysis re-evaluate contemporary evidence, incorporating new randomized trials and large observational cohorts. MethodsThis systematic review was conducted in accordance with PRISMA 2020 guidelines and prospectively registered in PROSPERO. PubMed, Scopus, Web of Science Core Collection, Embase, and CENTRAL were searched from inception to 12 September 2025 without language restrictions. Randomized controlled trials, prospective or retrospective cohort studies, and non-randomized clinical studies evaluating middle meningeal artery embolization (MMAE) for chronic subdural hematoma were eligible. Data extraction and risk-of-bias assessment were performed independently using Joanna Briggs Institute appraisal tools. Where outcomes were sufficiently comparable, quantitative synthesis was undertaken using random-effects single-arm proportion meta-analysis with logit transformation. Recurrence after MMAE was pooled across observational studies and MMAE arms of randomized trials with available event-level data, with prespecified subgroup analyses by study design. Mortality was synthesized from randomized trials reporting event-level data within a [&le;]90-day follow-up window. Complication rates and technical success were analyzed descriptively due to heterogeneity in definitions and follow-up durations. ResultsNineteen studies met eligibility criteria, including seven randomized controlled trials, sixteen retrospective cohorts, and one prospective cohort, comprising an elderly and medically complex population (mean ages 61-89 years). Common comorbidities included hypertension, diabetes, cardiovascular and cerebrovascular disease, renal dysfunction, and antithrombotic use. Technical success of middle meningeal artery embolization (MMAE) was consistently high, with a pooled success rate of 100% (95% CI 0.99-1.00; I2 = 0%). Recurrence after MMAE was consistently low across randomized and observational studies, including high-risk populations, and was uniformly lower than in comparator groups. Radiographic outcomes showed substantial hematoma volume reduction and high rates of complete or near-complete resolution, with favorable functional recovery. Complications were uncommon but heterogeneous; the pooled overall complication rate was 14% (95% CI 0.08-0.21). Pooled 90-day all-cause mortality from randomized trials was 8% (95% CI 0.07-0.10; I2 = 0%). ConclusionMMAE is a safe and effective adjunctive or alternative treatment for chronic subdural hematoma, demonstrating a reproducible and clinically meaningful reduction in recurrence across randomized and observational datasets with homogeneous outcome definitions. However, variability in adverse event reporting, insufficient documentation of rare complications, and inconsistent definitions of radiographic versus clinical recurrence highlight the need for standardized outcome frameworks and harmonized follow-up protocols. Future well-designed trials with robust adverse event adjudication are essential to define the long-term safety profile of MMAE and to guide its optimal integration into cSDH management pathways.

Optimal blood pressure (BP) management following endovascular treatment (EVT) for acute ischemic stroke (AIS) secondary to intracranial large vessel occlusion remains unestablished. The randomized HOPE trial (Hemodynamic Optimization of Cerebral Perfusion after Successful Endovascular Therapy in Patients with Acute Ischemic Stroke) (NCT04892511) seeks to determine if a strategy of hemodynamic optimization using different systolic BP targets, tailored to the degree of final recanalization, is superior to standard BP management in improving functional outcomes for these patients. This document outlines the final Statistical Analysis Plan (SAP) for the trial. This plan will be executed after the last follow-up is complete and the dataset has been locked.

BACKGROUNDSteno-occlusive diseases of the internal carotid artery (ICA) or middle cerebral artery (MCA) can lead to hemodynamic impairment, yet conventional imaging often fails to reflect metabolic dysfunction. Integrated positron emission tomography and magnetic resonance imaging (PET/MRI) allows simultaneous assessment of cerebral blood flow (CBF) and glucose metabolism. This study compared baseline perfusion and metabolic characteristics between patients receiving medical therapy or extracranial-intracranial (EC-IC) bypass surgery. METHODSThis retrospective study enrolled 34 patients with unilateral ICA/MCA stenosis or occlusion confirmed by digital subtraction angiography. All patients underwent 18F-FDG PET/MRI before treatment. Glucose metabolism was quantified using the cerebral metabolic rate of glucose (CMRGlu) from dynamic PET and the standard uptake value ratio (SUVR) from static PET. CBF was measured using three-dimensional arterial spin labeling with post-labeling delays of 2.0 and 2.5 seconds. Perfusion and metabolic parameters were compared across vascular territories. RESULTSBaseline clinical characteristics and long-term outcomes did not differ between groups (all P>0.05). Cerebral blood flow was similar across all arterial territories and post-labeling delays, with no hemispheric asymmetry detected (all P>0.05). In contrast, glucose metabolism was significantly lower in the surgical group, with reduced CMRGlu in the ischemic middle cerebral artery (23.58{+/-}7.46 vs 18.82{+/-}5.04mol/100g-1/min-1, P=0.037) and anterior cerebral artery territories (26.37{+/-}8.76 vs 20.71{+/-}5.78mol/100g-1/min-1, P=0.034). No differences were observed in the posterior cerebral artery or in SUVR across all regions (all P>0.05). CONCLUSIONSDespite similar perfusion profiles, the surgical group demonstrated lower glucose metabolism, suggesting that metabolic imaging may aid in identifying patients who could benefit from revascularization.

Background: Platform trials are an efficient trial design which enable testing of multiple interventions simultaneously. They could advance knowledge of treatments for intracerebral haemorrhage (ICH). We aimed to investigate the views of clinicians involved in stroke research on recruitment to a future platform trial for ICH. Methods: Between April and July 2025, we conducted a UK-wide online survey of clinicians actively involved in stroke research using convenience sampling through professional organisations. Participants considered factors related to the consent process and research environment and could provide optional free text responses about additional barriers or facilitators to recruitment. We used descriptive statistics for quantitative data and content analysis for qualitative data. Results: Among 73 respondents, 46 (63%) were female, 36 (50%) were stroke physicians, 24 (34%) nurses, 6 (8%) allied health professionals, and 7 (10%) were in other roles. 36 (49%) had >20 years of clinical experience, 45 (61%) reported spending <10% of their role in research. 66 (91%) thought that a platform trial would be a good option for testing interventions for patients with stroke due to ICH. Across 11 modifiable factors, clinicians most frequently rated perceived importance of the research question as a facilitator of recruitment (94%), while clinician preference for specific treatments was most frequently rated as a barrier (48%). Two themes emerged from free text responses: study design and infrastructure. Regarding study design respondents perceived consent procedures (n=9), study materials (n=8), study procedures (n=8), eligibility assessment (n=6), the research question (n=3) and randomization (n=3) as important for a future platform trial. Regarding infrastructure, emergent factors were staffing (n=17), local research culture and capacity (n=9), research governance and delivery (n=6), and training (n=6). Conclusion: The overwhelming majority of respondents from the UK clinical stroke community supported a platform trial for ICH, although the influence of survey responder bias is unknown.

BackgroundSuboptimal adherence to preventive medications and inadequate management of risk factors are major barriers to effective post-discharge care for individuals at high risk of stroke, particularly in resource-constrained settings. Digital health interventions delivered via widely accessible platforms offer a promising scalable approach. We conducted this trial to evaluate the efficacy of Social Network based patient care in improving medication adherence in high-risk populations for stroke. MethodCOMPLIANCE-MT is a multicenter, prospective, randomized, open-label, parallel-group trial with blinded outcome assessment (PROBE design) assessing the superiority of Social Network-based care versus conventional care in medication adherence for high-risk populations for stroke. A total of 720 participants will be recruited across 33 hospitals in China and randomized in a 1:1 ratio to either a 12-month Social Network (WeChat) based coordinated care program or routine follow-up. The primary outcome is the proportion of patients achieving more than 80% adherence to all indicated vascular prevention medications (antihypertensives, hypoglycemics, lipid-lowering agents, anticoagulants, and antiplatelets) at 12 months. Analysis will be performed on an intention-to-treat approach. DiscussionThe COMPLIANCE trial evaluates a social network-based intervention in improving adherence to five evidence-based vascular prevention medications in both primary prevention and secondary prevention. If proven effective, this model could inform national strategies for preventing strokes in resource-limited settings. Trial registration: ClinicalTrials.gov NCT05963828.

BackgroundRecurrent ischemic stroke remains a major concern in patients with nonvalvular atrial fibrillation (NVAF) despite anticoagulation. However, not all NVAF-related strokes are purely cardioembolic--concomitant large artery steno-occlusion (cLASO) is frequently observed and may represent an independent contributor to stroke recurrence. Current guidelines address these cases but focusing almost exclusively on the cardioembolic source. This approach contrasts sharply with the management of acute coronary syndrome in patients with NVAF, where identifying and targeting the culprit lesion is standard practice. We evaluated whether the presence and clinical relevance of cLASO predict stroke recurrence in NVAF-related acute ischemic stroke (AIS). MethodsThis prospective multicenter cohort study enrolled 2,035 patients with NVAF-related AIS at 14 stroke centers in South Korea between October 2017 and April 2020. Patients underwent brain magnetic resonance imaging and angiography. cLASO, defined as any degree of stenosis or occlusion in major cerebral arteries, was categorized by anatomical severity (mild, moderate-to-severe, or occlusion) and clinical relevance. Clinically relevant cLASO was defined as a steno-occlusive lesion topographically concordant with the infarction, thereby sufficiently explaining the index stroke regardless of concurrent cardioembolic source; otherwise, lesions were classified as bystander. The primary outcome was recurrent ischemic stroke within 3 years, analyzed using competing risk analysis. ResultsAmong 2,035 patients (mean age, 74.9 years; 54.8% male), 1,308 (64.3%) had cLASO, and 583 (28.6%) had clinically relevant cLASO. The 3-year cumulative incidence of recurrent ischemic stroke was 7.0%, with over 40% of recurrences occurring within the first month. Recurrence risk increased significantly with cLASO presence (4.5% vs. 8.1%), severity (mild, 5.7%; moderate-to-severe, 9.7%; occlusion, 9.1%) and clinical relevance (bystander, 3.8%; relevant, 13.9%) (all Ps < 0.05). In multivariable analysis, clinical relevance--rather than severity--was independently associated with recurrence (aHR, 4.10; 95% CI, 2.57-6.54). ConclusionsClinically relevant cLASO identifies a mechanistically distinct, high-risk phenotype that warrants a paradigm shift from a uniform cardioembolic model toward a lesion-specific approach. The early clustering of recurrence suggests an urgent window for intervention. This well-characterized phenotype may represent a potential target population for future trials evaluating intensified antithrombotic strategies that address both cardioembolic and atherothrombotic pathways. Clinical PerspectiveO_ST_ABSWhat is New?C_ST_ABSO_LITwo-thirds of patients with AF-related stroke harbor concomitant large artery steno-occlusion (cLASO), yet current guidelines provide no recommendations for this common dual-mechanism scenario C_LIO_LIThis prospective multicenter study introduces a novel classification distinguishing clinically relevant cLASO from bystander atherosclerosis; only clinical relevance--not anatomic severity--independently predicted stroke recurrence, conferring a fourfold increased risk. C_LIO_LIOver 40% of recurrences occurred within the first month, with relevant cLASO conferring a 6.0% early recurrence risk--substantially exceeding reported annual major hemorrhage risks in landmark anticoagulant trials. C_LI What Are the Clinical Implications?O_LIAF-related stroke is mechanistically heterogeneous; assuming all cases are cardioembolic may lead to suboptimal risk stratification and missed opportunities for targeted prevention. C_LIO_LIRoutine vascular imaging should assess not merely stenosis severity, but topographic concordance with the infarct pattern--a straightforward approach using standard DWI and MRA that can be applied in diverse healthcare settings. C_LIO_LIThe early clustering of recurrence in patients with relevant cLASO highlights a critical unmet need and identifies a well-characterized target population for future trials evaluating intensified antithrombotic strategies. C_LI

ObjectiveTo define contemporary medium and long term survival and durability outcomes after elective fenestrated and branched endovascular aortic repair (F/BEVAR) for complex abdominal and thoracoabdominal aneurysms and to assess the certainty of the available evidence. Data SourcesMEDLINE, Embase and the Cochrane Library were searched from January 2000 to February 2026, supplemented by citation screening. Review MethodsPublished Kaplan Meier time-to-event data were digitised and reconstructed into individual patient datasets. Pooled survival probabilities were generated using validated methods for meta-analytic methods for survival curves. Certainty of evidence was assessed using the GRADE framework. ResultsTwenty-four studies comprising 8,886 patients were included. Pooled overall survival was 91.3% (95% CI: 90.7, 91.9) at 1 year, 73.0% (95%CI: 71.9, 74.0) at 3 years and 55.4% (95% CI: 53.9, 56.8) at 5 years. Estimated median overall survival was 6.36 years. At 5 years, freedom from aneurysm-related mortality was 96.4% (95%CI: 95.3, 97.2), freedom from reintervention was 66.5% (95%CI: 64.6, 68.2), and target vessel patency (TVP) was 94.8% (95%CI: 93.3, 96.0). Certainty of evidence was low for overall survival, aneurysm related mortality and reintervention, and very low for TVP. ConclusionElective F/BEVAR provides durable aneurysm exclusion with low aneurysm related mortality; however, long term survival declines substantially. There is a need for more robust survival data and improved tools to support patient selection, shared decision making, and assessment of anticipated benefit when considering prophylactic complex endovascular repair. What this paper addsThis study provides a time-to-event synthesis of medium and long term outcomes after elective F/BEVAR for complex abdominal and thoracoabdominal aortic aneurysms, analysing reconstructed survival data from 8,886 patients across 24 studies published between 2000 and 2025. This analysis provides empirical survival data to inform recent European Society for Vascular Surgery guidance, demonstrating a median survival of 6.36 years and showing that most late deaths are not aneurysm related. These findings quantify the divergence between procedural durability and long term survival, supporting an individualised treatment strategy grounded in assessment of life expectancy, competing risk and shared decision making.

ObjectiveA comparative analysis was conducted on the rehabilitation effects of limb functions in patients with post-stroke yawning-induced parakinesia brachialis oscitansysis (PBO), patients without PBO, and patients whose PBO naturally disappeared after the onset of the disease. MethodsThe study included ischemic stroke patients diagnosed and treated in our hospital from March 2024 to June 2024. Patients were divided into two groups: the PBO group and the non-PBO group, based on whether PBO was administered. Propensity score matching was employed to account for all covariates and perform a 1:2 matching to balance the baseline characteristics of the two groups. The matched data were used for subsequent analysis to observe the Lovett scores and FMA scores of the two groups 3 months after the onset. For 33 patients with PBO, they were divided into two groups: the persistent group and the disappearing group, based on whether the PBO lasted for more than 1 month. The Lovett scores and FMA scores of the two groups were observed 3 months after the onset. ResultsAfter propensity score matching, there were 26 patients in the PBO group and 52 patients in the non-PBO group. The baseline characteristics of the two groups were basically balanced, and the difference was not statistically significant (P>0.05). Compared with the non-PBO group, the Lovett scores and FMA scores of the PBO group 3 months after the onset were higher, and the difference was statistically significant (P < 0.05). Compared with the PBO persistent group, the FMA score of the PBO disappearing group 3 months after the onset was higher than that of the persistent group, and the difference was statistically significant (P < 0.05). There was no statistically significant difference in Lovett muscle strength between the two groups (P > 0.05). ConclusionThe functional recovery of patients with PBO was better than that of patients without PBO manifestation 3 months after the initial diagnosis. Moreover, patients whose PBO appeared first and then disappeared had better functional recovery than those whose PBO persisted.

IntroductionStroke disproportionately affects minoritised ethnicities. While quantitative evidence has shown a difference in stroke risk and type of care received between UK ethnicity groups, qualitative data is sparse. We sought to explore experiences of in-hospital and community-based care from stroke survivors and caregivers from minoritised ethnicities.DD MethodsAudio recorded semi-structured interviews were conducted with stroke survivors and caregivers who self-identified as a minoritised ethnicity (e.g., Black, South Asian). Interviews covered experiences of incorporating cultural, religious, and/or dietary needs into stroke care, whether they perceived care was affected by ethnicity or cultural background, and ways to make care more culturally inclusive. Interviews were transcribed verbatim and analysed using reflexive thematic analysis. ResultsTwenty-four participants (n=16 stroke survivors, n=8 caregivers) took part. Themes included feeling different from a "typical" stroke survivor and affinity with British cultural norms ("I Feel Different in Stroke Care"); valuing culturally inclusive care but not always receiving it ("Culturally Inclusive Stroke Care is Important but Inconsistent"); individual perceptions of whether ethnicity affected care ("Personal Interpretations of the Role of Ethnicity in Stroke Care"); and tensions between caregivers advocating for cultural needs versus community perspectives of stroke ("Families Champion Stroke Survivors Cultural Needs, What about the Community?"). ConclusionsStroke survivors from UK minoritised ethnicity groups may feel "out of place" in care and may not receive sufficient cultural support. Individual interpretations of ethnicity, and affinity to British culture, affected perspectives on stroke care. Further efforts should be made to include culture and religion within person-centred stroke care.DD

AbstractsO_ST_ABSBackgroundC_ST_ABSSelf-management is essential for stroke survivors to maintain a healthy lifestyle and reduce recurrence risk. Although theory-based self-management interventions are widely recommended, the theoretical frameworks underpinning them and their comparative effectiveness remain unclear. AimsTo systematically identify the theories, models, and frameworks (TMFs) used in self-management interventions for stroke survivors, to explore how they guide interventions, and evaluate their effectiveness on self-management behaviors and self-efficacy. MethodsPubMed, Embase, Web of Science, ProQuest Health & Medical Collection and the Cochrane Library were searched from inception to July 15, 2025. Randomized controlled trials or quasi-experimental studies evaluating theory-based self-management interventions for stroke survivors were included. Two reviewers independently screened studies, extracted data, and assessed risk of bias (Cochrane RoB 2.0). Meta-analyses were performed using random-effects models. ResultsFrom 11,495 records, 32 studies with 3,212 participants were included. Sixteen distinct TMFs were identified; self-efficacy theory was most frequent (13/32), followed by social cognitive theory (6/32). All TMFs were middle-range theories. Meta-analysis showed TMFs-based interventions significantly improved self-management behaviors (SMD = 4.26, 95%CI: 0.20-8.31, I{superscript 2} = 98.2%) and self-efficacy (SMD = 0.60, 95%CI: 0.32-0.88, I{superscript 2} = 72.8%). However, the effect for behaviors is likely inflated due to extreme heterogeneity and theoretical diversity. Theory-specific analysis of self-efficacy theory (k = 8) confirmed significant effects on self-efficacy (SMD = 0.64, 95%CI: 0.21-1.08). ConclusionsThis review identified 16 distinct theoretical models; self-efficacy theory was most frequently applied, followed by social cognitive theory. Theory-based interventions significantly improved self-management behaviours and self-efficacy.

ObjectiveTo compare early cerebrospinal fluid (CSF) cytokine profiles in intracerebral hemorrhage (ICH) versus subarachnoid hemorrhage (SAH), with a focus on angiography-negative SAH (anSAH). MethodsWe conducted a retrospective observational cohort study of adults with spontaneous hemorrhagic stroke (ICH or SAH). For cytokine analyses, we included patients with external ventricular drains (EVDs) and analyzed the first CSF sample obtained within 72 hours of symptom onset. Cytokines were measured using a multiplex bead-based assay and included interleukin-6 (IL-6), interleukin-8 (IL-8), vascular endothelial growth factor A (VEGF-A), C-C motif chemokine ligand-2 (CCL2), and granulocyte colony-stimulating factor (G-CSF). Cytokine concentrations were log-transformed due to non-normal distribution. Functional outcomes were assessed using the modified Rankin Scale (mRS) at discharge and 3 months. ResultsCSF cytokine analyses included 120 patients with available CSF samples (43 ICH and 77 SAH), while functional outcome analyses included a broader cohort of 490 patients with ICH or SAH to characterize discharge and 3-month outcomes across hemorrhage subtypes. Compared with SAH, ICH demonstrated higher early CSF log[IL-8] and log[VEGF-A] and had worse functional outcomes at discharge and 3 months. Within SAH, anSAH had higher log[IL-8] and log[VEGF-A] than aSAH, and its cytokine profile more closely aligned with that of primary ICH in hemorrhages without vascular malformations. DiscussionEarly CSF cytokine patterns suggest anSAH shares a more ICH-like inflammatory signature than aneurysmal SAH, supporting anSAH as a potentially biologically distinct SAH phenotype.

ObjectiveTo evaluate whether novice, non-specialist operators can rapidly learn to use a handheld near-infrared (NIR) head scanner and maintain scan quality after brief training, supporting its use for point-of-care triage when computed tomography is unavailable or delayed. MethodsThirty-two right-handed adults with no prior NIR experience received a brief standardized training session ([~]2 minutes) on the ArcheOptix NIRD(R) device, which detects intracranial hemorrhage by tracking hemoglobin absorption during guided scalp scans. Operators then completed two full-head scans on a healthy volunteer: an initial competency assessment (Scan 1) and a follow-up assessment after one day without refresher training (Scan 2). Performance metrics included total scan time, frequency of repeat scans prompted by loss of contact or light leaks, and mean scanpath time as an index of handling efficiency and consistency. Scan quality was evaluated using Lift on dark and Noise on dark indices. User experience was measured after each scan with the 10-item System Usability Scale (SUS, 0-100). Within-participant changes were analyzed with paired t tests or Wilcoxon signed-rank tests. ResultsAll operators completed both sessions. Median performance improved from Scan 1 to Scan 2, with total scan time decreasing from 5 min 27 s to 2 min 53 s. The proportion of "Excellent" scans (<5 minutes) increased from 50% to 84%, and "Poor" scans (>10 minutes) fell to zero. Repeat scans per session declined from 38 to 24, and mean scanpath time shortened while becoming more consistent. Lift on dark and Noise on dark remained stable, indicating no degradation in signal quality as operators worked faster. SUS scores improved from 69.4 to 76.5, reflecting higher perceived ease of use and confidence. ConclusionsAfter minimal training, novice operators achieved rapid, reliable NIR scans with faster performance, fewer repeat scans, stable signal quality, and improved usability ratings. This work shows that portable NIR can practically complement CT by helping prioritize transport and focus scarce imaging resources in emergency, sideline, and remote head trauma triage.