I would like to express my sincere gratitude to the European Stroke Organisation (ESO) for granting me the opportunity to participate in the Department to Department Visit Programme. This experience offered an exceptional chance to expand my clinical and research competencies in stroke medicine, gain insights into a leading European stroke centre, and establish valuable professional connections.

My decision to choose UKE Hamburg as my host institution was straightforward. UKE has an outstanding reputation in stroke care, research, and innovation, and has played a significant role in several landmark clinical trials, including the WAKE-UP study, which investigated MRI-guided thrombolysis in wake-up strokes. The organisation of the visit was smooth and efficient, and I am deeply grateful to Prof. Dr. Götz Thomalla, who was exceptionally supportive and welcoming, as well as to Tamara Wichmann (Assistant to the Clinic Director) for her kind and helpful coordination.

Stroke Unit

During my stay, I was integrated into the daily workflow of UKE’s modern and well-organised Stroke Unit, which includes 10 single-bed rooms, two three-bed rooms, and two two-bed rooms.

My activities included:

• Participation in the evaluation of patients presenting with ischemic stroke, TIA, and hemorrhagic stroke,
• Differential diagnosis of acute neurological deficits, including stroke mimics,
• Attendance and participation in morning rounds with senior neurologists and residents,
• Observation of workflow, multidisciplinary communication, and logistics of the unit, from admission to discharge,
• Exposure to the use of echocardiography (TTE/TEE) and long-term ECG monitoring in stroke diagnostics,
• Daily admission and case discussion meetings,
• Insight into patient flow, decision-making pathways, and rapid diagnostic processes within a highly coordinated stroke centre.

Other Departments
Functional Diagnostics Laboratory

I visited the Functional Diagnostics Laboratory, where I had the opportunity to deepen my understanding of EEG usage in both outpatient settings and critical care.

Emergency Department

I spent several sessions in the Emergency Department, observing the acute triage and management of neurological patients. My activities included:

• Assessment of differential diagnoses, such as metabolic disturbances, seizures, migraines, and functional disorders,
• Observation of the acute stroke workflow, from prehospital notification to imaging and treatment decisions,
• Participation in the evaluation of both neurological and non-neurological emergencies.

Neuroradiology Department

In the Neuroradiology Department, I observed several interventional procedures, including:

• Coiling of intracranial aneurysms,
• Stenting of carotid artery,
• Imaging evaluation and treatment planning for complex neurovascular pathologies.

These experiences highlighted the importance of close collaboration between neurologists and interventional neuroradiologists.

Neurovascular Board

I attended the Neurovascular Board meetings, where neurologists and interventional neuroradiologists reviewed and discussed complex cases, arteriovenous malformations, carotid stenosis, and other challenging diagnostic and therapeutic cases. These multidisciplinary discussions offered valuable insights into structured decision-making and evidence-based treatment planning.

Personal Experience and Impressions

Hamburg is a vibrant and beautiful city, and I found it a very enjoyable place to stay. The atmosphere at UKE was extremely welcoming. My mentor, Priv.-Doz. Dr. Bastian Cheng, as well as all team members, were friendly, open, and always willing to explain clinical reasoning or procedures in detail. I felt fully integrated into the team and appreciated the collegial environment throughout my stay. A huge thank you to them!

Conclusions

My visit to UKE Hamburg was enriching both professionally and personally. I gained valuable clinical experience in stroke diagnostics and acute management, advanced my understanding of neurovascular interventions, and deepened my knowledge of essential diagnostic modalities.

Witnessing the organisation and efficiency of stroke care in a high-volume, research-active centre was particularly inspiring. I am deeply grateful to the European Stroke Organisation for supporting this programme and to UKE Hamburg for hosting me so warmly. This experience will significantly contribute to my future clinical work, academic development, and dedication to the field of stroke medicine.

The experience I had in Oxford and the knowledge I acquired over the past six months were highly meaningful and allowed me to grow both professionally and personally. This was made possible in part thanks to the funding provided by the European Stroke Organisation through its Department to Department Visit Programme. I am therefore very grateful for this support, as this research placement has enabled me to enrich my current project, which involves the application of a novel therapy using functional electrical stimulation coupled to a P300-based brain–computer interface for upper limb motor rehabilitation in chronic stroke survivors.

Spending six months studying and conducting research in Oxford was the most unique and special experience. At first, it was difficult to realise not only the fact that I was at one of the oldest universities in the world—where some of the brightest minds in history once shared the same libraries, laboratories, and lecture halls in which I was now standing—but also that the historic and quaint nature of its buildings, streets, and colleges creates the illusion that time has stood still, making you feel in a fairy tale or Harry Potter story.

Additionally, I was able to get the most out of my time in Oxford under the mentorship of Prof. Charlotte Stagg and Prof. Melanie Fleming, who served as my host co-supervisors within the Physiological Neuroimaging and Plasticity groups at the Oxford Centre for Integrative Neuroimaging. From the moment I arrived, I felt very welcome in their laboratories, and I was particularly impressed by the pleasant and friendly working environment I found there, where everyone was willing to help, fostering a dynamic of collaboration and cooperation that I greatly enjoyed.

Moreover, I would like to highlight the amazing academic and scientific activities in which I participated during my research stay. I learned how to analyse neuroimaging studies obtained from subjects in the project we are conducting in Mexico, including magnetic resonance imaging and electroencephalography studies. In addition, I also had the opportunity to get involved and assist in a clinical trial at the John Radcliffe Hospital, where we applied beta transcranial electrical stimulation to improve upper extremity motor recovery in stroke individuals. Furthermore, through various workshops, I learned how to apply other non-invasive brain stimulation and neuromodulation techniques, and I attended conferences, seminars and symposia that allowed me to appreciate different approaches and methodologies to conduct research.

Finally, I was not only able to learn and benefit from my time in Oxford, but I was also able to contribute my own skills. This included doing physical examination assessments for the clinical trial in which I participated in, as well as training other students on how to perform and evaluate different clinical scales used to assess motor function and recovery in stroke patients, given I was previously trained at a tertiary rehabilitation center in Mexico, the National Institute of Rehabilitation Luis Guillermo Ibarra Ibarra. The above demonstrates that bidirectional collaboration is possible and that both parties can learn and enrich each other.

The concept of brain health has gained increasing relevance in stroke care. Beyond its traditional definition as optimal cognitive, emotional, and physical function, brain health is increasingly recognised as a determinant of stroke risk and long-term neurological outcomes. Preserving brain health supports cognitive reserve and may prevent vascular and neurodegenerative disease. Stroke and dementia represent a growing global health burden, particularly in ageing populations¹. Silent cerebral small vessel disease contributes early to disease development and can be detected by neuroimaging markers such as white matter hyperintensities (WMH) long before cognitive impairment becomes clinically apparent².

Evidence underscores the importance of modifiable risk factors in preserving brain structure and function. Up to 40 % of dementia cases are attributable to such factors, highlighting opportunities for early intervention.¹ Hypertension, diabetes, dyslipidaemia and smoking remain the most important, already well-established determinants of impaired brain health. Their cumulative effects accelerate cerebral small vessel disease and increase the risk of ischemic and hemorrhagic events. Identification and management of these factors remain the cornerstone of stroke prevention.³

As these mechanisms are well established, they are not discussed in detail here. Instead, the following section focuses on additional modifiable factors and their underlying pathophysiological mechanisms that complement vascular risk management and offer further opportunities to preserve brain health. Accumulating evidence indicates that regular physical exercise can improve learning and memory and attenuate neurodegeneration by enhancing neuroplasticity through alterations in synaptic structure and function, supporting angiogenesis and glial activity, and maintaining a cerebral microenvironment conducive to synaptic plasticity. All these mechanisms are thought to underlie exercise‑induced benefits for brain health.⁴ Even moderate levels of sustained activity are associated with meaningful neurocognitive benefits.⁵ Adequate sleep is equally important. Chronic sleep disruption is linked to cognitive impairment and an increased susceptibility to neurodegenerative processes.⁶ Nutrition influences brain health through modulation of neuroinflammation and oxidative stress, with dietary patterns such as the Mediterranean diet consistently associated with reduced cognitive decline.⁷ Stress represents an additional, often under-recognised modifier of brain health and chronic stress can contribute to vascular injury. Behavioral interventions including mindfulness-based strategies or cognitive-behavioural approaches may improve vascular risk factors.⁸

Despite growing evidence, practical implementation of brain health concepts in stroke care remains limited and translating these insights into individualised interventions is challenging. The Brain Care Score (BCS) was developed as a simple tool that offers a broader construct of brain health than conventional scores by integrating physiological, lifestyle and social determinants. Unlike other risk-based tools such as Framingham, CAIDE or ASCVD, it is structured as a “positive” health metric, with higher values indicating more favourable behavioural and physiological profiles, empowering patients to take actionable steps toward improvement.⁹

It has been shown that a higher BCS is associated with a reduced risk of both dementia and stroke, underscoring the overlap in targeted prevention.⁹ A higher BCS was also linked to reduced WMH load and attenuated progression of white matter microstructural changes over time¹⁰. Ongoing studies aim to examine its predictive value for structural brain changes and cognitive deficits.

In conclusion brain health is strongly influenced by modifiable factors across the lifespan. Tools such as the BCS may help patients identifying their risk for stroke and dementia and guide behaviour change.

1. Livingston, G. et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. The Lancet 396, 413–446 (2020).
2. Zeestraten, E. A. et al. Change in multimodal MRI markers predicts dementia risk in cerebral small vessel disease. Neurology 89, 1869–1876 (2017).
3. Boehme, A. K., Esenwa, C. & Elkind, M. S. V. Stroke Risk Factors, Genetics, and Prevention. Circulation Research 120, 472–495 (2017).
4. Lin, T.-W., Tsai, S.-F. & Kuo, Y.-M. Physical Exercise Enhances Neuroplasticity and Delays Alzheimer’s Disease. Brain Plast 4, 95–110 (2018).
5. Augusto-Oliveira, M. et al. Exercise Reshapes the Brain: Molecular, Cellular, and Structural Changes Associated with Cognitive Improvements. Mol Neurobiol 60, 6950–6974 (2023).
6. Gottesman, R. F. et al. Impact of Sleep Disorders and Disturbed Sleep on Brain Health: A Scientific Statement From the American Heart Association. Stroke 55, (2024).
7. Franco, G. A., Interdonato, L., Cordaro, M., Cuzzocrea, S. & Di Paola, R. Bioactive Compounds of the Mediterranean Diet as Nutritional Support to Fight Neurodegenerative Disease. IJMS 24, 7318 (2023).
8. Zhang, X.-F. et al. Effects of mindfulness-based interventions on cardiovascular risk factors: An umbrella review of systematic reviews and meta-analyses. J Psychosom Res 177, 111586 (2024).
9. Singh, S. D. et al. The predictive validity of a Brain Care Score for dementia and stroke: data from the UK Biobank cohort. Front. Neurol. 14, 1291020 (2023).
10. Rivier, C. A. et al. Brain Care Score and Neuroimaging Markers of Brain Health in Asymptomatic Middle-Age Persons. Neurology 103, e209687 (2024).

Overview of Training and Activities

1. Acute Stroke Management: I studied the algorithms of emergency management for acute ischemic stroke, including the administration of thrombolytic agents (tenecteplase) and mechanical thrombectomy. A key point of interest was the clinical approach to using tenecteplase (TNK) as an alternative to alteplase, with individualised dose selection. I also familiarised myself with the rapid diagnostic workflow involving CT, MRI, and perfusion imaging, aimed at minimising door-to-needle time and optimising patient outcomes.
2. Work in the Stroke Unit: I observed patient care in the Stroke Unit under continuous neurological and cardiovascular monitoring. I participated in discussions on early rehabilitation planning with the multidisciplinary team (neurologists, physiotherapists, speech therapists, occupational therapists, and neuropsychologists). I learned about standardised clinical protocols focused on early recovery of motor and cognitive functions following stroke.
3. Diagnostics and Prevention: I became acquainted with modern diagnostic approaches for identifying the etiology of stroke — including cardiogenic, vascular, hematologic, and rare genetic causes. I studied contemporary approaches to lipid-lowering therapy, including the use of high-dose statins and dual-component therapy to achieve aggressive cholesterol reduction. I participated in consultations on secondary prevention, including the management of patients with TIA and cryptogenic stroke.

Academic and Educational Component

During the visit, I attended clinical case discussions and educational sessions dedicated to: The comparison of Inselspital’s stroke management protocols with national practices. The exchange of experience in diagnostic and therapeutic strategies in acute stroke; Observation of the role of teamwork and process standardisation in achieving high-quality patient outcomes.

Conclusions and Implementation of Knowledge

1. The knowledge and skills acquired during the visit will contribute to improving the quality of acute stroke care, particularly in optimising the time intervals before thrombolytic therapy initiation.
2. I plan to evaluate the feasibility of implementing tenecteplase-based protocols for ischemic stroke within the framework of national guidelines.
3. My competence in selecting and managing intensive lipid-lowering therapy has been enhanced, which will improve strategies for preventing recurrent vascular events.
4. The experience gained in multidisciplinary teamwork and rehabilitation planning will be applied to increase the efficiency of post-stroke recovery in my home institution.

The observership at Inselspital Bern, under the supervision of Dr. Seiffge, Dr. Bücke, and Dr. Birner, provided me with invaluable exposure to advanced European standards in stroke management and vascular neurology. The acquired knowledge will be implemented in my daily practice to improve the quality and effectiveness of stroke care in my department.

Acknowledgement

I would like to express my sincere gratitude to the European Stroke Organisation (ESO) for awarding the grant that made the D2D Visiting Programme possible. The support of the ESO has significantly contributed to my professional development and to international collaboration in vascular neurology.

Firstly, I sincerely thank the European Stroke Organisation and Prof. Dr. Daniel Bos for providing me with the opportunity to visit Erasmus MC, Rotterdam in June 2025 through the D2D Visit Programme. The visit offered an ideal combination of professional development, clinical teaching, interdisciplinary collaboration, new project ideas, and memorable experiences.

My passion for stroke care has grown significantly in recent years, leading me to combine my neurology residency with a doctoral research project focused on stroke. A key component of my PhD is an imaging sub-study of a randomised clinical trial, aiming to improve diagnostic and therapeutic strategies for stroke patients with atherosclerosis. I have collected and analysed more than 500 CTA and NCCT scans, assessing plaque characteristics to improve risk stratification in patients with vulnerable plaques.

Prof. Dr. Daniel Bos is a recognised expert in the field of extra- and intracranial atherosclerosis. The ESO Department-to-Department Visit Programme provided me with the opportunity to further analyse these scans using advanced software that enables detailed assessment of plaque volume and composition. In addition, we were able to initiate a new project focusing on intracranial atherosclerosis, thereby expanding our research collaboration.

From the very beginning, I was warmly welcomed by Prof. Bos and his team, whose support and enthusiasm made the experience both productive and enjoyable. During my two-week stay in Rotterdam, I had the opportunity to work closely with the Radiology Department on our ongoing collaborative research projects. I also visited the Neurology Department and participated in teaching activities with medical students and residents. Beyond the professional aspects, I also took the time to explore Rotterdam during a few “running breaks” and visited Hoek van Holland in beautiful weather.

In summary, it was a true privilege to visit Erasmus MC and the city of Rotterdam. I was delighted to learn that ESOC 2026 will be held in Maastricht, right on the border between the Netherlands and Belgium — a great opportunity to reconnect with the Erasmus MC team. I would once again like to express my sincere gratitude to the ESO for offering me the opportunity to participate in the D2D Visit Programme.

Early in my career, I embarked on what I believed was a groundbreaking project: exploring molecular and genetic biomarkers of Moyamoya disease and leveraging artificial intelligence to identify predictors of clinical outcome. The vision was ambitious—combining advanced techniques including omics with machine learning to improve prognostic accuracy in a such a rare and complex cerebrovascular disorder. Our team invested months in designing the study, building collaborations, and drafting a comprehensive grant proposal. I was confident this project was successfully funded allowing to improve personalised medicine in Moyamoya.

The outcome, however, was not what I expected. The funding application was rejected. The initial reaction was a mix of disappointment and self-doubt. When a project you deeply believe in is turned down, it feels like a personal failure. But after the first wave of frustration, I realised that resilience in research is not about avoiding setbacks—it’s about transforming them into stepping stones. I carefully reviewed the reviewers’ comments and understood that the main concern was the proposed team strenght and feasibility. In fact the proposal lacked preliminary data to support the integration of AI models with biomarker analysis.

Instead of abandoning the idea, we shifted strategy. We started creating an Italian network of centers involved in clinical and reaserch of Moyamoya disease to collect a dataset of clinical and biological data and evaluated molecular markers in a smaller cohort. This process not only strengthened the scientific foundation but also expanded our network of collaborators, including data scientists and bioinformaticians. Months later, we resubmitted a revised proposal—and this time, it was funded. Today, the project is generating insights on molecular biomarkers of Moyamoya disease and we are working on the prediction model development that may help predict outcomes and guide treatment decisions in Moyamoya disease.

What did I learn? First, rejection is not the end—it is feedback. Second, resilience is not passive endurance; it is active adaptation. In research, flexibility and persistence are as important as innovation. Finally, collaboration is key: complex challenges require multidisciplinary approaches and open minds.

As Chair of the ESO Education Committee, I often remind young researchers that science is rarely a straight path. It is a journey with detours, and those detours teach us how to navigate better. Embrace setbacks, learn from them, and keep moving forward—because resilience is the true engine of discovery.

The 26th webinar of the European Stroke Organisation’s educational series focused on the critical topic, “When the weather strikes: understanding stroke risk in the era of climate extremes”. Moderated by Dr Marieta Peycheva and Dr Vojtech Novotny, the session was delivered by two expert neurologists.

The first speaker, Dr. Vasileios Tentolouris Piperas (from the National and Kapodistrian University of Athens, Greece), presented evidence linking air pollution and wildfires to increased stroke risk. Climate change, defined as a long-term shift in average weather patterns, is contributing to an increase in intense and destructive wildfires. In Europe alone, approximately 1 million hectares were burned in 2025 up to October 28th, an area equivalent to Montenegro. Wildfires are significant sources of pollution, as well as the energy production industry and the urban traffic. One of the main air pollutants is the Particulate Matter (PM) 2.5, extremely small particles associated with cerebrovascular risk. The talk highlighted that outdoor air pollution is now recognised as the second most important modifiable risk factor globally for stroke-related disability, according to the 2025 World Stroke Organisation fact sheet. Epidemiological data confirms that exposure to wildfires or high PM 2.5 concentrations leads to a short-term rise in cerebrovascular events, especially within the first few days and among adults over 65. Long-term exposure also increases stroke incidence and mortality. The mechanisms involve the activation of sensory receptors in the respiratory system, leading to a sympathetic response (vasospasm/arrhythmias); an inflammatory response causing oxidative stress and hypercoagulable states; and the potential translocation of particles that contribute to platelet aggregation and atherosclerotic plaque formation. It was suggested that future interventions should focus on reducing pollution in high-risk areas globally, such as South Asia and Northern Africa, but also monitor susceptible areas in Europe, like the Mediterranean and the Balkans.

The second speaker, Professor Anita Arsovska (from the University Clinic of Neurology, University Ss Cyril and Methodius in Skopje, North Macedonia), discussed how ambient temperature extremes and rapid fluctuations affect stroke occurrence, defining climate change as a fundamental threat to human health. Research consistently links both high and low temperatures to increased stroke events, though the pattern differs by stroke subtype. Ischemic stroke risk peaks during warmer months and is associated with heat extremes and heat waves, with effects often immediate, occurring within the first four days. In contrast, intracerebral hemorrhage shows a stronger association with cold temperatures. The effects of cold often exhibit a longer lag, extending up to 30 days, reflecting delayed consequences of cold-induced blood pressure changes. Rapid temperature fluctuations (e.g., changes between 5 and 8 degrees Celsius) also increase stroke risk. Pathophysiologically, extreme cold triggers vasoconstriction and hypertension, increasing hemorrhagic risk, while extreme heat leads to dehydration and hypercoagulable states, increasing ischemic risk. The elderly and those with comorbidities like heart failure are highly vulnerable. It was proposed that public health strategies should include early warning systems using machine learning models combined with weather data to forecast high-risk days and enhance hospital preparedness. Furthermore, incorporating temperature risk into discharge planning and patient counseling is crucial.

Finally, during the Q&A session, the speakers agreed that incorporating climate-related risk factors into professional education and national registries is an essential next step for the stroke community.

Learn more about our Educational Webinars: ESO Educational Webinars -European Stroke Organisatoin

This report follows my one-week observership at the Istituto Neurologico Carlo Besta in Milan, Italy, under the mentorship of Dr. Anna Bersano. Earlier this year, in March, I had the privilege of attending the ESO Focused Workshop on Cerebral Amyloid Angiopathy (CAA), organised by Dr. Bersano’s team. Returning in September for this observership provided a natural and enriching continuity: the insights gained during the workshop became the foundation for the clinical experiences and impressions I developed during my stay.

From the very first day, the institute’s rich heritage and reputation were immediately evident. Founded in 1918 and officially recognised by the Italian government as an Institute of Research and Treatment since 1981, Carlo Besta Institute seamlessly blends tradition with cutting-edge clinical and research excellence. I was intrigued to learn that Newsweek ranks the institute among the world’s leading specialised neurology hospitals—a recognition that is clearly reflected in both the care provided and the quality of ongoing research.

My observership was profoundly enriched by the mentorship of Dr. Anna Bersano, whose expertise as Director of the Cerebrovascular Unit made the experience both educational and inspiring. Her generous guidance enabled me to engage fully with both the clinical and scientific dimensions of advanced cerebrovascular medicine.

The primary focus of my stay was on rare cerebrovascular diseases, including Moyamoya disease, CADASIL, and cerebral amyloid angiopathy. I was particularly struck by the meticulous care with which each patient’s journey was approached: reconstructing clinical histories, and integrating neuroimaging and biomarker insights into a cohesive diagnostic and therapeutic strategy. A defining strength of the institute is its truly multidisciplinary approach, especially in managing highly complex neurosurgical and endovascular cases. I had the opportunity to observe detailed planning and execution of treatments for arteriovenous malformations, dural fistulas, and complex aneurysms. One of the most impressive aspects was witnessing surgical treatment for Moyamoya disease, where cerebral bypass procedures offered patients renewed hope and quality of life. The seamless collaboration between neurologists, neurosurgeons, and interventional neuroradiologists was exemplary, representing an outstanding level of integration.

Equally impressive was the work of the Laboratory of Cellular Neurobiology, led by Dr. Laura Gatti. Her team conducts highly specialised investigations and in-depth biomarker analyses essential for diagnosing of cerebral small vessel diseases. Observing the precise and effective translation of laboratory science into clinical decision-making was profoundly enlightening, reaffirming the institute’s stature as a center of excellence. My daily rhythm at Carlo Besta Institute was intensive and deeply inspiring. Mornings were spent on the ward, discussing and examining patients, while afternoons were devoted to outpatient follow-ups with patients affected by rare cerebrovascular disorders. In parallel, I was able to engage with ongoing research activities, further enriching my experience.

Throughout my visit, I felt genuinely welcomed by the entire team. I am especially grateful to Dr. Benedetta Storti, Dr. Nikola Rifino, Dr. Isabella Canavero, Dr. Irene Scala and psychologists Giulia Marinoni and Carolina De Toma, who created an open, collegial, and intellectually stimulating environment. Their willingness to share knowledge and involve me in clinical reasoning processes made me feel part of the team, despite the brief nature of my stay.

I returned home with not only new knowledge but also a strong sense of connection—to the people, to the institute, and to a global community dedicated to advancing the understanding and treatment of rare cerebrovascular disorders.

With deep gratitude, I wish to thank Dr. Anna Bersano for her exceptional mentorship and leadership, as well as my colleagues for their generosity, kindness, and dedication. My week in Milan was more than a professional milestone—it was a personal inspiration. It was a true privilege to witness the highest standards of care and research in the field of rare vascular diseases.

Learn more about the Emerging Leader Programme here:

https://eso-stroke.org/resources/emerging-leader-programme/

and explore the D2D Programme here:

https://eso-stroke.org/resources/department-to-department-visit-programme/

The latest ESO Educational Webinar on Small Vessel disease was moderated by Professor Anna Bersano from Milan, Italy, chair of the ESO Educational Committee and by Dr Marieta Peycheva, Vascular Neurologist from Plovdiv, Bulgaria.

The first captivating presentation was delivered by Dr. Lina Palaiodimou, Assistant Professor of Neurology at the National and Kapodistrian University of Athens, Greece. She discussed three illustrative cases of small vessel disease (SVD), engaging the audience in an online poll on several clinically relevant issues.

The first case concerned a patient with covert SVD, a condition associated with at least a twofold increased risk of stroke and dementia. Dr. Palaiodimou highlighted the absence of specific guidelines for managing such cases and the considerable variability in treatment decisions among physicians, an issue reflected in the audience’s responses to the related poll question.

The second case concerned an acute minor but disabling thalamic stroke, for which 60% of the audience voted in favor of intravenous thrombolysis (IVT). Dr. Palaiodimou noted that IVT for disabling lacunar stroke is recommended by the ESO guidelines.

The final case addressed the dilemma of administering IVT in patients with cerebral microbleeds (CMBs). In accordance with the ESO guidelines, IVT may be withheld when >10 CMBs are present. However, performing a brain-MRI prior to IVT solely to exclude multiple CMBs is not recommended. Finally, in patients with acute ischemic stroke (AIS) and atrial fibrillation who present with multiple CMBs, the most common practice is to use non–vitamin K oral anticoagulants (preferably apixaban) combined with strict blood pressure (BP) control.

In turn, Hugh Markus, Professor of Stroke Medicine at the University of Cambridge, UK, delivered an excellent talk on the diagnosis and management of SVD. He noted that SVD, a condition with a very high prevalence, is a common cause of AIS and the leading cause of intracerebral hemorrhage (ICH) and vascular dementia. Moreover, SVD frequently coexists and interacts with other etiologies of dementia.

Next, Professor Markus focused on the diagnosis of acute lacunar stroke which typically affects at least two body parts, and highlighted the importance of brain MRI, as patients with typical clinical lacunar syndromes may sometimes have other causes not clear on CT imaging, such as multiple infracts due to an embolic source.

Regarding treatment, Professor Markus discussed the results of the SPS3 and SPIRIT trials, which demonstrated an increased risk of bleeding with long-term dual antiplatelet therapy (DAPT) or oral anticoagulation compared with aspirin in patients with recent lacunar stroke. Accordingly, long-term single antiplatelet therapy is recommended.

Moreover, strict BP control is of paramount importance, as supported by the results of the SPRINT trial and it is the associated SPRINT MRI and SPRINT-MIND substudies, which demonstrated that intensive BP lowering to a systolic of 120mmHg ( compared with standard lowering to 140mmhg)  reduced the risk of cardiovascular events, and also white matter lesion progression, and cognitive decline. According to the PRESERVE study, intensive BP management is also safe in patients with severe SVD, and does not result in cerebral hypoperfusion.

Finally, targeting neurovascular unit dysfunction (endothelial cell injury, BBB leakage and inflammation) opens up a new treatment approach for SVD.

During the Q&A session, the audience raised clinical questions concerning the optimal duration of DAPT after lacunar AIS, the intensity of diabetes management, and the impact of SVD burden on acute recanalisation therapies for AIS.