clinical – European Stroke Organisation

In Memoriam – Professor Emeritus Nils Wahlgren

Carine Legio — Wed, 25 Feb 2026 09:50:59 +0000

25/02/2026/in ESO, Stroke Research /by Carine Legio

It is with deep sorrow that we announce the sudden passing of Professor Emeritus Nils Wahlgren.

Professor Wahlgren was a visionary leader in stroke medicine and a pioneer whose work transformed acute stroke care across Europe and beyond. He founded the SITS International Stroke Thrombolysis Registry, creating a global platform that has shaped clinical practice and research for decades. As the leading investigator of the SITS-MOST study, he laid the scientific foundation for the approval of intravenous thrombolysis in acute ischemic stroke in Europe — a milestone that has benefited countless patients.

Nils also served as Chairman of the Karolinska Stroke Update from 1996 until his retirement, fostering international collaboration and advancing knowledge in the field of stroke medicine. At Karolinska University Hospital, he was the driving force behind the establishment of the Hyperacute Stroke Triage (HASTA) system in the Stockholm region and a strong advocate for the implementation of endovascular treatment in stroke care. His vision, determination, and unwavering commitment have enabled us today to work in a field that is both scientifically pioneering and profoundly meaningful.

Beyond his remarkable professional achievements, Nils was a colleague, mentor, and friend to many. He meant an extraordinary amount of colleagues at SITS, as well as to colleagues at Karolinska Institutet and Karolinska University Hospital, where many shared long and close professional and personal relationships with him.

We remember him with warmth, laughter, and gratitude — and with great pride in all that he accomplished during his lifetime. His legacy will continue to inspire future generations of clinicians and researchers.

Our thoughts are especially with his family, whom we came to know through his vivid and loving stories. We extend our heartfelt condolences to them during this difficult time.

Memoria eius in operibus vivit.

–

Simona Sacco, ESO president

Niaz Ahmed, Professor of Neurology, Karolinska Institutet, Senior consultant Karolinska University Hospital, FESO

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In memory, Hans-Henning Eckstein

Carine Legio — Tue, 05 Mar 2024 14:54:55 +0000

05/03/2024/in ESO, Stroke Research /by Carine Legio

–

Prof. Dr. med. Dr. h. c. Hans-Henning Eckstein passed away on February 24, 2024, at the age of 68 after long illness.

The graduate of Heidelberg University’s Faculty of Medicine became a vascular surgeon, senior physician, and associate professor at the Department of Vascular Surgery at Heidelberg University Hospital. In 2004, he was elected Chair and Professor of the Department of Vascular and Endovascular Surgery at the University Hospital “Rechts der Isar” of the Technical University of Munich (TUM).

Professor Eckstein has made this department known far beyond the borders of Munich and developed it into a leading center for patients with vascular diseases with a focus on aortic and carotid diseases. He retired in autumn 2023. Professor Eckstein was President of the German Society for Vascular Surgery and Vascular Medicine (DGG) from 2009 to 2010 and made a significant contribution to the forward-looking multimodal orientation of the discipline.

His leading role in randomized controlled trials on symptomatic and asymptomatic carotid stenosis made him well-known in vascular neurology. He was co-chair of the steering committee of SPACE and SPACE 2 representing vascular surgery in both multicenter trials. In this role, he was instrumental in defining the demanding quality requirements for the participating vascular surgery departments. He also managed to motivate other vascular surgeons to participate in these randomized trials, even at the risk that their patients might end up in the stenting or conservative treatment arm – not an easy task, as we all know.

He played a leading role in the development of national and international guidelines for carotid surgery, including the German S3 guideline on the diagnosis, treatment, and follow-up of patients with carotid stenosis and the ESO guideline for carotid stenosis.

In 2017, Professor Eckstein was awarded an honorary doctorate from the medical faculty of the University of Larisa in Greece for his achievements in the field of vascular surgery. Since 2019, he has also been a visiting professor at the Medical School of Pittsburgh and at Stanford University.

We are deeply saddened by the death of Hanns-Henning Eckstein. Our sincere condolences go out to his wife Dr. Jutta Eckstein, his three children, and his entire family. In Hans-Henning Eckstein we have lost an extremely dedicated colleague and excellent physician, an outstanding researcher, university lecturer, bridge-builder between vascular surgery and neurology, and a friend.

Werner Hacke and Peter Ringleb, Heidelberg

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In memory, Ralph L Sacco, MD MS FAHA FAAN

Michele Schaub Jackson — Fri, 20 Jan 2023 17:55:33 +0000

20/01/2023/in ESO, Stroke Research /by Michele Schaub Jackson

–

Our esteemed friend and colleague, Ralph Sacco, died peacefully on January 17^th in New York in the company of his family. He will be greatly missed. Ralph was Olemberg Family Chair in Neurological Disorders and Professor of Neurology at Leonard M Miller School of Medicine at the University of Miami.

Ralph grew up in New Jersey in a busy Italian-American family, and was the first of his family to go to medical school. After completion of his undergraduate degree at Cornell University, he did his medical degree at Boston University, where he first discovered his lasting passion for stroke prevention, working under the mentorship of Philip Wolf on the Framingham Study. By the time he was an intern, he had published his first two lead-author papers on stroke risk, an early marker of his star qualities. He completed his training with a Neurology residency in Columbia University Medical Centre in New York, followed by a Masters in Epidemiology, before joining the faculty at Columbia.

From the beginning, Ralph championed the importance of stroke, with particular focus on prevention in minority and under-served communities, who had been often overlooked in earlier studies. At Columbia, he established the Power to End Stroke initiative with the American Heart Association, focussing on stroke prevention in African-American communities, and the multi-ethnic Northern Manhattan Study (NOMAS). Through his work on NOMAS and related studies, he produced an important body of clinical science clarifying the role of modifiable risk factors for stroke across ethnic groups in the USA, which has informed subsequent policy and prevention initiatives. In 2007, Ralph was appointed Chair of Neurology at the University of Miami. He continued his research in Florida, leading the foundation of initiatives such as the Florida Stroke Registry, Florida-Puerto Rico Collaboration to Reduce Stroke Disparities, and the Family Study of Stroke Risk and Carotid Atherosclerosis. He was also instrumental in driving translational research via his leadership of the University of Miami Clinical and Translational Science Institute.

Ralph joined the American Heart Association as a medical student in the 1980s. He remained a lifelong committed volunteer in the AHA, chairing the Stroke Advisory Committee from 2005-2008, and was elected President in 2010, the first neurologist to hold this position. Typically, in his inauguration speech, he emphasised his goals to increase the focus on stroke and cardiovascular prevention in minority American communities. In 2017 he was elected President of the American Academy of Neurology, the first time that a neurologist had led both AAN and AHA, and served on the World Stroke Organisation Board of Directors. In 2020, he was appointed Editor-in-Chief of the AHA journal Stroke.

A regular visitor to ESOC and Europe, Ralph had many friends and scientific collaborators in ESO, with whom he was always excellent company, often accompanied by good food and wine. He was highly supportive of younger colleagues, which I experienced personally at our first meeting at ISC in the late 1990s. He will be remembered as an outstanding Clinician-Scientist, a role model, a leader, and a friend to many in the field of Stroke Medicine.

Ní bheidh a leithéid ann arís (We will not see his like again soon).

–

Peter Kelly,

University College Dublin

President, European Stroke Organisation

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Thrombectomy vs. thrombectomy plus intravenous alteplase – Full results of SWIFT DIRECT and DIRECT-SAFE

Meaghan Dreyer — Mon, 11 Jul 2022 09:05:45 +0000

Märit Jensen, MD, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Clinical Stroke and Imaging Research (CSI) group

Follow on Twitter: @CSI_Lab

Thrombectomy alone fails to show non-inferiority compared with thrombectomy plus intravenous alteplase – Full results of SWIFT DIRECT and DIRECT-SAFE published in The Lancet

Over the past years there has been a controversial debate over the additional value of intravenous thrombolysis prior to mechanical thrombectomy in patients with large vessel occlusion. Doubts about the effect of intravenous thrombolysis for large thrombi and concerns about potential risks, mainly the risk of intracerebral hemorrhage, have motivated a series of clinical trials comparing thrombectomy alone to thrombectomy plus intravenous thrombolysis.

Previous studies yielded controversial results. Two trials from China (DIRECT-MT and DEVT)^{1, 2} found direct thrombectomy to be non-inferior to thrombectomy plus intravenous thrombolysis. However, these trials have been criticized for different reasons including wide non-inferiority margins and organizational aspects as well as rather long door-to-needle time for alteplase. In contrast, two further trials from Europe (MR CLEAN-NO IV)³ and Japan (SKIP)⁴ did not show non-inferiority.

In the current issue of The Lancet two further trials on this research question have been published which will likely end the debate.

SWIFT DIRECT⁵ randomized 423 patients with stroke due to large vessel occlusion referred to 42 endovascular centers in Europe and Canada to either thrombectomy alone or intravenous thrombolysis plus thrombectomy. Primary outcome was a score of 2 or less on the modified Rankin scale at 90 days, and a non-inferiority margin of 12% was prespecified. Overall, rates of favorable outcome were high in both groups (57% in the thrombectomy alone group and 65% in the thrombectomy plus thrombolysis group). The adjusted risk difference was -7.3% with the lower limit of one-sided 95% CI of -15.1 crossing the predefined non-inferiority margin of -12%. Thus, thrombectomy alone was not shown to be non-inferior to thrombolysis plus thrombectomy. There were no differences in the frequency of symptomatic intracranial hemorrhage between the groups (2% vs. 3%) nor for any other safety endpoints. On the other hand, successful reperfusion was less common in the thrombectomy alone group.

The study is to be commended for the high quality of treatment in all participating centers reflected by short procedural times, high recanalization rates and an overall high percentage of patients achieving good functional outcome. In SWIFT DIRECT, rigorous inclusion and exclusion criteria ensured enrollment of a population most likely to benefit from thrombectomy alone. Nevertheless, point estimates favored combined treatment of intravenous alteplase plus thrombectomy. In patients below the age of 70, thrombectomy alone was even significantly less effective with lower odds of independent outcome at 90 days as compared to thrombectomy plus alteplase. SIWFT DIRECT also yield novel findings. The rates of postinterventional reperfusion where higher with combined treatment, which provides a likely explanation for the favorable outcome shifts observed in patients treated with alteplase plus thrombectomy.

The second trial, DIRECT-SAFE⁶ randomized 295 patients in 24 centers in Australia, New Zealand, China and Vietnam. The primary outcome was also an mRS score of 0-2 at 90 days, with a non-inferiority margin of -0.1. As in SWIFT DIRECT the trial did not show non-inferiority. Patients treated with thrombectomy alone had numerically lower rates of functional independence (55% vs. 61%) with a risk difference of -0.051 (95% CI -0.160 to 0.059). Safety outcomes were also comparable between the groups. In contrast to SWIFT DIRECT, DIRECT-SAFE also allowed for the use of Tenecteplase (17% of patients in the combined treatment group) and for enrollment of patients with M2 or basilar artery occlusion. Of note, almost half of the patients were enrolled in Asian regions, and in a region-based subgroup analysis Asian patients with combined treatment even showed significant better outcomes than those treated with thrombectomy alone. This makes it unlikely that the previous contrary results from the Chinese trials (DIRECT-MT and DEVT) are specific for Asian patients.

The main results of SWIFT DIRECT and DIRECT-SAFE are in line with those of MR CLEAN-NO IV and SKIP. Taken together, these four trials provide a clear answer to the question whether intravenous thrombolysis can be omitted prior to thrombectomy in patient with large vessel occlusion stroke. The answer is no, thrombolysis should not be omitted in these patients unless there are contraindications against intravenous thrombolysis.

References

Yang P, Zhang Y, Zhang L, Zhang Y, Treurniet KM, Chen W, et al. Endovascular thrombectomy with or without intravenous alteplase in acute stroke. N Engl J Med. 2020;382:1981-1993
Zi W, Qiu Z, Li F, Sang H, Wu D, Luo W, et al. Effect of endovascular treatment alone vs intravenous alteplase plus endovascular treatment on functional independence in patients with acute ischemic stroke: The devt randomized clinical trial. JAMA. 2021;325:234-243
LeCouffe NE, Kappelhof M, Treurniet KM, Rinkel LA, Bruggeman AE, Berkhemer OA, et al. A randomized trial of intravenous alteplase before endovascular treatment for stroke. N Engl J Med. 2021;385:1833-1844
Suzuki K, Matsumaru Y, Takeuchi M, Morimoto M, Kanazawa R, Takayama Y, et al. Effect of mechanical thrombectomy without vs with intravenous thrombolysis on functional outcome among patients with acute ischemic stroke: The skip randomized clinical trial. JAMA. 2021;325:244-253
Fischer U, Kaesmacher J, Strbian D, Eker O, Cognard C, Plattner PS, et al. Thrombectomy alone versus intravenous alteplase plus thrombectomy in patients with stroke: an open-label, blinded-outcome, randomised non-inferiority trial. The Lancet. 2022;400:104-15
Mitchell PJ, Yan B, Churilov L, Dowling RJ, Bush SJ, Bivard A, et al. Endovascular thrombectomy versus standard bridging thrombolytic with endovascular thrombectomy within 4·5 h of stroke onset: an open-label, blinded-endpoint, randomised non-inferiority trial. The Lancet. 2022;400:116-25

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Cerebral venous thrombosis, HIT and VITT: from antibodies to management

Michele Schaub Jackson — Sat, 25 Jun 2022 12:10:29 +0000

Michele Romoli, MD, PhD, FEBN – Neurology and Stroke Unit, Bufalini Hospital, Cesena, Italy

Diana Aguiar de Sousa, MD, PhD, Stroke Center, Lisbon Central University Hospital, Lisboa; Instituto de Medicina Molecular; Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal

Follow Michele Romoli and Diana Aguiar de Sousa on Twitter.

Cerebral venous thrombosis (CVT) is a less common type of stroke, happening approximately in 1.5:100’000 adults¹. A surge of interest in CVT has developed over the last years, particularly in relation to the recent pandemic. As COVID-19 spread through nations, and vaccination campaigns rolled out worldwide, reports on CVT during infection or after immunization have accumulated^2,3. Several factors can contribute to CVT, including oral contraception, pregnancy or hormonal treatments, thrombophilia, cancer and several medications. Often CVT can be a first manifestation of a systemic condition. Examples of this type of situation can be when CVT develops as part of an autoimmune-mediated thrombocytopenia, as for heparin-induced thrombocytopenia (HIT)⁴ or as part of a vaccine-induced thrombocytopenia (VITT), with thrombosis happening also at other uncommon sites^3,5.

After heparin exposure, heparin-induced thrombocytopenia (HIT) can develop, with a concrete risk of developing thrombosis at both arterial and venous sites^4,6. HIT, either in classical and autoimmune form, is not just a drug-induced thrombocytopenia, as it is based on an autoimmune process, which also justifies the timing of onset, usually 5 days after heparin exposure. In classical HIT, antibodies form against platelet factor 4 (PF4), a tetramer that has an heparin-binding site but also heparin-independent binding sites for other antigens⁷. In HIT, heparin-dependent antibodies against PF4 form PF4/heparin/IgG immune complexes. This leads to moderate platelet consumption and thrombin formation, with a prothrombotic state. Such mechanism differs from other drug-induced thrombocytopenia (e.g., vancomycin), which usually have a steep decrease in platelet count, due to direct platelet clearance (disruption). Is CVT common in HIT? Based on a recent systematic review, CVT develops in 1.6% of people with HIT⁴. Despite being uncommon, HIT-related CVT carries a 82% rate of hemorrhagic lesions and has a 33% mortality, which is higher compared to CVT without HIT, but also compared to HIT alone⁴. Management is based on withdrawing heparin, as this promotes the formation of PF4/heparin/IgG complexes, and use of non-heparinoid anticoagulants, including vitamin-K antagonists or direct oral anticoagulants⁴. As a delay in identification translates into less accurate management, early suspicion is crucial.

VITT develops in relation to heparin-independent antibodies, although also with formation of PF4/IgG complexes leading to platelet consumption, clearance and pancellular activation⁷. VITT represents a very rare adverse effect of adenovirus-based SARS-CoV2 vaccines that may occur in the first 30 days after vaccination with ChAdOx1 nCov-19⁸, especially in younger age groups⁹. Thrombocytopenia can be severe, and thrombosis can happen at unusual sites, including the splanchnic vein. CVT is critically more frequent in VITT compared to HIT, a further point suggesting that main or secondary pathophysiological mechanisms differ⁴. VITT diagnostic criteria also include low platelet count (<150 × 10⁹/L), elevated plasma D-dimer levels (>0.5 mg/L), and positive test for anti-PF4 (platelet factor 4) antibodies^8,10. Management has to focus on immediate immunomodulation, including intravenous immunoglobulin (1 mg/kg/d for 2 days) and/or plasma exchange. Anticoagulation can be started directly with non-heparinoids, although it is currently not clear whether heparin has a deleterious effect¹¹, and platelet transfusion should be avoided unless for treating a life-threatening bleeding or before surgery¹⁰.

Despite sharing an autoimmune mechanism, VITT and HIT differ for thrombotic complications and mortality. Despite the rarity of this syndrome, CVT is critically more frequent in VITT compared to HIT⁴. Efforts should be made to adhere to treatment recommendations, as this might improve survival¹².

References

Coutinho JM, Zuurbier SM, Aramideh M, et al. The Incidence of Cerebral Venous Thrombosis. Stroke 2012; 43: 3375–3377.
Baldini T, Asioli GM, Romoli M, et al. Cerebral venous thrombosis and severe acute respiratory syndrome coronavirus-2 infection: A systematic review and meta-analysis. Eur J Neurol. Epub ahead of print 2021. DOI: 10.1111/ene.14727.
See I, Su JR, Lale A, et al. US Case Reports of Cerebral Venous Sinus Thrombosis with Thrombocytopenia after Ad26.COV2.S Vaccination, March 2 to April 21, 2021. JAMA – J Am Med Assoc 2021; 325: 2448–2456.
Aguiar de Sousa D, Romoli M, Sánchez Van Kammen M, et al. Cerebral Venous Thrombosis in Patients With Heparin-Induced Thrombocytopenia a Systematic Review. Stroke 2022; 53: 1892–1903.
Schultz NH, Sørvoll IH, Michelsen AE, et al. Thrombosis and Thrombocytopenia after ChAdOx1 nCoV-19 Vaccination. N Engl J Med 2021; 384: 2124–2130.
Warkentin TE. Think of HIT. Hematol Am Soc Hematol Educ Progr 2006; 408–414.
Warkentin TE. Platelet-activating anti-PF4 disorders: An overview. Semin Hematol 2022; 59: 59–71.
Pavord S, Scully M, Hunt BJ, et al. Clinical Features of Vaccine-Induced Immune Thrombocytopenia and Thrombosis. N Engl J Med 2021; 1–10.
Krzywicka K, Van De Munckhof A, Van Kammen MS, et al. Age-Stratified Risk of Cerebral Venous Sinus Thrombosis after SARS-CoV-2 Vaccination. Neurology 2022; 98: E759–E768.
Ferro JM, Sousa DA de, Coutinho JM, et al. European stroke organization interim expert opinion on cerebral venous thrombosis occurring after SARS-CoV-2 vaccination. Eur Stroke J 2021; 6: CXVI–CXXI.
Singh A, Toma F, Uzun G, et al. The interaction between anti-PF4 antibodies and anticoagulants in vaccine-induced thrombotic thrombocytopenia. Blood 2022; 139: 3430–3438.
Scutelnic A, Krzywicka K, Mbroh J, et al. Management of cerebral venous thrombosis due to adenoviral COVID-19 vaccination This article is protected by copyright . All rights reserved . DOI: 10.1002/ana.26431.

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The power of translational research for acute ischemic stroke

Carine Legio — Fri, 17 Jun 2022 11:33:12 +0000

‘3D angiographies of our swine model of recanalized acute ischemic stroke during baseline, occlusion and recanalization.’

Aladdin Taha^1,2, MD; Joaquim Bobi¹, DVM, PhD; Diederik W.J. Dippel², MD, PhD; Heleen M.M. van Beusekom¹, PhD.

Erasmus MC University Medical Center, Division of Experimental Cardiology, Department of Cardiology, Rotterdam, the Netherlands.
Erasmus MC University Medical Center, Stroke Center, Department of Neurology, Rotterdam, the Netherlands.

Follow Erasmus MC University Medical Center and Joaquim Bobi on Twitter to stay up to date with the latest news

Large animal modeling

Despite numerous successful drug studies in rodents, translation of promising results to men has turned out to be a great challenge in acute ischemic stroke (AIS) research.¹ To prevent futile clinical trials in humans, STAIR and RIGOR guidelines recommend studies in multiple species, including a gyrencephalic species.^2,3 Rather than rodents, large animal gyrencephalic species allow for studies in a larger brain, with a structure that is more similar to the human brain. Larger species, such as swine, dogs, sheep and non-human primates can undergo imaging and catheterization procedures using the exact same clinical devices to further increase translational capacity. Furthermore, the larger circulating volume provides many opportunities in biomarker research that can be matched to clinical trial sampling strategies.

As part of the pre-clinical work package of the CONTRAST-Consortium we recently published a review comparing large gyrencephalic animals being used in translational AIS research, together with international leading experts in this field.⁴ In this review, we compared benefits and challenges of four species, aimed to assist researchers in selecting the appropriate model for their studies. In Rotterdam, we decided to work with the swine model. It is a well-characterized model in cardiovascular research and offers many opportunities for integrating comorbidities in AIS modeling.^5,6

Cerebral ischemia-reperfusion in swine

We have set-up a swine model for cerebral ischemia-reperfusion, allowing us to study the additional value of neuroprotective treatments in the setting of a recanalized AIS. The model is established in both farm-bred swine and adult minipigs, and was presented at ESOC 2022.⁷ Working with swine allows us to use clinical MRI and CT-scanners, and (3D) digital subtraction angiography, which can be combined with extensive histopathological and ultrastructural outcome measures. Adding comorbidities such as atherosclerosis, hypertension and diabetes can further increase the translational power of these models.

Vessel wall injury due to Endovascular Treatment (EVT)

Following a study on endothelial injury due to coronary interventions,⁸ we studied vascular injury and healing due to stent-retriever and direct aspiration treatment in a swine model of autologous thrombo-embolic occlusion. Selecting arteries with similar size and anatomy to the human MCA, using the exact same EVT devices as in clinic, and having the opportunity to study the luminal damage and repair at an ultrastructural level is what makes this model particularly valuable. Our main goal is to understand injury and healing patterns, how this could affect patient outcome, and potentially optimize treatment strategies and pharmacologic treatment. The first results were presented at ESOC 2022.⁷ In addition, this model is used for EVT training and device optimization.

Combining the clinical and pre-clinical biobank

Within the CONTRAST-Consortium, we have built both clinical and pre-clinical biobanks of tissue, thrombus and serial plasma samples. For clinical studies,^9-11 thrombi removed during EVT and plasma samples are stored systematically. For pre-clinical studies, brain samples, thrombi and serial plasma samples are collected. This way, biomarker findings from animal studies can be validated in patient samples and vice versa. Additionally, having studied thrombus characteristics in patient thrombi,¹² we aim to recreate similar thrombi for our swine model of thrombo-embolic occlusion. This way, we link preclinical and clinical research. We hope that by this approach, we will improve our understanding of cerebrovascular disease mechanisms and progress, and ultimately, of ways to improve outcome not only of our animals but of our patients as well.

References

O’Collins VE, Macleod MR, Donnan GA, Horky LL, van der Worp BH, Howells DW. 1,026 experimental treatments in acute stroke. Ann Neurol. 2006;59:467-477. doi: 10.1002/ana.20741

Fisher M, Feuerstein G, Howells DW, Hurn PD, Kent TA, Savitz SI, Lo EH, Group S. Update of the stroke therapy academic industry roundtable preclinical recommendations. Stroke. 2009;40:2244-2250. doi: STROKEAHA.108.541128 10.1161/STROKEAHA.108.541128

Lapchak PA, Zhang JH, Noble-Haeusslein LJ. RIGOR guidelines: escalating STAIR and STEPS for effective translational research. Transl Stroke Res. 2013;4:279-285. doi: 10.1007/s12975-012-0209-2209

Taha A, Bobi J, Dammers R, Dijkhuizen RM, Dreyer AY, van Es A, Ferrara F, Gounis MJ, Nitzsche B, Platt S, et al. Comparison of Large Animal Models for Acute Ischemic Stroke: Which Model to Use? Stroke. 2022;53:1411-1422. doi: 10.1161/STROKEAHA.121.036050

van de Wouw J, Sorop O, van Drie RWA, van Duin RWB, Nguyen ITN, Joles JA, Verhaar MC, Merkus D, Duncker DJ. Perturbations in myocardial perfusion and oxygen balance in swine with multiple risk factors: a novel model of ischemia and no obstructive coronary artery disease. Basic Res Cardiol. 2020;115:21. doi: 10.1007/s00395-020-0778-210.1007/s00395-020-0778-2

van Ditzhuijzen NS, van den Heuvel M, Sorop O, van Duin RW, Krabbendam-Peters I, van Haeren R, Ligthart JM, Witberg KT, Duncker DJ, Regar E, et al. Invasive coronary imaging in animal models of atherosclerosis. Neth Heart J. 2011;19:442-446. doi: 10.1007/s12471-011-0187-0

ESOC 2022 Abstract Book. Eur Stroke J. 2022;7:3-588. doi: 10.1177/23969873221087559

Autar A, Taha A, van Duin R, Krabbendam-Peters I, Duncker DJ, Zijlstra F, van Beusekom HMM. Endovascular procedures cause transient endothelial injury but do not disrupt mature neointima in Drug Eluting Stents. Sci Rep. 2020;10:2173. doi: 10.1038/s41598-020-58938-z10.1038/s41598-020-58938-z

LeCouffe NE, Kappelhof M, Treurniet KM, Rinkel LA, Bruggeman AE, Berkhemer OA, Wolff L, van Voorst H, Tolhuisen ML, Dippel DWJ, et al. A Randomized Trial of Intravenous Alteplase before Endovascular Treatment for Stroke. N Engl J Med. 2021;385:1833-1844. doi: 10.1056/NEJMoa2107727

Pirson F, Hinsenveld WH, Goldhoorn RB, Staals J, de Ridder IR, van Zwam WH, van Walderveen MAA, Lycklama ANGJ, Uyttenboogaart M, Schonewille WJ, et al. MR CLEAN-LATE, a multicenter randomized clinical trial of endovascular treatment of acute ischemic stroke in The Netherlands for late arrivals: study protocol for a randomized controlled trial. Trials. 2021;22:160. doi: 10.1186/s13063-021-05092-010.1186/s13063-021-05092-0

van der Steen W, van de Graaf RA, Chalos V, Lingsma HF, van Doormaal PJ, Coutinho JM, Emmer BJ, de Ridder I, van Zwam W, van der Worp HB, et al. Safety and efficacy of aspirin, unfractionated heparin, both, or neither during endovascular stroke treatment (MR CLEAN-MED): an open-label, multicentre, randomised controlled trial. Lancet. 2022;399:1059-1069. doi: S0140-6736(22)00014-9 10.1016/S0140-6736(22)00014-9

Autar ASA, Hund HM, Ramlal SA, Hansen D, Lycklama ANGJ, Emmer BJ, de Maat MPM, Dippel DWJ, van der Lugt A, van Es A, et al. High-Resolution Imaging of Interaction Between Thrombus and Stent-Retriever in Patients With Acute Ischemic Stroke. J Am Heart Assoc. 2018;7. doi: JAHA.118.008563 10.1161/JAHA.118.008563

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Clinical implications of ischaemic core volume in acute stroke setting: beyond revascularization therapies

Lara Le Noan — Fri, 09 Oct 2020 08:09:37 +0000

09/10/2020/in ESO, Stroke Research /by Lara Le Noan

By Barbara Casolla, MD, PhD, Univ. Lille, Inserm U1172, Degenerative and Vascular Cognitive Disorders, CHU Lille, Department of Neurology, France

Twitter: @BarbaraCasolla

In the acute stroke setting, accurate estimation of ischemic core volume has important therapeutic and prognostic implications. However, ischaemic core volume thresholds need to be interpreted with caution. Indeed, type of neuroimaging and technical parameters impact reproducibility, intraobserver and interobserver variability and therefore, measurement results^1–4. Automated software limits human errors but introduce a software-related variability. Moreover, neuronal death “maturation” is a dynamic process, in both time and space, and delays of ischaemic core volume measurement from stroke onset also impact its clinical meaning.

Diffusion-weighted magnetic resonance imaging (DWI) measures cytotoxic edema: it has been considered the gold standard for ischemic core estimation and it is the most accurate method for prediction of malignant middle cerebral artery (MCA) infarct^4,5. Accordingly, infarct volume thresholds for decompressive hemicraniectomy (DH) indications are based on b-1000 DWI^6–8. However, in the era of mechanical thrombectomy, infarct volume measurement is routinely performed using semi-automatic methods based on apparent diffusion coefficient (ADC) maps⁹. Discrepancies between infarct volumes on b-1000 DWI and ADC are expected, because ischaemic region on b-1000 DWI contains voxels with a wide range of ADC values and potentially different physiopathological meanings. Therefore, using ADC maps instead of b-1000 DWI volumes for DH candidates may have implications for surgery indications and prognostic prediction. For instance, in patients treated with DH for large MCA infarcts, the cut off for the prediction of catastrophic outcome (defined as a modified Rankin Scale (mRS) of 5 or 6) differs according to the methods of measurement, with significantly higher optimal b-1000 DWI volume thresholds compared to ADC maps¹⁰. Importantly, b-1000 DWI and ADC volume thresholds seem to have similar sensitivity and specificity, suggesting that both of them can be used in clinical practice¹⁰.

Indeed, as elegantly discussed in a recent review, clinicians should be aware that the physiopathological meaning of the ischaemic core volume is uncertain and needs clinical interpretation in the real life⁴. This is an important field of research with many potential implications, for acute phase therapy and beyond.

REFERENCES

Brott T, Marler JR, Olinger CP, Adams HP, Tomsick T, Barsan WG, Biller J, Eberle R, Hertzberg V, Walker M. Measurements of acute cerebral infarction: lesion size by computed tomography. Stroke. 1989;20:871–875.
van der Worp HB, Claus SP, Bär PR, Ramos LM, Algra A, van Gijn J, Kappelle LJ. Reproducibility of measurements of cerebral infarct volume on CT scans. Stroke. 2001;32:424–430.
Schaefer PW, Souza L, Kamalian S, Hirsch JA, Yoo AJ, Kamalian S, Gonzalez RG, Lev MH. Limited Reliability of Computed Tomographic Perfusion Acute Infarct Volume Measurements Compared With Diffusion-Weighted Imaging in Anterior Circulation Stroke. Stroke. 2015;46:419–424.
Goyal M, Ospel JM, Menon B, Almekhlafi M, Jayaraman M, Fiehler J, Psychogios M, Chapot R, van der Lugt A, Liu J, et al. Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging. Stroke . 2020 ;Available from: https://www.ahajournals.org/doi/10.1161/STROKEAHA.120.030620
Oppenheim C, Samson Y, Manaï R, Lalam T, Vandamme X, Crozier S, Srour A, Cornu P, Dormont D, Rancurel G, et al. Prediction of Malignant Middle Cerebral Artery Infarction by Diffusion-Weighted Imaging. Stroke. 2000;31:2175–2181.
Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard J-P, Boutron C, Couvreur G, Rouanet F, Touzé E, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke. 2007;38:2506–2517.
Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, Amelink GJ, Schmiedeck P, Schwab S, Rothwell PM, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007;6:215–222.
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The post Clinical implications of ischaemic core volume in acute stroke setting: beyond revascularization therapies first appeared on European Stroke Organisation.

Stroke outcome prediction: new opportunities from Clinical Neurophysiology

Lara Le Noan — Fri, 02 Oct 2020 07:03:19 +0000

02/10/2020/in ESO, Stroke Research /by Lara Le Noan

By Giuseppe Reale, MD, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy

In daily clinical practice, it is common experience to be asked to formulate a stroke prognosis soon after the index event. This task requires caution and experience. The strongest stroke outcome predictor is clinical severity, while other additional predictors of outcome are age, infarct volume and location, aetiology, revascularization treatment and comorbidities1-6. Nevertheless, even if all the mentioned stroke outcome predictors are taken into account, it is easy to make mistakes.

In this view, Clinical Neurophysiology and its commitment to obtain objective, quantitative and reproducible measurements might offer new perspectives.

Non-invasive brain stimulation is a fascinating branch of Clinical Neurophysiology. Motor evoked potential (MEP) are electric signals recorded from the descending motor pathways or from muscles following a stimulation of the motor pathways within the brain. In a recently published study, Greve and Colleagues described that upper limb MEPs recovery during mechanical thrombectomy can predict three-months clinical outcomes7. In particular, during mechanical thrombectomy, they applied a transcranial electrical stimulation (TES) on the primary motor cortex and recorded MEPs from abductor pollicis brevis muscle bilaterally. The Authors of this study found that the return of a stable MEP (if absent at the baseline) or a >50% amplitude increase (if reduced at the baseline) was an outcome predictor stronger than successful recanalization (defined as TICI >2b). Moreover, MEP recovery was associated to small infarcts sparing the motor pathways descending from primary motor cortex.

Moving from single pathways to widespread brain networks, electroencephalography (EEG) analysis can describe with high temporal resolution the interdependent relationship between cortical areas in terms of synchronization (functional connectivity). Moreover, EEG can describe brain networks’ behavior analyzing each frequency band that lies under the electrical storm registered at the scalp. Each frequency band (alpha, beta, delta, theta and gamma) has its own generator and its own function, from “physiological” rhythms such as alpha, beta and gamma, to more “pathological” rhythms such as delta and theta. It has been demonstrated that acute ischemic stroke changes the “network signature” for each band and these modifications can predict functional outcome8,9.

From electrical waves to limb movement, a new frontier is sensors. Movement sensors can detect linear accelerations (acceleromters) or angular accelerations (gyroscopes). Actigraphy is a well-known technique usually used in sleep medicine, where it is possible to track sleep behavior using wristwatch-like accelerometers. However, several studies have provided evidence that spontaneous movements monitoring of paretic limb using actigraphy can be used to assess and monitor stroke clinical severity in both the acute and the chronic phase10,11 . From these data it is possible to obtain precise indices that describe the spontaneous movements of paretic limbs over a period of hours or days, giving precise information on the motor recovery trend.

This is just an overview on how an old-fashioned but ever extremely creative branch of the Neurosciences can provide a new insight on the difficult task of formulating a reliable stroke prognosis.

References
1. Adams HP, Davis PH, Leira EC, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. 1999;53:126-131.
2. Weimar C, König IR, Kraywinkel K, Ziegler A, Diener HC, German Stroke Study Collaboration. Age and National Institutes of Health Stroke Scale Score within 6 hours after onset are accurate predictors of outcome after cerebral ischemia: development and external validation of prognostic models. Stroke. 2004;35:158-162.
3. Petty GW, Brown RD, Whisnant JP, Sicks JD, O’Fallon WM, Wiebers DO. Ischemic stroke subtypes : a population-based study of functional outcome, survival, and recurrence. Stroke. 2000;31:1062-1068.
4. Paciaroni M, Caso V, Venti M, et al. Outcome in patients with stroke associated with internal carotid artery occlusion. Cerebrovasc Dis. 2005;20:108-113.
5. Schiemanck SK, Kwakkel G, Post MWM, Prevo AJH. Predictive value of ischemic lesion volume assessed with magnetic resonance imaging for neurological deficits and functional outcome poststroke: A critical review of the literature. Neurorehabil Neural Repair. 2006;20:492-502.
6. Sommer P, Posekany A, Serles W, et al. Is Functional Outcome Different in Posterior and Anterior Circulation Stroke? Stroke. 2018;49:2728-2732.
7. Greve T, Wagner A, Ille S, et al. Motor evoked potentials during revascularization in ischemic stroke predict motor pathway ischemia and clinical outcome. Clin Neurophysiol. 2020;131:2307-2314.
8. Caliandro P, Vecchio F, Miraglia F, et al. Small-World Characteristics of Cortical Connectivity Changes in Acute Stroke. Neurorehabil Neural Repair. 2017;31:81-94.
9. Vecchio F, Tomino C, Miraglia F, et al. Cortical connectivity from EEG data in acute stroke: A study via graph theory as a potential biomarker for functional recovery. Int J Psychophysiol. 2019;146:133-138.
10. Iacovelli C, Caliandro P, Rabuffetti M, et al. Actigraphic measurement of the upper limbs movements in acute stroke patients. J Neuroeng Rehabil. 2019;16(1):153
11. Urbin MA, Waddel KJ, Lang CE. Acceleration metrics are responsive to change in upper extremity function of stroke survivors. Arch Phys Med Rehabil. 2015;96:854–61.

The post Stroke outcome prediction: new opportunities from Clinical Neurophysiology first appeared on European Stroke Organisation.

Call for members of the ESO Stroke Education Platform Editorial Board

ESO-admin — Tue, 28 Jan 2020 05:25:13 +0000

The ESO Education Committee and Young Stroke Physicians Committees are looking for interested and enthusiastic stroke neurologists or physicians, stroke researchers or associated health professionals to become members of the new Editorial Board of the ESO Stroke Education Platform.

The ESO Stroke Education Platform is a new ESO initiative to provide a coherent, and ultimately comprehensive, source of up-to-date educational content related to the clinical management of all aspects of the stroke pathway, and the world-class science and research underlying it. It will take advantage of the wealth of educational material produced through ESO supported courses and the ESO Conference, and ultimately aims to commission content to create a comprehensive and structured resource covering all aspects of stroke.

The Editorial Board will have responsibility for the hands-on management of the website, ensuring the high quality of its content, that the material remains up to date and to further develop the platform to provide a modern and innovative, web-based training environment. The Board will include representatives from the ESO Education Committee and the Young Stroke Physicians committee, but we are also looking for 2 independent members to commit to this important work. These roles are open to all, and are ideally suited to clinicians or researchers early in their careers or towards the end of their training.

If you are interested in applying, or if you wish for further information, please contact Dr Alastair Webb, chair of the ESO Education Committee, at alastair.webb@ndcn.ox.ac.uk and Daniela.niederfeld@eso-stroke.org. To apply, please send your CV and letter of motivation.

The post Call for members of the ESO Stroke Education Platform Editorial Board first appeared on European Stroke Organisation.