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.