As part of the ESO TF4UKR Department-to-Department Visiting Programme, I had the privilege of completing a ten-day internship at the Stroke Unit of the University Hospital de Santa Maria under the supervision of Professor Ana Catarina Gaspar Fonseca, a highly qualified neurologist with extensive expertise in cerebrovascular medicine. Hospital de Santa Maria is the largest university hospital in Portugal and the country’s leading medical center, closely affiliated with the University of Lisbon. The Department of Neurology and Stroke Unit plays a central role in providing specialised care while integrating clinical practice, scientific research, and teaching.

During the internship, I followed the full pathway of patients with acute stroke – from admission at the emergency department to clinical evaluation, neuroimaging, and decision-making regarding treatment (thrombolysis or mechanical thrombectomy). Particular attention was given to ensuring alignment between presenting symptoms and diagnostic findings, which enabled a highly personalised approach to each patient. The Stroke Unit can be highly estimated by its high level of organisation: efficient triage, standardised imaging protocols, and well-coordinated teamwork of a multidisciplinary staff (neurologists, interventional neuroradiologists, anesthesiologists, and nurses). A key feature was that physicians strictly adhered to acute ischemic stroke treatment protocols, and patients are sure to receive timely and effective care. The level of interventional stroke therapy meets the highest international standards.

The atmosphere at the Stroke Unit was exceptionally welcoming and hospitable. Doctors were eager to share their expertise, explain the organisational structure of stroke care in Portugal, and engage me in clinical discussions. I also had the opportunity to observe other departments of the hospital, which provided a broader perspective on how practical stroke care is integrated within a large university medical center.

I am deeply grateful to Professor Ana Catarina Gaspar Fonseca as well as the entire team of the Stroke Unit at Hospital de Santa Maria, and the ESO TF4UKR programme for this invaluable professional experience.

Learn more about the TF4UKR Programme: https://eso-stroke.org/resources/tf4ukr/

An incredible learning experience at Karolinska University Hospital through the D2D programme by the European Stroke Organisation (ESO)!

Together with a physician in physical and rehabilitation medicine (Dr. Guliaieva) we observed the highly skilled work of a multidisciplinary team: doctors, nurses, speech &language therapists, and other specialists.

During my clinical training at Karolinska University Hospital in Stockholm, I had the opportunity to observe and participate in the work of speech and language therapists (SLTs) in both acute and post-acute care settings. This was an extremely valuable and enriching experience that allowed me to broaden my professional knowledge and gain insight into interdisciplinary collaboration in a world-renowned medical facility.

Part of the SLT team works with patients in the acute phase of their condition, particularly those in intensive care units (ICUs). I had the opportunity to accompany the SLTs during the clinical assessment of such patients. Additionally, I was involved in two gold-standard instrumental swallowing assessments: Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and Videofluoroscopic Swallow Study (VFSS). These procedures were followed by team discussions to determine appropriate therapeutic strategies and treatment plans based on the results.

I also participated in the diagnostic process for patients with head and neck cancer. These patients were evaluated both before and after tumor resection. It was insightful to observe how assessments and therapy planning are tailored to each patient’s condition and surgical outcomes.

Furthermore, I visited a rehabilitation center where patients stay after the acute phase of their illness. There, I observed the evaluation and treatment of patients with aphasia. I attended outpatient rehabilitation sessions and became familiar with the tools and scales used for aphasia diagnostics. Among these were standardised assessments such as:

• Western Aphasia Battery (WAB)
• Boston Diagnostic Aphasia Examination (BDAE)
• Aachen Aphasia Test (AAT)

This clinical experience deeply inspired me. I was particularly impressed by the professionalism, empathy, and scientific approach demonstrated by every member of the speech and language therapy team. The high level of interdisciplinary cooperation and the attention given to each individual patient were exemplary and serve as a model for clinical work.

I am sincerely grateful to the entire SLT team at Karolinska University Hospital for their openness, support, and willingness to share their experience and knowledge. Their mentorship made my stay not only educational but also personally meaningful. This training has strengthened my motivation to continue developing in the field of speech-language pathology and to implement the best international practices in my own work.

My name is Mariia Mykhailova, and I am a neurology resident at the Stroke Centre of Oberig Universal Clinic in Kyiv, Ukraine. With the support of the ESO TF4UKR Department to Department Visit Programme, I had the opportunity to complete a two-week clinical observership at the Stroke Unit of Mater Misericordiae University Hospital in Dublin. I was warmly welcomed by the team and had the opportunity to closely observe clinical practice under the supervision of consultant neurologists Professor Peter Kelly and Dr. Michael Marnane, who generously shared their expertise. Their guidance and openness were incredibly valuable, and I am excited to bring many of the insights I gained back to my work in Ukraine.

Throughout the observership, I was able to observe the full continuum of stroke care, including emergency assessments, inpatient rounds, and outpatient follow-ups. I was particularly impressed by how well-coordinated and fast the stroke team operated upon patient arrival. It was also remarkable to see how openly doctors consulted with one another – less experienced clinicians receiving real-time support and guidance from senior colleagues, including remotely when needed. This collaborative approach stood out to me as a strength and gave me ideas for enhancing shared decision-making in our own practice.

It was also valuable to observe the structure and operations of the Hyper Acute Stroke Unit (HASU), as such units are not yet common in Ukraine. The clearly defined workflows and systematic documentation offered a clear and efficient model that could be beneficial in our context.

I attended multidisciplinary meetings and joined one of the radiology case discussions, where consultants and radiologists reviewed selected imaging cases together. This kind of collaborative review was a helpful addition to clinical decision-making and could be a useful format to implement in our own practice.

At the outpatient clinic, I observed structured follow-up visits 3–6 months after discharge. I found the discharge booklet given to each patient particularly impressive – it includes a summary of their condition, relevant contacts, lifestyle recommendations, and diaries for tracking blood pressure and lab results. This kind of patient-centred resource could be very helpful if adapted for use in Ukrainian stroke services.

In addition, I learned several therapeutic approaches that were new to me, including aspects of blood pressure management in acute stroke. I was also inspired by how well the system supports rehabilitation after discharge – from social worker involvement to options for continued care at home or in rehabilitation centres. These practices could significantly improve stroke recovery outcomes if integrated into our own system.

This observership gave me the chance to compare stroke care in two different healthcare systems and reflect on what could be adapted locally. I also had the opportunity to build professional connections that I hope will lead to future collaboration and knowledge exchange.

Overall, this was a highly enriching and motivating experience. I am sincerely grateful to the European Stroke Organisation for supporting this opportunity, and I look forward to applying what I’ve learned to strengthen stroke care in Ukraine.

From 1–3 September 2025, early-career researchers from all over the world gathered in Edinburgh for the 12th ESO Stroke Research Workshop. Hosted at the marvellous St Leonard’s Hall of the University of Edinburgh, the event offered an immersive three-day programme blending lectures, interactive sessions, and networking opportunities. The faculty, consisting of highly respected experts and leaders in the field, shared practical tools and fresh perspectives on stroke research. The aim was clear: to equip participants with the skills, confidence, and connections needed to shape impactful future stroke research projects.

Lectures: The lecture programme served as the backbone of the course, guiding participants through every stage of the research process. The programme opened with sessions on how to frame meaningful research questions, choose between observational studies and randomised controlled trials, and set priorities, followed by guidance on publication strategies, research impact, and the role of qualitative methods. Day two turned to practicalities: navigating regulations, critically appraising literature, and presenting data with clarity. Sessions also highlighted the value of statistics and strategies for organising research efficiently. The final day centred on communication and funding, featuring insights from funders, participant presentations, a grant board exercise, and closing reflections on the future of stroke research and researcher wellbeing.

Interactive sessions to develop a research project: Alongside lectures, the heart of the workshop laid in sessions dedicated to building and refining research ideas. Participants were guided step by step, from brainstorming relevant questions to designing studies that are both feasible and impactful. Small group discussions with faculty created a supportive environment where early concepts could be tested, reshaped, and expanded with constructive feedback. The iterative structure of these sessions allowed projects to evolve day by day. Initial drafts were challenged by peers and experts, helping participants to sharpen hypotheses, anticipate obstacles, and think creatively about methodology. The process culminated in short presentations where each participant distilled their proposal into just a few slides – a valuable exercise in clarity and precision.

The simulated grant board meeting was a highlight: reviewing written applications exposed the group to the realities of competition for funding. This session encouraged critical but collegial assessment, providing insight into what makes an application stand out and what risks might raise red flags for reviewers.

One of the most appreciated parts was the speed networking session. In a fast-paced yet supportive setting, participants had the chance to present their project one-on-one, receive immediate feedback, and explore others’ ideas. The format encouraged openness and collaboration, breaking down barriers between researchers at different stages of their careers and from diverse backgrounds.

Networking: Equally central to the workshop was the opportunity to connect with peers and faculty. Informal conversations during coffee and lunch breaks, as well as evening dinners, created a relaxed atmosphere that fostered genuine exchange. Discussions often moved beyond research, touching on personal interests and experiences, making the interactions more memorable and meaningful. Social gatherings helped to strengthen these connections. Sharing a table with colleagues from across the globe built a sense of community that is expected to last well beyond the workshop itself. Many participants left Edinburgh with new contacts, valuable collaborations in sight, and perhaps even friendships that will grow through future ESO events and annual conferences.

In conclusion, the 12th ESO Edinburgh Stroke Research Workshop once again proved to be more than just a course. By blending high-level lectures, hands-on research development, and inspiring networking opportunities, it provided a unique platform to learn, share, and grow as researchers. Participants returned home not only with stronger projects and sharper skills, but also with an expanded network ready to support the next steps in their careers.

Antonio Ciacciarelli¹, Bogdan Cășaru², Lina Palaiodimou³

1. Emergency Department, Policlinico Umberto I Hospital, Sapienza University of Rome (Italy)
2. Department of Neurology, Emergency University Hospital Bucharest (Romania)
3. Second Department of Neurology, National and Kapodistrian University of Athens (Greece)

As part of the European Stroke Organisation’s Department to Department (D2D) Visit Programme, I had the privilege of completing a short observership at the Department of Clinical Neuroscience, Karolinska University Hospital.

The Karolinska University Hospital is one of Europe’s largest and most prestigious academic medical centers. It operates across two main campuses — Karolinska Solna and Karolinska Huddinge — and is closely affiliated with the Karolinska Institutet, forming a powerful hub for medical research, education, and advanced clinical care. The hospital plays a pivotal role in Sweden’s healthcare system and is internationally recognised for its leadership in stroke care, neurosciences, and translational medicine. Danderyd Hospital, which belongs to the same healthcare region, is one of Sweden’s largest emergency hospitals and shares an academic affiliation with the Karolinska University. It has strong clinical and academic programs in neurology and rehabilitation medicine.

My main goal during this observership was to familiarise myself with the advanced stroke care pathway implemented at Karolinska, including the integrated stroke network that ensures seamless transitions from hyperacute stroke care through rehabilitation and social reintegration.
This multidisciplinary approach is designed to maximise patient outcomes and quality of life following stroke.
The visit began with a meeting with Dr. Michael Mazya, Associate Professor and Senior Consultant Neurologist specialising in cerebrovascular diseases and acute neurological care. He works at the Department of Clinical Neuroscience, Karolinska Institutet, and serves as Head of the Stroke Service at the Department of Neurology, Karolinska University Hospital.

We began with a clinical orientation in the relevant department of Karolinska University Hospital, where I was introduced to the clinical workflows and organisational structure involved in the treatment of acute stroke patients.

Acute stroke care at Karolinska meets the highest international standards. The “door-to-needle” time for thrombolysis is impressively short, averaging just 15–18 minutes. The team of neurologists, radiologists, and nurses functions as a unified and highly coordinated system. Early access to patient medical information, transmitted by ambulance teams prior to hospital arrival, significantly supports timely clinical decision-making and appropriate neurointervention.

During the following days, we conducted a site visit to Danderyd Hospital, where we met with the Department of Neurology and the Department of Rehabilitation. These sessions provided valuable insight into subacute and long-term care strategies, including both inpatient and outpatient stroke rehabilitation models. The meetings also fostered professional exchange and laid the groundwork for potential future collaboration.

Together with Dr. Mazya, I continued to explore the regional stroke advisory service at Karolinska. One particularly striking experience was learning about the role of medical aviation in stroke care, illustrated by a case in which a patient was transported by helicopter from a remote island. This underscored the vital importance of clear protocols and structured algorithms to ensure effective coordination between pre-hospital and in-hospital care.

An important element of clinical practice at Karolinska is the weekly interdisciplinary cerebrovascular conference, where complex cases such as cervical carotid artery disease and PFO are reviewed and discussed. I also attended a neurovascular multidisciplinary meeting focusing on rare and challenging conditions such as Moyamoya disease, intracranial artery stenosis, and intracranial stenting. This format of collaborative discussion and continuous professional education is highly effective, and we plan to implement similar multidisciplinary meetings as a routine practice at our hospital in Kyiv.

In addition, numerous meetings with colleagues from various departments — including anesthesiology, neurology, interventional neuroradiology, and neurorehabilitation — provided a valuable platform for the exchange of ideas and experiences related to stroke care in both Sweden and Ukraine. This observership provided a unique opportunity to gain in-depth insight into one of Europe’s leading stroke care systems. The structured program, rich interdisciplinary interaction, and exposure to both acute and rehabilitative services were highly educational and inspiring.

I am sincerely grateful to Dr. Michael Mazya and the entire teams at Karolinska University Hospital and Danderyd Hospital for their warm hospitality and excellent organisation of this visit.

Special thanks to the European Stroke Organisation (ESO) for providing the opportunity to participate in this invaluable programme. I am confident that this experience will contribute to further collaboration between our institutions and to the advancement of stroke care both regionally and internationally.

For the second consecutive year, ESO has supported a dedicated version of the Department to Department Visit Program by TF4UKR specifically for Ukrainian doctors.  This year, I was fortunate to be one of the participants in the program, and thanks to the kind invitation of Professor Heldner, I had the privilege of visiting the stroke unit at Inselspital (Bern, Switzerland). Witnessing firsthand the work of one of Europe’s leading clinics and meeting colleagues whose research shapes best practices in stroke medicine worldwide was an invaluable experience for a practicing physician.

At the unit, I was warmly welcomed by Professor Seiffge. For two weeks, I immersed myself in studying the operations of the clinic’s stroke service. I am sincerely grateful to the doctors and staff for their hospitality and the insightful conversations during my visit.

Despite the predominance of German and French in the country, my colleagues generously explained key processes, schedules, and organisational structures in English, which made me feel fully engaged and not like an outsider.

The level of organisation and teamwork at every stage of care was truly impressive. Each department performed its duties with excellence.

I was particularly interested in comparing patient pathways and task distribution among departments, noting aspects that could be implemented in stroke services in Ukraine. In Ukraine, we are currently working on implementing more comprehensive neuroimaging. As a result, in many cases, time boundaries and scales still serve as significant benchmarks for us. However, we are striving to ensure maximum accessibility and the scope of neuroimaging that would provide the most extensive information necessary for making the best decisions for patients. During my time in Bern, I had the opportunity to see how this works when it becomes routine practice, with the actions of emergency teams, radiologists, and stroke unit physicians coordinated and well-aligned. Here, the choice of tactics and the patient’s pathway is all about teamwork and collaboration.

What was also interesting and new for me, compared to the work of the service in Ukraine, was the separation of structures and the distribution of functions between the physicians in the stroke unit and the emergency department. Concentrating urgent interventions and reperfusion therapy within the emergency department ensures swift and effective care for stroke patients, addressing their most critical needs. This approach embodies the “time is brain” principle, where not a single precious minute is wasted.

The stroke unit’s focus on thorough diagnostics and tailored secondary prevention measures was inspiring. The methodology at Inselspital serves as a benchmark that more Ukrainian colleagues should witness. Understanding stroke etiology is like solving a detective case—every patient deserves an answer to prevent future events. This experience reaffirmed that no two strokes are alike.

This approach allows for complete focus on the most critical needs of the patient according to the stage of the disease. It prevents the fragmentation of the physician’s attention and efforts, ensuring a clear determination of the sequence and scope of necessary interventions.

Ultrasound diagnostics play a crucial role in this investigation. The skill of the local specialists is remarkable, showcasing how many questions they can answer with this non-invasive method. I also visited the interventional neuroradiology department, where I observed precise, meticulous work akin to fine craftsmanship.

This fascinating and seamless process is deeply integrated with ongoing research and scientific discussions. Without familiarity with the inner workings of a stroke service, one might mistakenly believe that treating strokes is simple and always results in happy endings.

The thrombolysis procedures using tenecteplase indeed seem magical, especially when a critically ill, comatose patient regains consciousness with minimal neurological deficits after reperfusion therapy.

I am profoundly grateful to my colleagues for this experience. Beyond learning what a high-quality stroke service looks like, they shared valuable insights into the time and effort required to achieve such excellence. It involves ongoing discussions about the relevance of the issue at various levels to secure support and resources, educating non-medical audiences, establishing communication between departments and care providers, and continuously researching best practices. The effort, time, and resources invested are extraordinary.

I sincerely thank the ESO for supporting such a program and providing this opportunity, as well as Professor Heldner for the invitation, Professor Seiffge, Dr. Meinel, Professor Gralla, and all the other colleagues and staff for their hospitality and support.

I had the opportunity to visit the Stroke Center of Graz Medical University at the invitation of the Univ. FA Priv.-Doz. Dr.med.univ. Dr.scient.med. Simon Fandler-Hofler. During my time in the hospital, all the staff were very kind and responsive to me. The doctors were happy to share clinical cases and answer questions that arose.

My day began with a morning round with the Neurology Department team. One of the great things was a discussion of the neuroimaging study of each patient. I observed all the parts of a team that have dealt with patients with stroke from the emergency department to a rehabilitation team working with stroke patients and stroke outpatient clinic. It was very interesting for me to see how all the modern research and recommendations are put into practice and to see the positive results. The hospital is conducting a lot of research aimed at improving care for patients with acute stroke. As part of my visit, I spent a lot of time in the emergency department, where I observed the journey of an acute stroke patient from presentation, and neuroimaging, to treatment decisions. I have seen a lot of patients with different neurological diseases who were admitted to the emergency department.

One of the interesting events was a meeting with a scientific club. I am very grateful to the team of the Neurology Department at Graz Medical University under the guidance of a Univ.-Prof. Priv.-Doz. Dr.med.univ. Christian Enzinger, MBA for the interesting and informative days. Thanks to ESO and TF4UKR for this opportunity. It was two wonderful weeks in which I compared two different healthcare systems. The knowledge I acquired will help me improve care for patients with acute stroke and expand this knowledge all over the whole of Ukraine.

Sincerely,

Yaroslav Saminin

Between 2.5% and 4% of patients with an acute ischaemic stroke (AIS) and an arterial occlusion have an isolated cervical internal carotid artery occlusion (c-ICA-O).^1,2

The management of these patients can be particularly challenging due to both diagnostic uncertainties and therapeutic dilemmas.

In the presence of a patent intracranial circulation, these patients often exhibit fluctuating neurological deficits, requiring intensive clinical monitoring and complex treatment decisions. The underlying stroke mechanism is frequently perceived as predominantly hemodynamic, leading clinicians to favor medical strategies such as head-down (lying-flat) positioning, fluid resuscitation, and/or the use of vasoactive agents. However, even when presenting with mild or remitting symptoms, patients with isolated c-ICA-O are at higher risk for early neurological deterioration when managed conservatively.^3,4 This observation raises important questions about the role and timing of recanalisation therapies in this subgroup.

Imaging also presents diagnostic difficulties. Differentiating between extracranial and intracranial carotid occlusion can be challenging using CTA or MRA.⁵ Clinicians should be aware of the phenomenon of pseudo-occlusion, in which a distal intracranial ICA or proximal MCA occlusion results in absent or severely reduced antegrade flow in the cervical ICA. This may lead to non-opacification or a tapering appearance on CTA/MRA, mimicking a true proximal ICA occlusion.^6,7 Furthermore, differentiating acute from chronic ICA occlusions may influence management strategies. Beyond assessing the extent of collateral circulation, specific imaging features—such as the morphology of the occlusion stump and vessel wall characteristics can aid in distinguishing acute thrombotic events from chronic atherosclerotic occlusions.⁸

Regarding recanalisation therapies, IVT presents a theoretical double-edged sword: While it may promote recanalisation or prevent thrombus propagation, it may also induce thrombus fragmentation and distal embolisation, thereby worsening clinical outcomes. In the absence of large, high-quality studies specifically designed to address this treatment decision, data from studies evaluating IVT in patients with cervical artery dissection may represent the most relevant evidence available.^9,10

For EVT decisions, there are no data from randomised-controlled clinical trials (RCTs), since patients with isolated c-ICA-O were not included in any of the studies assessing safety and efficacy of EVT in anterior circulation AIS.¹¹ Nevertheless, over the last years, small observational studies have been published suggesting that EVT was feasible, while it remains to be shown whether EVT is associated with improved clinical outcomes and safety.^2,12,13 Notably, two large observational studies published this year offer new insights.

The ACOBOW study, a retrospective, observational, multicenter cohort study, included patients from 23 centers, between January 2015 and June 2022. The main inclusion criteria were the diagnosis of an AIS due to an acute isolated occlusion of the carotid artery with no occlusion in or beyond the circle of Willis, receiving either EVT or best medical management (BMT). The authors included 354 patients (EVT=291 and BMT=63), with a median NIHSS of 13. After multivariable logistic regression and inverse probability weighting analyses, no difference in clinical and functional outcomes was observed between the two treatment groups.

The ETIICA study, a retrospective, observational, multinational cohort study, enrolled patients from 42 centers, between January 2018 and December 2022. The main inclusion criteria were the diagnosis of an AIS due to an acute isolated occlusion of the carotid artery located exclusively in the carotid bulb and/or ascending cervical carotid segment, receiving either EVT or BMT. 998 patients were included (EVT=487 and BMT=511), with a median NIHSS of 9. After statistical analyses combining inverse probability of treatment weighting with regression models or using propensity score matching, the authors found that EVT was associated with similar odds of disability and intracranial bleeding compared to BMT.

In subgroup analyses, neither study showed an interaction between treatment strategy and stroke severity, etiology or time-to-treatment. In both studies, rates of complete recanalisation of the ICA and of distal embolisation were similar (respectively 80.9% vs. 76.8% and 27.8% vs. 29.4%).

Despite limitations inherent to observational designs—including potential selection and misclassification biases—these studies represent the most robust data available on EVT in isolated c-ICA-O. RCTs are urgently needed to determine optimal management. However, challenges are anticipated regarding patient selection criteria. Currently, one RCT is underway in France (NCT05832762), enrolling patients with NIHSS >5 and perfusion mismatch (based on DEFUSE-3 criteria) or clinical–imaging mismatch (ASPECTS >5).

In conclusion, although an uncommon stroke presentation, patients with AIS and isolated c-ICA-O face particular diagnostic and therapeutic challenges that demand attention. Recent observational data have questioned the benefit of EVT in this context. Further studies, including carefully designed RCTs and focused subgroup analyses, are essential to refine patient selection and optimise treatment strategies.

—

References

1. Haussen DC, Al‐Bayati AR, Mohammaden MH, et al. The Society of Vascular and Interventional Neurology (SVIN) Mechanical Thrombectomy Registry: Methods and Primary Results. Stroke: Vascular and Interventional Neurology. 2022;2:e000234.
2. Kaiser DPO, Reiff T, Mansmann U, et al. Endovascular Treatment for Acute Isolated Internal Carotid Artery Occlusion: A Propensity Score Matched Multicenter Study. Clin Neuroradiol. 2023; 34(1):125-133.
3. Boulenoir N, Turc G, Henon H, et al; MINOR-STROKE Collaborators. Early neurological deterioration following thrombolysis for minor stroke with isolated internal carotid artery occlusion. Eur J Neurol. 2021;28(2):479-490.
4. Khazaal O, Neale N, Acton EK, et al. Early neurologic deterioration with symptomatic isolated internal carotid artery occlusion: a cohort study, systematic review, and meta-analysis. Stroke Vasc Interv Neurol. 2022;2(5):e000219.
5. Diouf A, Fahed R, Gaha M, et al. Cervical internal carotid occlusion versus pseudo-occlusion at CT angiography in the context of acute stroke: an accuracy, interobserver, and intraobserver agreement study. Radiology. 2018;286(3):1008–15.
6. Kim JJ, Dillon WP, Glastonbury CM, Provenzale JM, Wintermark M. Sixty-four-section multidetector CT angiography of carotid arteries: a systematic analysis of image quality and artifacts. AJNR Am J Neuroradiol. 2010;31(1):91-9.
7. Caldwell J, Heran MKS, McGuinness B, Barber PA. Imaging in acute ischaemic stroke: pearls and pitfalls. Pract Neurol. 2017;17(5):349-358.
8. Michel P, Ntaios G, Delgado MG, et al. CT angiography helps to differentiate acute from chronic carotid occlusion: the “carotid ring sign”. Neuroradiology. 2012 Feb;54(2):139-46.
9. Shu L, Akpokiere F, Mandel DM, et al. Intravenous Thrombolysis in Patients With Cervical Artery Dissection: A Secondary Analysis of the STOP-CAD Study. Neurology. 2024;103(7):e209843.
10. Shu L, Lee E, Field TS, et al. Intravenous Thrombolysis in Cervical Artery Dissection-Related Stroke: A Nationwide Study. J Am Heart Assoc. 2025;14(5):e039662.
11. Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischemic stroke: a meta-analysis of individual patient data from five randomized trials. Lancet. 2016;387(10029):1723-31.
12. Jadhav A, Panczykowski D, Jumaa M, et al. Angioplasty and stenting for symptomatic extracranial non-tandem internal carotid artery occlusion. J Neurointerv Surg. 2018;10:1155–1160.
13. Waters MJ, McMullan P, Mitchell PJ, et al. Endovascular Therapy Versus Medical Therapy for Acute Stroke Attributable to Isolated Cervical Internal Carotid Artery Occlusion Without Intracranial Large Vessel Occlusion Stroke Vasc Interv Neurol. 2022;2:e000174.
14. Meyer L, Broocks G, Alexandrou M, et al.Endovascular versus Best Medical Treatment for Acute Carotid Occlusion BelOw Circle of Willis (ACOBOW): The ACOBOW Study. Radiology.;314(1):e240293
15. Marto JP, Riegler C, Gebert P, et al. Endovascular treatment for isolated cervical internal carotid artery occlusion: ETIICA study. Eur Stroke J. 2025 Feb 28:23969873251323488.

The latest 23^rd ESO Educational Webinar on 24 June 2025 focused on TIA with insightful presentations from Dr Linxin Li (UK) and Dr Vojtech Novotny (Norway), moderated by Dr Xabier Urra (Spain) and Dr Maria Peycheva (Bulgaria) followed by a discussion based on questions from the audience.

Dr Vojtech Novotny, after giving a short introduction on the evolving definition of TIA presented 4 cases to illustrate the challenge of TIA diagnosis. Case 1 was an elderly male patient with typical vertebrobasilar symptoms and DWI negative MRI managed as a TIA. Case 2 was an elderly female with isolated transient vertebrobasilar symptoms but with DWI positive MRI in the brainstem. Case 3 was a young male patient with a history of migraine who had migraine aura-like symptoms but infarction on MRI related to PFO- which could be regarded as a “chameleon TIA”. Case 4 was an elderly male patient with isolated recurrent diplopia and headache together with elevated ESR and CRP, who was diagnosed with biopsy proven giant cell arteritis (GCA).

After this practical introduction, Dr Linxin Li gave a comprehensive overview of the definition, diagnosis, management and prognosis of TIA. She mentioned the new tissue-based versus previous clinical based definition and the potential impact on epidemiological studies. Because acute MRI is not readily available in many healthcare settings, the clinical based definition is still widely used.

Dr Li elaborated on the often-challenging diagnosis of TIA in cases of atypical symptoms, such as non-consensus TIA symptoms (e.g. isolated brainstem symptoms) and non-focal transient neurological attacks. (e.g. migraine-like, transient confusion/unresponsiveness) That should be taken seriously, especially in the elderly with vascular risk factors. She mentioned that isolated diplopia can be a sign of GCA requiring urgent steroid treatment and shared their experience on the most common TIA mimics such as migraine, syncope, peripheral vertigo, seizures, functional deficits and transient global amnesia. She mentioned useful features for the differential diagnosis, but also emphasised the importance of clinical judgement in these cases.

Dr Li mentioned the possible patient pathways and management options in patients with suspected TIA, such as the TIA clinic or specialist-led inpatient care. Secondary prevention is guided by risk stratification for future stroke: single antiplatelet (AP) for low risk, double AP (aspirin+clopidogrel) for high risk (ABCD² >=4). There are also evolving data looking at ticagrelor as an alternative to clopidogrel in patients with very high risk (ABCD² >=6 plus intracranial stenosis) or in those with clopidogrel resistance. Other treatment options are under study, such as colchicine, tirofiban or factor XI inhibitors (asundexian, milvexian).

From a consultation point of view, Dr Li highlighted that although the risk of recurrent stroke after TIA has significantly decreased over the last decade with the help of TIA clinics and effective and prompt secondary prevention, there is still room for improvement, and that TIA patients are not only at higher risk of stroke but also dementia. This latter is also true for tissue-based definition TIA (without a brain lesion), the pathomechanism of which is still poorly understood.

After the presentations, a few interesting questions from the audience were discussed. These included thrombolysis in TIA in case of repetitive symptoms such as crescendo TIA, or as presented in Case 5, with perfusion deficit and vessel occlusion on imaging despite resolution of symptoms. Finally, discussion on the recommended length of cardiac monitoring and lower sensitivity of DWI for minor stroke in posterior circulation ended the webinar.

More about ESO Webinars