Effects of Intradural Extension of Extracranial Cervical Artery Dissection on Outcomes: A Secondary Analysis From the STOP-CAD Study Issa Metanis, Liqi Shu, Favour Akpokiere, Hamza Jubran, Daniel M. Mandel, et al. Annals of Neurology, 2026 Objective Cervical artery dissection (CeAD) may be limited to the extracranial extradural space or extend to the intradural space. Intradural extension can potentially increase the risk of stroke and subarachnoid hemorrhage. However, the factors associated with intradural extension and its impact on clinical outcome remain unclear. Methods This was a secondary analysis of the STOP‐CAD observational, multi‐center study. Patients with CeAD and intradural extension (CeADid) were compared with those with pure CeAD extradural dissections (CeADed) using multiple regression analyses. Results Of 4,023 patients with CeAD, 534 (13.3%) had CeADid. In comparison to patients with CeADed, those with CeADid more often had clinical overt stroke or transient ischemic attack (TIA) at presentation, acute infarcts on imaging, a vertebral artery affected, and severe stenosis of the involved vessel ( p < 0.001 for all). In contrast, carotid involvement and complete occlusions were more frequent in patients with CeADed ( p < 0.001 for both). CeADid was associated with a shift in the distribution of scores on the modified Rankin Scale (mRS) toward worse functional outcome (odds ratio [OR] = 0.76, 95% confidence interval [CI] = 0.62–0.92) but the odds for favorable outcomes (mRS = 0–2) did not differ between the groups after appropriate adjustments on multivariate analysis. CeADid was independently associated with higher mortality at 180 days on multivariate analysis (adjusted OR = 2.84, 95% CI = 1.50–5.38). Interpretation CeADid is associated with more severe clinical presentation, a shift toward less favorable outcomes, and higher mortality rates. These findings suggest that CeADid may represent a high‐risk type of CeAD. ANN NEUROL 2026
Aiming for TICI 4: angiographic and ultrasonographic predictors of parenchymal hemorrhage after successful thrombectomy João André Sousa, Carolina Maia, Catarina Bernardes, Henrique Queirós, Ana Isabel Rodrigues, et al. Journal of Neurointerventional Surgery, 2026 BackgroundHemorrhagic transformation after thrombectomy is associated with poor outcomes. This study aimed to assess post-thrombectomy angiographic signs and increased blood flow on transcranial Doppler as potential predictive factors for parenchymal hemorrhage after successful endovascular stroke treatment.MethodsThis cohort study included consecutive patients who underwent endovascular stroke treatment at a comprehensive stroke center with successful recanalization and 24-hour follow-up imaging available. Angiographic post-thrombectomy signs, including the blush sign, early venous filling, and punctate dilations, were retrospectively and blindly assessed. The mean blood flow velocity ratio of the recanalized artery was collected and compared with the contralateral artery, defining hyperperfusion as a ratio greater than 1.3. Control 24-hour CT scans were reviewed, and hemorrhagic transformation was classified. Unadjusted and clinical variable-adjusted logistic regression analyses were performed.ResultsA total of 362 patients were included in the analysis, with 28 (7.7%) presenting with parenchymal hemorrhage. The blush sign (adjusted OR 3.6, 95% CI 1.3 to 9.4, P=0.01), early venous filling (adjusted OR 6.1, 95% CI 1.9 to 20.0, P=0.003), a combination of both signs (adjusted OR 7.9, 95% CI 2.0 to 30.8, P=0.003), and Doppler-assessed hyperperfusion (adjusted OR 5.9, 95% CI 1.1 to 31.5, P=0.038) were independent predictors of parenchymal hemorrhage. A model incorporating these three variables presented an area under the curve of 0.82 (95% CI 0.67 to 0.99, P<0.001), indicating excellent predictive accuracy for identifying parenchymal hemorrhage following successful thrombectomy.ConclusionAngiography and transcranial Doppler ultrasonography may provide early signs that accurately predict parenchymal hemorrhage following successful recanalization.
Rescue Versus First-Line Intracranial Stenting During Thrombectomy for Acute Ischemic Stroke: A Propensity-Weighted Analysis of the RESISTANT Registry Aaron Rodriguez-Calienes, Dileep R. Yavagal, Negar Asdaghi, Marta Olivé-Gadea, Francesco Diana, et al. Stroke, 2026 BACKGROUND: While rescue stenting (RS) is a recognized bailout strategy following failed endovascular thrombectomy for acute ischemic stroke with large vessel occlusion, first-line stenting (FLS) has emerged as a potential alternative to avoid vascular injury and improve outcomes. However, direct comparisons between these strategies remain limited. We conducted a comparative analysis of FLS versus RS using data from a large, multicenter international registry to evaluate their relative safety and effectiveness. METHODS: We conducted a comparative analysis of FLS versus RS using data from the RESISTANT registry (Registry of Endovascular Salvage for Intracranial Stenting in Thrombectomy-Refractory Stroke), a multicenter, international, retrospective cohort of patients with acute ischemic stroke treated with intracranial stenting during endovascular thrombectomy (2016–2023). Patients were categorized by stenting strategy: FLS (stent placed without prior thrombectomy) or RS (stent placed after failed thrombectomy). The primary effectiveness outcome was functional independence (modified Rankin Scale score, 0–2) at 90 days; the primary safety outcome was symptomatic intracranial hemorrhage. Propensity score inverse probability of treatment weighting was used to adjust for baseline differences. RESULTS: Among 827 patients, 723 were in the RS cohort (median age, 67 [interquartile range, 59–77] years; 64.2% male) and 104 in the FLS cohort (median age, 65.5 [interquartile range, 58.8–77] years; 72.1% male). Using FLS as the reference strategy, inverse probability of treatment weighting–adjusted analyses did not detect significant differences in functional independence (odds ratio [OR], 0.64 [95% CI, 0.38–1.07]) or symptomatic intracranial hemorrhage (OR, 0.93 [95% CI, 0.34–2.59]). No significant differences were observed in secondary outcomes, including successful reperfusion, mortality, or procedural complications. In the anterior circulation cohort (n=589), outcomes were likewise comparable (functional independence: OR, 0.62 [95% CI, 0.60–1.25]; symptomatic intracranial hemorrhage: OR, 0.81 [95% CI, 0.30–2.18]). Similarly, in the posterior circulation cohort (n=234), no significant differences were found (functional independence: OR, 0.82 [95% CI, 0.32–2.10]; symptomatic intracranial hemorrhage: OR, 0.81 [95% CI, 0.30–2.18]). CONCLUSIONS: In this study, no significant differences in safety or effectiveness were detected between FLS and RS strategies during endovascular thrombectomy for acute ischemic stroke. Prospective, randomized trials are needed to better define optimal treatment approaches.
Clinical Significance of Microembolic Signal Detection in Acute Ischemic Stroke: Insights Into Ongoing Cerebral Embolization and Occult Etiologies Eleni Bakola, Lina Palaiodimou, Aikaterini Theodorou, Maria Chondrogianni, Georgia Papagiannopoulou, et al. European Journal of Neurology, 2026 Background and Purpose Transcranial Doppler (TCD) detects microembolic signals (MES), reflecting ongoing cerebral embolization. MES have been studied across stroke subtypes and may clarify etiology, monitor treatment, and predict recurrence. We aimed to determine the prevalence of MES in acute ischemic stroke (AIS), explore clinical and laboratory associations, and assess their role in etiological workup. Methods We conducted a prospective single‐center study over 3 years including anterior circulation AIS patients within 24 h of onset. Stroke subtype was classified by TOAST criteria. Bilateral middle cerebral artery TCD monitoring was performed for 30 min to detect and quantify MES. Results Among 136 patients (mean age 60.1 ± 12.4 years), MES were detected in 22 (16.2%; 95% CI: 10.4%–23.5%). MES(+) patients had more often multiple‐territory infarcts (36.4% vs. 10.5%, p = 0.005), newly detected atrial fibrillation (13.6% vs. 0.9%, p = 0.013), and cancer‐associated stroke (18.2% vs. 0.9%, p = 0.002), whereas cryptogenic etiology was less common (18.2% vs. 41.2%, p = 0.041). MES were absent in lacunar stroke. MES positivity correlated with higher D‐dimer levels (median 932 vs. 456 ng/mL, p < 0.001), and MES counts correlated strongly with D‐dimer values (Spearman coefficient: 0.393, p < 0.001). Conclusions MES were detected in one‐sixth of anterior circulation AIS patients, but were absent in lacunar stroke. Their presence was associated with multiple‐territory infarcts, newly detected atrial fibrillation, and cancer‐related stroke. MES counts correlated with D‐dimer levels, supporting their role as markers of ongoing cerebral embolization and underlying prothrombotic state, with potential utility in revealing occult embolic mechanisms.
HARMONICS: feasibility of a holistic value-based care hybrid programme that maximises clinical outcomes after stroke Marta Rubiera, Alvaro Garcia-Tornel, Marian Muchada, Francisco Purroy, Joao Sargento-Freitas, et al. European Stroke Journal, 2026 Introduction The increasing number of stroke survivors underscores the need for coordinated post-discharge care and systematic outcome monitoring. HARMONICS aimed to provide standardised follow-up, integrating clinician-reported (CROMs) and patient-reported outcomes (PROMs) into a value-based care model. Patients and methods Using lean methodology, post-stroke care pathways were mapped, and a harmonised workflow was implemented across 6 comprehensive stroke centres (CSCs) in Spain and Portugal. Consecutive patients discharged home or to socio-rehabilitation facilities with an mRS &lt; 5 were offered participation. Follow-up was conducted via a smartphone app or telephone, enabling bidirectional communication with a case manager for health education, vital sign monitoring and PROMs collection. Feasibility required meeting 4 predefined indicators: inclusion &gt; 60%, 3-month retention &gt; 75%, PROMs completion &gt; 60% and satisfaction &gt; 70% measured by patient-reported experience measurement (PREM). Secondary analyses compared outcomes with historical cohorts. Results Between 2022 and 2024, 4209 patients were recruited (40.2% women; median age 73 [IQR 62–81]; 75.6% ischaemic; median admission NIHSS 3 [1–6]; median discharge mRS 2 [1–3]). App use occurred in 59.9% (56% independently). Feasibility was achieved for inclusion (82.8%), retention (84.6%) and satisfaction (72.9%), but PROMs completion was 53.7% at 90 days. Despite mild severity, many reported suboptimal PROMs at 3 months, improving modestly by 1 year. Compared with historical controls, HARMONICS patients showed a better 3-month mRS distribution (OR 1.124; 95% CI, 1.042–1.213; P = .0026) and improved PROMs (P &lt; .05). Discussion and Conclusion HARMONICS is a feasible multicentre value-based follow-up model that promotes education, engagement and self-responsibility, with high rates of healthcare satisfaction reported by stroke survivors.
Influence of spot sign on the association between rapidly achieving blood pressure reduction and intracerebral haemorrhage outcomes João André Sousa, Olalla Pancorbo, Renato Simonetti, Laura Llull, Pilar Coscojuela, et al. European Stroke Journal, 2026 Introduction Patients with a CTA spot sign could benefit more from interventions to limit ICH expansion. We evaluated whether its presence modifies the association between systolic blood pressure (SBP) reduction and ICH outcomes. Patients and methods A prospective study of patients with ICH &lt; 6 hours and SBP ≥ 150 mmHg at 2 Comprehensive Stroke Centers in Barcelona over 4.5 years. Patients underwent multiphase CTA (arterial, peak venous and late venous phases) and received treatment targeting SBP ≤ 140 mmHg ≤ 60 minutes. We assessed independent associations and interaction of achieving SBP target ≤ 60 minutes and spot sign status (arterial, or secondarily any phase) with hematoma expansion (&gt;6 mL or &gt; 33%) at 24 hours (primary outcome) and 90-day mRS. Results Among 207 patients (mean age 71 ± 13.2 years, 134 [64.7%] male), 67 (32.4%) presented an arterial spot sign and 122 (58.9%) achieved SBP target ≤ 60 minutes. Target rates were similar with and without arterial spot sign (38 [56.7%] vs 84 [60.0%], P = .653). Hematoma expansion occurred in 46/177 (26.0%), and median 90-day mRS was 4 (2–5). Arterial spot sign and SBP target ≤ 60 minutes were independently associated with hematoma expansion (adjusted odds ratio [aOR] 4.07; 95% CI, 1.74–9.89 and aOR 0.27; 95% CI, 0.11–0.64) and 90-day mRS (aOR 2.23; 95% CI, 1.23–4.07 and aOR 0.43; 95% CI, 0.24–0.76), with no interaction between them (P = .575 and P = .187, respectively). Similar results were observed considering spot sign in any multiphase CTA phase. Conclusion The association between rapidly achieving SBP reduction and ICH outcomes appears neither dependent on nor modified by spot sign status.
Impact of intraprocedural antiplatelet therapy on stent patency and safety after emergent intracranial stenting in acute ischaemic stroke: insights from the RESISTANT registry Francesco Diana, Ameer E Hassan, Santiago Ortega-Gutierrez, Samantha Miller, Aaron Rodriguez-Calienes, et al. European Stroke Journal, 2026 Introduction Emergent intracranial stenting (EIS) is increasingly employed in the context of the acute ischaemic stroke treatment, but requires intraprocedural antiplatelet therapy (APT), which may raise haemorrhagic risk. This study aimed to evaluate the safety and effectiveness of different APT regimens during EIS. Patients and methods This is a subanalysis of the RESISTANT registry, which is a multicenter retrospective registry of patients with acute ischaemic stroke treated with intracranial EIS between 2016 and 2023. Patients receiving intraprocedural antithrombotics were included. Primary efficacy outcomes were stent patency (intraprocedural and within 24 hours) and 3-month mRS. Secondary outcome was successful reperfusion (modified thrombolysis in cerebral infarction ≥ 2b), and the safety outcome was sICH. Multivariable and propensity score-matched analyses were performed. Results Among 827 patients, 4 APT strategies were identified: single APT (n = 102), oral dual antiplatelet therapy (dAPT) (Aspirin + Clopidogrel or Ticagrelor; n = 83), Cangrelor (n = 92) and GP IIb/IIIa inhibitors (GPi) (n = 550). Intravenous agents (Cangrelor/GPi) showed a trend towards lower risk of intraprocedural stent occlusion compared to oral dAPT (adjusted odds ratio [aOR] 0.30, [95% CI, 0.09–1.01], P = .053), though this did not reach statistical significance. GP IIb/IIIa inhibitors continued to demonstrate a protective trend at 24 hours (aOR 0.25, [95% CI, 0.06–0.99], P = .047), without a significant increase in sICH. Both intravenous agents were independently associated with higher odds of successful final reperfusion (odds ratio [OR] 4.35, [95% CI, 1.57–12.09], P = .001). No significant differences emerged between GPi and Cangrelor in matched analysis. No significant difference was observed on good functional outcome between APT strategies. Conclusion In the setting of EIS, intravenous APT agents (Cangrelor or GPi) were associated with improved stent patency and higher rates of successful reperfusion, without a significant increase in symptomatic haemorrhage.
Anesthesia Modality in Intracranial Stenting for Acute Stroke—A Sub-Analysis of the RESISTANT International Registry João André Sousa, Marta Olivé-Gadea, Francesco Diana, Johannes Kaesmacher, Adnan Mujanovic, et al. Clinical Neuroradiology, 2026 Purpose The optimal anesthetic approach for intracranial stenting in acute stroke remains unclear. We compared outcomes of patients under general anesthesia (GA) versus local anesthesia or conscious sedation. Methods The RESISTANT registry is a multicenter observational study on acute intracranial stenting during thrombectomy. Patients treated between January 2016 and June 2023 were included and stratified into GA and local anestesia/conscious sedation groups. The primary outcome was an adjusted shift analysis of the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included mRS 0–2 at 90 days and final modified Thrombolysis in Cerebral Infarction (mTICI) 2c/3 scores. Safety outcomes were symptomatic intracranial hemorrhage (sICH) and mortality. Adjusted ordinal and logistic regression with mixed-effects models were performed. Results Of 876 patients, 445 (50.8%) received GA. Median age was 67 years [59–77]; 567 (64.8%) were men. No differences were found in 90-day mRS (adjusted common OR = 1.256 [0.887–1.780], p = 0.199). Rates of functional independence (39.0% vs 44.5%; aOR = 0.956 [0.606–1.507], p = 0.846), mTICI 2c/3 (68.9% vs 68.7%; aOR = 0.941 [0.602–1.471], p = 0.790), and sICH (8.0% vs 8.6%; aOR = 0.769 [0.374–1.584], p = 0.477) were comparable. In-hospital (23.0% vs 12.0%; aOR = 2.39 [1.35–4.22], p = 0.003) and 90-day mortality (33.3% vs 21.1%; aOR = 2.017 [1.227–3.315], p = 0.006) were higher in the GA group. Conclusion In patients undergoing intracranial stenting during thrombectomy, anesthesia modality was not associated with better outcomes. GA was linked to higher mortality, likely due to indication bias.
Hemorrhagic transformation after intracranial stenting for acute stroke: Clinical insights from the RESISTANT registry Marta Olivé-Gadea, Adnan Mujanovic, Johannes Kaesmacher, Serdar Geyik, Songul Senadim, et al. International Journal of Stroke, 2026 Background and aim: Acute intracranial stenting is increasingly used as a rescue strategy during endovascular treatment for large vessel occlusion strokes. Limited data exist regarding the risk, clinical relevance, and optimal management of hemorrhagic transformation (HT) in this context. We aimed to evaluate the incidence, predictors, outcomes, and post-interventional antiplatelet management of HT in an international multicentric registry. Methods: We analyzed data from the RESISTANT registry, including patients who underwent emergent intracranial stenting for acute stroke between 2016 and 2023. Two complementary analyses were performed: (1) characterization of HT subtypes and associated outcomes (NIHSS at discharge, mortality, and mRS at discharge and 90 days) and (2) evaluation of antiplatelet management after Heidelberg class-1 HT detection and its impact on stent occlusion, hemorrhage progression, in-hospital mortality, and 90-day mRS. Results: Among 809 patients included, 177 (22%) experienced HT, of which 63 (8%) were symptomatic intracranial hemorrhage. Parenchymal hematomas (PH-1 and PH-2) and HI-2 were associated with worse functional outcomes and higher mortality. In the post-HT management cohort (n = 117), use of a high-intensity antiplatelet regimen (dual oral antiplatelet or any intravenous agent) was associated with lower risk of stent occlusion (adjusted risk ratio (aOR) = 0.21 [0.05–0.86]) and in-hospital mortality (aOR = 0.08 [0.01–0.50]) without increased hemorrhagic progression (0.52 [0.09–3.07]). Conclusion: HT remains a relevant complication after emergent intracranial stenting, particularly in patients with parenchymal hematoma. High-intensity antiplatelet therapy appears safe in select HT subtypes and was linked to reduced occlusion and mortality.
Emergent Carotid Stenting During Endovascular Therapy for Isolated Cervical Internal Carotid Artery Occlusion Christoph Riegler, João Pedro Marto, Pimrapat Gebert, Tilman Reiff, Marek Sykora, et al. Journal of Stroke, 2026 Background and Purpose In patients with ischemic stroke and isolated cervical internal carotid artery occlusion (c-ICA-O), endovascular therapy (EVT) can improve cerebral perfusion. To maintain vessel patency, EVT is frequently combined with carotid artery stenting (CAS). We assessed the efficacy and safety of emergent CAS during EVT for isolated c-ICA-O.Methods This retrospective multinational cohort study (42 centers) included consecutive patients who underwent EVT for isolated c-ICA-O within 24 hours from the time last seen well. Patients who underwent emergent CAS were compared with those who did not. Co-primary outcomes were c-ICA vessel patency and symptomatic intracerebral hemorrhage (sICH) 24 hours post-EVT. Secondary outcomes included any intracerebral hemorrhage (ICH) at 24 hours and disability at 3 months (modified Rankin Scale [mRS] shift). Outcomes were adjusted using inverse probability of treatment weighting.Results Of 317 patients (mean age, 68.6 years [standard deviation, 12.9]; median National Institutes of Health Stroke Scale 11 [interquartile range, 6–17]; 26.8% female), 219 (69.1%) underwent CAS, whereas 98 (30.9%) did not. At 24 hours, vessel patency was more common after CAS (83.5% vs. 40.7%; adjusted odds ratio [aOR], 9.45; 95% confidence interval [CI], 4.91–18.17); sICH rates did not differ (2.3% vs. 3.1%; aOR, 0.92; 95% CI, 0.18–4.73). Any ICH was more common after CAS (19.3% vs. 9.3%; aOR, 2.50; 95% CI, 1.12–5.60). CAS was not associated with mRS at 3 months (adjusted common odds ratio, 0.98; 95% CI, 0.62–1.56).Conclusions In patients undergoing EVT for isolated c-ICA-O, emergent CAS was technically effective and reasonably safe. More frequent vessel patency in patients who underwent CAS did not translate into improved functional outcome at 3 months.
Neurosonology Survey in Europe and Beyond Claudio Baracchini, Elsa Azevedo, Uwe Walter, João Sargento-Freitas, Branko Malojcic, et al. Ultrasound International Open, 2023
Therapeutic Approaches for Stroke: A Biomaterials Perspective Artur Filipe Rodrigues, Catarina Rebelo, Tiago Reis, João André Sousa, Sónia L. C. Pinho, et al. Engineering Biomaterials for Neural Applications Targeting Traumatic Brain and Spinal Cord Injuries, 2022
