BACKGROUND:Intracerebral hemorrhage (ICH) survivors are at increased risk of major adverse cardiovascular and cerebrovascular events (MACE) compared with population controls; however, little is known about the annual rates and risk factors for MACE. METHODS:We searched Medline, Embase, and trial registries systematically in April 2024 for studies of adults with ICH, reporting either a MACE composite outcome or both ischemic and hemorrhagic outcomes, with at least one year of follow-up. We excluded studies limited to secondary ICH or isolated non-ICH intracranial hemorrhages. We used the QUIPS tool to assess studies' risk of bias. The primary outcome was the rate of MACE. We used a random-effects meta-analysis to estimate the annual event rate (per 100 person-years, expressed as %) for each outcome. We conducted subgroup analyses and meta-regression to explore heterogeneity. RESULTS:We included 26 studies, involving 198,289 ICH survivors. Individual studies' reported annual rate of MACE ranged 4.2-14.6%. The pooled annual rate of recurrent ICH was 2.1% (95% confidence interval (CI) = 1.7-2.6; 26 studies; I2 = 94%) and of ischemic stroke was 2.0% (95% CI = 1.5-2.7; 24 studies; I2 = 95%). Meta-regression analyses identified one statistically significant association between a higher prevalence of atrial fibrillation and an increased risk of ischemic stroke. DISCUSSION:The rates of recurrent ICH and ischemic stroke were comparable among ICH survivors, but evidence about other MACE outcomes remains limited. An individual participant data meta-analysis is needed to investigate the predictors of MACE outcomes, which may help inform risk stratification and prognosis among ICH survivors.

Abstract Background and aims Intracerebral haemorrhage (ICH) a medical emergency causes more than 1.7 million strokes worldwide/year with over 40% mortality. Tranexamic acid (TXA) when given early, may reduce mortality and haematoma expansion in spontaneous ICH. Methods We aim to assess the clinical effectiveness of TXA after ICH and determine whether TXA should be used in clinical practice. Results TICH-3 is a pragmatic phase III prospective double-blinded randomised placebo-controlled trial. 5500 adult patients (≥18) with spontaneous ICH (including direct oral anticoagulants (DOAC) associated ICH) will be recruited within 4.5 hours of onset across UK and International sites. Exclusion criteria include known indication for TXA, contraindications for TXA, known to be on anticoagulation (except DOAC), massive ICH(>60ml), severe coma (GCS<5) and palliative care. Rapid emergency consent utilised, and patients will be randomised (1:1) by simple randomisation to receive intravenous TXA 2g; 1g bolus loading dose given as 100ml infused over 10 minutes, followed by another 1g in 250ml infused over 8hrs or matching comparator. The primary outcome is mortality by day 7. Secondary outcomes include dependency (using the modified Rankin Score), Quality of Life at day 180, serious adverse events (SAE) up to 7 days, and fatal SAEs up to day 180. Conclusions The results of TICH-3 will determine whether tranexamic acid should be implemented into standard of care for spontaneous intracerebral haemorrhage. Conflict of interest

BACKGROUND:Cerebral small vessel disease (CSVD) is a common incidental MRI finding in patients with transient ischemic attack (TIA) and stroke and has been linked to cognitive decline. This study investigated the prevalence of CSVD imaging biomarkers in TIA patients and their association with cognitive performance over 3 years. METHODS:We included 246 TIA patients from the INSPiRE-TMS study (ClinicalTrials.gov: NCT01586702). CSVD was assessed on baseline 3 T MRI using a composite score (0-4) including white matter hyperintensities (WMH), lacunes, cerebral microbleeds (CMBs), and enlarged perivascular spaces (PVS). Cognitive performance was evaluated using the Montreal Cognitive Assessment (MoCA) at baseline and annually for 3 years. RESULTS:At least one CSVD imaging biomarker was present in 58.5% of patients. Lacunes (36.6%) were the most common, followed by PVS (28.1%), WMH (19.5%), and CMBs (17.9%). Higher CSVD-score was independently associated with greater cognitive decline over 3 years (β = -0.52, 95% CI -0.95- -0.08, p = 0.020), along with older age (β = -0.08, 95% CI -0.13 to -0.03, p = 0.001). CMB burden was the strongest predictive component of the CSVD-score (β = 0.42, 95% CI -0.63 to -0.22, p < 0.001). CSVD-score was particularly associated with decline in the memory domain (adjusted β of -0.18, 95% CI -0.32 to -0.04, p = 0.015). CONCLUSION:CSVD imaging markers are present in over half of TIA patients and are independently associated with cognitive decline up to 3 years, with the strongest effect on memory. Whether the presence of CMBs is the strongest predictive imaging biomarker of cognitive decline in TIA patients requires confirmation in further studies.

BACKGROUND:Glenzocimab is a humanized fragment of a monoclonal antibody directed against the human platelet glycoprotein VI, which has shown promising features, including thrombus growth inhibition and minimal bleeding risk. The first inpatient study suggested the benefit of glenzocimab with alteplase in subgroups of patients with acute ischemic stroke (AIS) receiving endovascular treatment (EVT), with increased reperfusion rates and decreased risk of symptomatic hemorrhagic transformation. The objective of the GREEN (Glenzocimab for REperfusion in the setting of Endovascular therapy for brain infarctioN) study is to evaluate the efficacy of glenzocimab with EVT compared with EVT plus placebo, with or without intravenous thrombolysis (IVT), on functional outcome. METHODS:GREEN is a multicenter, randomized, double blind, placebo controlled study. Participants presenting with AIS and a large vessel occlusion of the anterior circulation (intracranial internal carotid artery or middle cerebral artery, or both), with symptoms onset within 24 hours, will be randomized to one of two groups: intravenous glenzocimab 1000 mg with standard of care (SoC-EVT±IVT) or SoC (EVT±IVT) plus placebo. The main primary efficacy endpoint is functional outcome (assessed by the modified Rankin Scale score) at 90 days. CONCLUSION:This is the first randomized trial evaluating the efficacy of glenzocimab with EVT. This prospective trial aims to determine whether glenzocimab with EVT improves functional outcome. TRIAL REGISTRATION:ClinicalTrials.gov NCT05559398.

INTRODUCTION:Genetic deficiency of factor XI is associated with a reduced risk of ischemic stroke. Asundexian is a direct inhibitor of activated factor XIa (FXIa) with a low risk of bleeding in early trials. We seek to determine its efficacy and safety combined with antiplatelet therapy for prevention of ischemic stroke. PATIENTS AND METHODS:Oral faCtor Eleven A iNhibitor asundexian as novel antithrombotiC (OCEANIC-STROKE) is a placebo-controlled, double-blind, event-driven randomised trial including participants with stroke (NIHSS ≤ 15) or high-risk TIA (ABCD2 6 or 7) within 72 h of onset. Participants had at least one of the following: atherosclerosis of extra- or intracranial vessels, a medical history of atherosclerosis or an imaged acute non-lacunar infarct. We excluded sources of stroke requiring anticoagulation and active non-trivial bleeding other than hemorrhagic infarction (HI 1 or 2). Participants received asundexian 50 mg daily or placebo stratified by planned concurrent antiplatelet therapy (single vs dual). The primary endpoint is time to ischemic stroke. We present baseline characteristics as of 5 June 2025. RESULTS:Between January 2023 and February 2025, we randomised 12,327 participants. Participants were 67% male with a mean (SD) age of 68 (11) years. Ischemic stroke was the index event for 95% of whom 27.4% had thrombolysis and/or mechanical thrombectomy. By TOAST classification, 43% of index strokes were LAA, 22% small vessel disease, 30% undetermined and 2% cardioembolic. Dual antiplatelets were planned in 63% as standard initial treatment. Trial completion is anticipated in October 2025. CONCLUSION:OCEANIC-STROKE will be the first completed trial of FXIa inhibition for prevention of stroke after non-cardioembolic stroke or TIA. TRIAL REGISTRATION:ClinicalTrials.gov (NCT05686070).

Introduction Despite advances in clinical care and treatment options, recurrent stroke risk remains significant. The unmet needs and challenges in secondary stroke prevention (SSP) after a non-cardioembolic ischaemic stroke are not fully understood, leaving many patients at risk of stroke recurrence. This study summarises expert consensus on the challenges in current SSP treatment and management. Patients and methods We conducted a 2-round modified Delphi study with 13 international stroke experts. This multidisciplinary panel included stroke neurologists, a stroke nurse, a dementia care nurse with lived experience and patient advocacy group representatives. The Delphi co-chairs developed 11 statements which were presented to the experts. Agreement was sought through a 2-round, anonymous survey and a final consensus discussion. Results All 11 statements achieved consensus after the 2 survey rounds. The statements addressed key areas including the burden of recurrent stroke, treatment and lifestyle interventions, management of stroke care and future needs to enhance SSP. Conclusion This is the first Delphi-based global consensus focused specifically on unmet needs in SSP. The experts agreed on several challenges-notably, recurrent stroke risks-and consistently emphasised that the impact of recurrent stroke is underappreciated. This Delphi panel's strong consensus underscores the real-world barriers, clinical inefficiencies and unmet needs that remain in SSP treatment and management. Addressing these challenges will require sustained investment in SSP treatments, education and innovation.

BACKGROUND:Comparative data on tenecteplase versus alteplase in patients aged ≥80 years undergoing bridging therapy before thrombectomy are limited. METHODS:We retrospectively analyzed two prospective cohorts of patients aged ≥80 years with anterior circulation large-vessel occlusion treated with bridging intravenous thrombolysis: the multicenter TETRIS registry (tenecteplase) and a single comprehensive stroke center (alteplase). Propensity score matching (1:1, 11 covariates, caliper 0.2 SD logit) was performed, with overlap weighting as sensitivity analysis; matched dichotomous outcomes were analyzed by conditional logistic regression and generalized estimating equations clustered on the matched pair. Because treatment was completely confounded with center and data source, analyses compare cohorts rather than isolate a drug effect. The primary outcome was modified Rankin Scale (mRS) ≤3 at 90 days. Secondary outcomes included substantial early neurological improvement (ENI: ≥8-point NIHSS improvement or NIHSS ≤1 at 24 h), complete early neurological recovery (NIHSS = 0 at 24 h), early reperfusion (eTICI 2b-3), symptomatic intracranial hemorrhage (sICH), and 90-day mortality. RESULTS:Among 720 eligible patients, 278 matched pairs were analyzed. The primary outcome (mRS ≤3) occurred in 48.0% of tenecteplase- versus 43.5% of alteplase-treated patients (OR 1.20, 95% CI 0.86-1.67); an excellent outcome (mRS 0-2: 27.6% vs 27.0%), the ordinal mRS shift (common OR 1.06), early reperfusion (16.9% vs 16.5%), substantial ENI (40.2% vs 34.9%), sICH (3.7% vs 4.4%), and 90-day mortality (30.2% vs 30.2%) did not differ. Complete early neurological recovery (NIHSS = 0 at 24 h) was more frequent with tenecteplase (10.3% vs 2.6%; OR ≈4.3), but this difference was confined to the single NIHSS value 0, reversed at NIHSS = 1, left no trace in any 90-day endpoint, and was nullified by modest unmeasured confounding (E-value for the lower confidence bound ≈2-3). CONCLUSIONS:In patients aged ≥80 years undergoing bridging therapy, tenecteplase and alteplase were associated with similar 90-day functional outcomes and similar safety. An isolated 24-hour complete-recovery signal favoring tenecteplase is hypothesis-generating and vulnerable to ascertainment bias, given complete confounding of treatment with center. Dedicated randomized data in this age group are warranted.

Ischemic stroke in young adults is a significant social and economic burden. Machine learning (ML) techniques can potentially predict the outcomes of recurrence and functional status after a stroke more accurately than traditional statistical methods. We sought to predict these outcomes in young individuals with stroke with machine learning and compare that with traditional statistical methods. This study is part of Global Outcome Assessment Lifelong After Stroke in Young Adults (GOAL) initiative, which collects individual patient data from hospital-based young stroke (18–50 years) cohorts from 29 countries covering all continents worldwide. We compared several common machine learning models with traditional logistic regression to investigate the best models for predicting functional outcome, as measured by the modified Rankin scale at three months post-stroke, and stroke recurrence during follow-up. Functional outcome was available for 7937 patients, and stroke recurrence for 9366 patients. Poor functional outcomes post-stroke occurred in 27.0

Abstract Background and aims Risk and impact of stroke recurrence is high. Advancements in secondary stroke prevention (SSP) have not substantially reduced since the millennium. Consensus (75% agreement) was gained by a multi-stakeholder expert panel on challenges in SSP. We present their call for multistakeholder action to enable meaningful reduction in recurrence risk and improved patient outcomes. Methods We conducted a modified Delphi study with 13 international stroke experts, including stroke survivors and patient advocates. After two anonymous survey rounds and one discussion, consensus was achieved on 11 statements relating to challenges in SSP treatment and management. Results Our study achieved consensus that sustained investment in management, support and new treatment options for SSP is needed to improve quality of life for survivors and caregivers, and to achieve long-term cost savings. Optimal prevention of recurrence requires healthcare professionals, stroke survivors and their caregivers to be ‘partners in prevention’. Consensus on this was achieved by 100% of panel members following the discussion round. Our analysis also identified measures for implementation and advocacy to improve outcomes for stroke survivors. Conclusions We demonstrate multidisciplinary consensus on the need for sustained attention to SSP management, support and innovation. This will enable new developments in SSP to achieve their potential to improve outcomes, while optimising use of post-stroke resources. Realisation of these changes will require aligned action across key stakeholders, including those involved in stroke care and beyond – with stroke and cardiovascular health plans including SSP, supported by clear guidelines and policies. Conflict of interest All authors received honoraria from Bayer AG in recognition of their participation in the Delphi process. VC reports receiving payment or honoraria for lectures, presentations, speaker bureaus, manuscript writing or educational events from Daiichi Sankyo, Pfizer BMS, Bayer and Ever Pharma; consulting fees from Daiichi Sankyo, Pfizer BMS and Bayer; support for attending meetings and/or travel for Daiichi Sankyo, Bayer and Ever Pharma; participation on a data safety monitoring board or advisory board for Bayer. TH reports payment or honoraria for lectures, presentations, speaker bureaus, manuscript writing or educational events from Bayer and Daiichi Sankyo. LL reports she is the Deputy vice president of Chinese stroke association (unpaid role). GMD reports consulting fees from Bayer as well as being part of a steering committee. CC reports payment or honoraria for lectures, presentations, speaker bureaus, manuscript writing or educational events from Biogen, BMS, Bayer, Amgen; participation on a data safety monitoring board or advisory board from Novartis and Boehringer-Ingelheim. The other authors report no competing interests.

A state-of-the-art lecture titled, "New Treatment Targets in Intracerebral Hemorrhage," was presented at the International Society on Thrombosis and Haemostasis (ISTH) Congress in 2025. Intracerebral hemorrhage remains one of the most devastating forms of stroke, with high rates of mortality and long-term disability. Unlike ischemic stroke, treatment options remain limited, but advances in pathophysiological understanding and clinical trials have expanded the range of potential therapeutic strategies. This review synthesizes current evidence across 3 major interdependent domains. First, hematoma stabilization focuses on preventing hematoma expansion through intensive blood pressure control, hemostatic agents, and reversal of antithrombotic therapies, with recent prehospital and care bundle trials demonstrating promise. Second, strategies to reduce hematoma burden and the mass effect include both surgical evacuation and enhancement of endogenous clearance mechanisms. While minimally invasive surgery has shown selective benefits in carefully chosen patients, increasing attention is being directed toward accelerating natural hematoma resolution via microglial and macrophage-mediated phagocytosis, as well as modulating iron toxicity. Third, mitigation of secondary brain injury targets perihematomal edema, oxidative stress, and neuroinflammation. Recent trials of glibenclamide, anti-inflammatory agents, COX-2 inhibitors, and antioxidants have indicated both the challenges and opportunities of modulating secondary injury. Together, these developments represent a transition from therapeutic nihilism toward optimism but emphasize a need for multimodal and time-sensitive interventions. Finally, we summarize relevant new data on this topic presented during the 2025 ISTH Congress.

INTRODUCTION:Predicting the occurrence of late seizures after intracerebral haemorrhage may help in making clinical decisions about treatment. Currently, the CAVE score is the best performing risk score. We aimed to design a different, pragmatic risk prediction score and compared it to the CAVE score. PATIENTS AND METHODS:The South Limburg (Netherlands) intracerebral haemorrhage registry, consisting of patients with a primary intracerebral haemorrhage in 2004-2009, was used for the derivation cohort. We made a prediction model using Cox proportional hazard analyses; comparisons between models were made with the c-statistic. We validated our model externally in three independent cohorts. RESULTS:Our derivation cohort consisted of 781 patients, of whom 78 (10%) developed late seizures. We found the following independent predictors for late seizures: any neurosurgical procedure, age < 65 years, lobar haemorrhage, and early seizures (occurring within the first week). These formed our new prediction score (LEAN score), which had an optimism-corrected c-statistic of 0.80 (95%-confidence interval 0.78-0.86). The LEAN score predicts late seizure risk as 0.7%, 1.6%, 8.8%, 22.0%, 29.8%, 43.5%, 100% for the increasing score groups respectively. External validation showed comparable optimism-corrected c-statistics for both the LEAN score and the CAVE score. CONCLUSION:The newly developed LEAN score consists of easily available clinical variables and performs equally to the CAVE score. Additionally, the high risk of late seizures in patients with the maximum LEAN score might make a diagnosis of epilepsy possible according to international guidelines despite these patients only had early seizures.

Introduction: Intracranial hemorrhage (ICrH) is an umbrella term that encompasses any bleeding within the skull. The underlying mechanisms, clinical presentations, and management strategies of ICrH vary considerably based on the anatomical location of the blood. However, the current terminology surrounding ICrH is often ambiguous and inadequate for conveying the precise anatomical origins and extent of the bleeding, contributing to confusion and inconsistency in both clinical practice and research. Methods: To address these challenges, we identify six key shortcomings in current usage and propose a harmonized terminology for anatomical classification. Results: We propose the following clarifications: (i) intraparenchymal hemorrhage (IPH) refers to any bleeding within the parenchyma of the brain or the brainstem; (ii) isolated intraventricular hemorrhage (IVH) denotes bleeding within the ventricles, not secondary to intraparenchymal or subarachnoid hemorrhage; (iii) intracerebral hemorrhage (ICH) includes both IPH and IVH; (iv) ICrH encompasses all bleeding within the skull (i.e., intraparenchymal, intraventricular, subarachnoid, subdural and epidural hemorrhages); (v) precise anatomical terminology should be favored over the ambiguous term “hemorrhagic stroke”; and (vi) the term “hemorrhage” indicates an active bleeding process, whereas “hematoma” describes the resulting mass or collection of blood. Conclusion: We invite stroke physicians and researchers to use this harmonized terminology to standardize and facilitate communication, as well as the interpretation and translation of research findings.

BACKGROUND:The best revascularization strategy for acute ischemic stroke from isolated vertebral artery occlusion remains unclear. METHODS:This retrospective, international, multicenter cohort study included patients from 30 comprehensive stroke centers across Europe (n=23), North America (n=5), and Asia (n=2) between 2016 and 2022. Eligible patients presented with acute ischemic stroke within 24 hours of last seen well and had imaging-confirmed isolated vertebral artery occlusion. Two treatment comparisons were analyzed: intravenous thrombolysis (IVT)-only versus conservative treatment (Cx), and endovascular treatment (EVT)±IVT versus medical management (Cx and IVT). The primary outcome was the shift in 3-month modified Rankin Scale (mRS) score; secondary outcomes included early neurological improvement (24-hour-delta National Institutes of Health Stroke Scale score), recanalization, early neurological deterioration of ischemic origin, symptomatic intracerebral hemorrhage, and 3-month mortality. Analyses were adjusted using inverse probability of treatment weighting (IPTW). RESULTS:Among 494 patients, 143 (29%) received Cx, 218 (44%) IVT-only, and 133 (27%) EVT±IVT. Compared with Cx, IVT-only showed similar 3-month mRS score (IPTW-adjusted odds ratio [aOR] mRS shift score, 1.32 [95% CI, 0.80-2.18]), greater early neurological improvement (IPTW-adjusted-β coefficient, -1 [95% CI, -2.05 to 0.05]), and higher recanalization rates (IPTW-aOR, 4.33 [95% CI, 1.36-13.78]). Compared with MM (=IVT+Cx), EVT±IVT was associated with an unfavorable mRS shift score (IPTW-aOR mRS shift score, 0.51 [95% CI, 0.35-0.74]), higher early neurological deterioration of ischemic origin (IPTW-aOR, 9.06 [95% CI, 2.86-28.67]), and symptomatic intracerebral hemorrhage (IPTW-aOR, 6.05 [95% CI, 1.14-32.1]) though recanalization was over 4-fold higher (OR, 4.64 [95% CI, 1.90-11.33]). Patients with National Institutes of Health Stroke Scale score ≥10 showed point estimates favoring EVT+IVT (Pinteraction=0.025). CONCLUSIONS:IVT-only appeared safe and was associated with better early recovery and recanalization. EVT±IVT showed overall worse outcomes, potentially due to increased early neurological deterioration of ischemic origin and symptomatic intracerebral hemorrhage rates, but may confer benefit in moderate-to-severe strokes, warranting prospective trials in symptomatic isolated vertebral artery occlusion.

The complexity and incomplete understanding of the pathophysiology of stroke poses substantial challenges to personalised medicine and the development of novel therapies, as reflected in the neutral results of many randomised trials. Current clinical algorithms lack the precision to diagnose stroke before hospital admission, predict disease progression and recovery, or assess recurrence risk. Biomarkers are urgently needed, yet the absence of a robust evidence base hinders their clinical translation. To lay the groundwork for addressing this knowledge gap, an international multidisciplinary panel of stroke experts conducted a literature review that informed a Delphi consensus process. The stroke experts panel proposes 17 research priorities and five minimum reporting datasets for stroke biomarker studies, each corresponding to a key domain of stroke care: prehospital diagnosis, ischaemic stroke progression, atrial cardiopathy, plaque vulnerability, and intracerebral haemorrhage. This framework will promote consistency and collaboration towards the discovery, validation, and clinical translation of biomarkers to improve stroke care.

BACKGROUND:Patients with noncardioembolic ischemic stroke or transient ischemic attack (TIA) are at risk for recurrent stroke. Low factor XI levels are associated with a reduced risk of ischemic stroke. Asundexian inhibits activated factor XI. Whether the addition of asundexian to antiplatelet therapy would be superior to antiplatelet therapy alone for the secondary prevention of ischemic stroke is unclear. METHODS:In this phase 3, double-blind trial, we randomly assigned patients within 72 hours after the onset of a noncardioembolic ischemic stroke or high-risk TIA to receive asundexian (50 mg once daily) or placebo, in addition to planned dual or single antiplatelet therapy. Patients had at least one of the following: a nonlacunar infarct on imaging, a history of atherosclerosis, or evidence of atherosclerotic plaque at any location on cerebrovascular imaging. The primary efficacy outcome was ischemic stroke. The composite of death from cardiovascular causes, myocardial infarction, or stroke was a key secondary outcome. The primary safety outcome was major bleeding. RESULTS:Among 12,327 patients who underwent randomization (6162 to the asundexian group and 6165 to the placebo group), the incidence of ischemic stroke was lower in the asundexian group than in the placebo group (6.2% vs. 8.4%; cause-specific hazard ratio, 0.74; 95% confidence interval [CI], 0.65 to 0.84; P<0.001). The incidence of the composite of death from cardiovascular causes, myocardial infarction, or stroke was lower in the asundexian group than in the placebo group. The incidence of major bleeding was similar in the asundexian group and the placebo group (1.9% and 1.7%, respectively; cause-specific hazard ratio, 1.10; 95% CI, 0.85 to 1.44). The incidence of adverse events was 69.3% in the asundexian group and 70.1% in the placebo group; the incidence of serious adverse events was 19.2% and 19.5%, respectively. CONCLUSIONS:Among patients with noncardioembolic ischemic stroke or high-risk TIA treated with antiplatelet therapy, asundexian at a daily dose of 50 mg resulted in lower risks of ischemic stroke and major cardiovascular events than placebo, without a higher risk of major bleeding. (Funded by Bayer; OCEANIC-STROKE ClinicalTrials.gov number, NCT05686070.).

Understanding the pathophysiology and predictive factors of poor prognosis in intracerebral hemorrhage has significantly advanced over the past decade. The development of animal models and translational research has demonstrated that targeting a single pathway is insufficient to improve the vital and functional outcome of patients who have suffered this severe type of stroke. The various key stages of intracerebral hemorrhage pathophysiology, which occur sequentially over time, require complementary and innovative therapeutic approaches. Current therapeutic strategies under development focus on three main targets: (i) limiting hemorrhage expansion, (ii) promoting hematoma evacuation, and (iii) reducing perihematomal edema and optimizing hematoma resorption. While these innovative strategies are still being developed, the management of intracerebral hemorrhage remains rooted in the concept applied for over 20 years in ischemic stroke: acting quickly because "time is brain."(c) 2025 l'Academie nationale de medecine. Published by Elsevier Masson SAS. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Cerebral amyloid angiopathy (CAA) is a well-recognized and challenging disease for neurologists and other clinicians caring for the rapidly aging worldwide population. CAA is a major cause of spontaneous lobar intracerebral hemorrhage (ICH), and can also cause transient focal neurological episodes, and convexity subarachnoid hemorrhage, CAA-associated ICH has a high mortality, morbidity, and recurrence rate. CAA can affect a wide range of clinical decisions including use of antithrombotic medications, safety for anti-β-amyloid peptide (Aβ) immunotherapy, and need for anti-inflammatory or immunosuppressive treatment. We present guidelines, intended to inform the approach to individuals with suspected CAA, written on behalf of the International CAA Association and the World Stroke Organization (WSO). We cover five areas selected for their relevance to practice: (1) diagnosis, testing, and prediction of intracerebral hemorrhage risk; (2) antithrombotic agents and vascular interventions; (3) vascular risk factors and concomitant medications; (4) treatment of CAA manifestations; and (5) diagnosis and treatment of CAA-related inflammation and vasculitis. The statement has been reviewed and approved by the Executive Committee of the WSO, and the International CAA Association.

Over a third of minor stroke patients experience post-stroke cognitive impairment (PSCI), but no validated tools exist to identify at-risk patients early. This study investigated whether disconnection features derived from infarcts and white matter hyperintensities (WMH) could serve as markers for short- and long-term cognitive decline in first-ever minor ischemic stroke patients. First-ever minor ischemic stroke patients (NIHSS ≤ 7) were prospectively followed at 72-h, 6 months, and 36 months post-stroke with cognitive tests and brain MRI. Infarct and WMH volumes were semi-automatically assessed on DWI and FLAIR sequences. Bayesian tract-based disconnection models estimated remote pathological effects of infarcts and WMH. Associations between disconnection features and cognitive outcomes were analyzed using canonical correlation analyses, adjusted for age, education, and multiple comparisons. Among 105 patients (31% female, mean age 63 ± 12 years), infarct volume averaged 10.28 ± 17.10 cm 3 and predominantly involved the middle cerebral artery territory (83%). WMH burden was higher in frontal periventricular white matter. Infarct-based features did not significantly relate to PCSI. However, a WMH-derived disconnection factor, involving commissural and frontal tracts, and the right superior longitudinal fasciculus, was significantly associated with PSCI at 6 months (OR = 9.96, p value = 0.02) and 36 months (OR = 12.27, p value = 0.006), particularly in executive/attention, language, and visuospatial domains. This factor, unrelated to WMH volume, outperformed demographic and clinical predictors of PSCI. WMH-induced disconnection may be associated with short- and long-term PSCI in minor stroke. Routine MR-derived features could identify at-risk patients for rehabilitation trials.