Evidence supporting mechanical thrombectomy (MT) in very elderly patients remains limited, as nonagenarians are underrepresented in randomized trials and frequently excluded from MT in routine practice. We evaluated the effectiveness and safety of MT in carefully selected patients aged ≥ 90 years treated at a comprehensive stroke center. We conducted a retrospective single-center cohort study including consecutive patients with anterior circulation large vessel occlusion treated with MT. Fifty nonagenarians treated between 2017 and 2025 were compared with 100 younger patients treated in 2023. In both groups, only patients with preserved pre-stroke functional independence (modified Rankin Scale [mRS] 0–2) were included. Nonagenarians underwent detailed pre-treatment clinical assessment prior to treatment. Primary outcomes were functional independence (mRS 0–2) and all-cause mortality at 90 days. Secondary outcomes included successful reperfusion (mTICI 2b–3), neurological status at discharge, and hemorrhagic complications. Multivariable regression models were used to adjust for baseline imbalances and clinically relevant prognostic factors. Nonagenarians had a substantially higher burden of comorbidities and worse pre-stroke functional status than younger patients. Successful reperfusion rates were similar between groups (92

Background/Objectives: Acute ischemic stroke (AIS) associated with cervical carotid artery pathology remains a therapeutic challenge due to uncertainty regarding emergent carotid artery stenting (eCAS) and the need for intensified antithrombotic therapy, which may increase the risk of hemorrhagic transformation (HT). This retrospective cohort study evaluated the functional and safety outcomes of eCAS within an extended treatment time window. Methods: We analyzed 139 consecutive patients with anterior circulation AIS and large vessel occlusion treated with mechanical thrombectomy between 2019 and 2024. Patients were eligible for MT within 24 h based on clinical-core mismatch (DAWN) or perfusion-core mismatch (DEFUSE 3) criteria. Outcomes were compared between patients treated with eCAS and those undergoing MT without stenting. Results: Twenty-five patients underwent eCAS, predominantly for tandem lesions (80%). Median age was 66 years, median baseline NIHSS was 14, and median infarct core volume on DWI/CTP was 15 mL. Baseline characteristics were comparable between groups, except for the site of occlusion (p < 0.001). A good functional outcome (modified Rankin Scale, mRS 0-2 at 90 days) was observed in 60% of patients in the eCAS group versus 43% in the non-stenting group, without statistical significance (p = 0.067). Rates of parenchymal hematoma (12% vs. 18.4%) and symptomatic intracerebral hemorrhage (8% vs. 3.5%) were similar between groups. Conclusions: In this single-center cohort, eCAS performed in an extended time window did not demonstrate a clear signal of increased hemorrhagic risk. However, residual confounding and imbalance between treatment groups persisted despite the application of inverse probability weighting (IPW), and the findings should be interpreted cautiously.

BACKGROUND:Cardioembolic stroke accounts for more than 20% of all acute ischemic strokes (AIS) and is mainly caused by cardiac arrhythmias, particularly atrial fibrillation (AF). The presence of specific or multiple additional vascular risk factors indicates the need for oral anticoagulant (OAC) therapy in AF patients (according to the CHA2DS2-VASc classification). While OAC treatment significantly reduces the risk of AIS by over 80% in this population, the risk remains higher compared to the general population. Approximately half of AF patients on OAC therapy who experience AIS do not meet the criteria for thrombolytic (high blood activity of OAC) or mechanical thrombectomy (non-large vessel occlusion stroke) treatment. AIM:This study aims to assess the efficacy and safety of recombinant tissue plasminogen activator (rtPA) in AIS patients who have been on chronic non-vitamin K antagonist oral anticoagulant (DOAC) therapy after receiving a specific reversal agent. METHODS AND DESIGN:Patients with acute ischemic stroke (AIS) who are treated with specific oral anticoagulants (OACs) with anti-Xa activity have been on chronic non-vitamin K antagonist oral anticoagulant e included in the study. The protocol involves administering a fast-acting antidote (andexanet alfa for rivaroxaban or apixaban) or a placebo, followed by intravenous thrombolytic therapy with rtPA or a placebo. The study arms for rivaroxaban and apixaban are designed as prospective, randomized, placebo-controlled interventional trials that meet phase II trial criteria. DISCUSSION:The STRoke on Oral AntiCoagulants for Thrombolysis (STROACT) trial is, to our knowledge, the first randomized phase II study designed to explore the feasibility, efficacy, and safety of reversal-enabled intravenous thrombolysis in a highly selected population of acute ischemic stroke patients on factor Xa inhibitors. The results are expected to be hypothesis-generating and may inform the design of future confirmatory trials. TRIAL REGISTRATION:www.clinicaltrialsregister.eu ; EudraCT Nr: 2020-004898-41; March 31, 2021.

Abstract Background and aims Mechanical thrombectomy (MT) is the standard treatment for ischemic stroke due to large vessel occlusion. Although advanced age is associated with poorer outcomes, age alone should not contraindicate endovascular therapy. Data on patients aged ≥90 years remain scarce in clinical practice. Methods We conducted a retrospective, single-center cohort study of consecutive patients treated with MT. Fifty patients aged ≥90 years were compared with 100 younger patients. In nonagenarians, eligibility for MT was determined individually by a multidisciplinary stroke team. Baseline characteristics, procedural variables, and outcomes were analyzed. Inverse probability weighting (IPW) was used to adjust for baseline imbalances. Primary outcomes were functional independence at 90 days (modified Rankin Scale [mRS] 0–2) and 90-day mortality. Secondary outcomes included successful reperfusion (TICI 2b–3), neurological status at discharge, and hemorrhagic complications. Results Nonagenarians had worse baseline characteristics. Successful reperfusion (TICI 2b–3) was similar in patients aged ≥90 years and younger patients (92.0% vs 89.0%). Functional independence at 90 days occurred in 18.0% versus 49.0%, respectively, but the difference was no longer significant after IPW adjustment (risk difference −0.10, 95% CI −0.29 to 0.09). Ninety-day mortality was higher in unadjusted analyses (48.0% vs 20.0%), but not after IPW-weighted analysis. Parenchymal hemorrhage was more frequent in nonagenarians (28.0% vs 10.0%), while symptomatic intracerebral hemorrhage rates were similar. Conclusions After adjustment for baseline differences, carefully selected nonagenarians achieved outcomes comparable to younger patients undergoing MT, despite a higher risk of parenchymal hemorrhage. These findings support individualized, multidisciplinary patient selection rather than age-based exclusion from thrombectomy. Conflict of interest Bartosz Jabłoński: nothing to disclose. Aleksandra Pracoń: nothing to disclose. Adam Wyszomirski: nothing to disclose. Anna Gwiazda: nothing to disclose. Marcin Stańczak: nothing to disclose. Łukasz Maciołek: nothing to disclose. Dariusz Gąsecki: nothing to disclose. Edyta Szurowska: nothing to disclose. Bartosz Karaszewski: nothing to disclose. Table 1 - belongs to Results

BackgroundHypertension is one of the main modifiable risk factors for ischemic stroke related to large artery atherosclerosis. Arterial stiffness indices may improve risk stratification beyond blood pressure (BP) measurement alone. Increased pulse wave velocity (PWV) is a risk and prognostic factor for ischemic stroke (IS) and is associated with carotid artery atherosclerosis. We investigated whether the aortic–brachial pulse wave velocity (PWV) ratio differs between stroke subtypes and whether it is independent of mean blood pressure (MBP) in ischemic stroke patients.MethodsWe measured carotid-radial (cr-PWV) and carotid-femoral PWV (cf-PWV) on day 6 of hospitalization in 188 IS subjects. PWV ratio was calculated as cf-PWV/cr-PWV. The etiology of stroke was determined following appropriate diagnostic investigations. Stroke etiology was determined according to TOAST classification. Associations between PWV ratio, stroke subtype, and MBP were analyzed using uni- and multivariate models.ResultsForty-one patients (21.8%) had stroke related to large artery atherosclerosis (LAA). The PWV ratio was higher in LAA compared with non-LAA stroke [1.26 (1.09–1.58) vs. 1.10 (0.95–1.36), p < 0.01], remaining significant after adjustment (OR = 3.40, 95%CI = 1.18–9.79, p = 0.02). PWV ratio was not associated with MBP (p = 0.79).ConclusionsPWV ratio is elevated in LAA-related ischemic stroke and was not significantly associated with BP, supporting its potential role as a vascular risk marker.

INTRODUCTION:Accurately stratifying the risk of poor outcomes after acute ischaemic stroke remains a critical challenge. Complete blood count (CBC)-derived indices, such as the neutrophil-to-lymphocyte ratio (NLR), have been proposed as prognostic markers. However, their performance compared to other recently proposed CBC-based parameters, including the derived neutrophil-to-lymphocyte ratio (dNLR) and neutrophil-to-lymphocyte-and-platelet ratio (NLPR), remains unclear. MATERIAL AND METHODS:A retrospective analysis of records from 202 patients with acute ischaemic stroke treated with intravenous thrombolysis (IVT) was performed. NLR, dNLR, NLPR and six other novel inflammatory indices - lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), mean platelet volume to platelet count ratio (MPR), systemic inflammatory index (SII), systemic inflammation response index (SIRI), and aggregate index of systemic inflammation (AISI) - were calculated from the CBC acquired upon admission and one day after IVT. Differences in laboratory parameters and ratios between groups of diverse outcomes were tested, and diagnostic performance between ratios was compared using multivariate logistic regression models. RESULTS:Three inflammatory ratios (NLR, dNLR, NLPR) measured the day after IVT were found to be independent risk factors for a poor functional outcome at discharge. The upper quartile of NLR and dNLR alone presented similar performance (OR = 4.04, 95% CI: 2.06-7.92, p < 0.001; sensitivity 40%, specificity 86%, AUC = 0.63). However, dNLR showed higher discrimination value in the combined model with pre-mRS and NIHSS (OR = 5.50, 95% CI: 2.02-14.93, p < 0.001; sensitivity 81%, specificity 93%, AUC = 0.929). This parameter, along with glucose levels, was also associated with the risk of early intracranial bleeding (OR = 4.74, 95% CI: 1.24-18.21, p = 0.023). CONCLUSIONS:In this exploratory study, dNLR measured on the day after IVT was superior to NLR and other parameters in prognosis of unfavourable outcomes and recognition of intracranial haemorrhage. Nevertheless, clinical data such as pre-mRS and NIHSS combined remain the most important predictors.

Although intracerebral haemorrhage (ICH) represents a minority of all strokes, it remains a significant cause of morbidity and mortality worldwide. Early BP elevation is common after ICH, with many observations showing strong associations between increasing BP values and haematoma growth and subsequent poor outcomes. Recent evidence suggests that early intensive SBP lowering in acute ICH to <140 mmHg within a few hours is feasible and safe and can be effective in improving functional outcomes. The optimal timing for initiating BP lowering after ICH is unknown. However, optimal protection against death or disability after ICH was observed in patients without severe ICH and early planned surgery who achieved the greatest SBP reductions in the first hour after randomization, which was maintained consistently for 7 days. The optimal choice of drug and intensity of treatment remain elusive. Other factors, such as BP variability, obstructive sleep apnoea, obesity and other vascular risk factors, should also be considered in the acute care of ICH patients. Current large-scale trial results are needed to determine whether control of these potentially modifiable factors may improve clinical outcomes.

Increased blood pressure (BP) is a common problem in acute ischaemic stroke (AIS). The acute hypertensive response in stroke is of prognostic relevance. The pathophysiology of high BP in stroke is complex and poorly understood. The available evidence is insufficient to guide therapeutic decisions and does not show that lowering BP reduces mortality or disability in patients with subacute ischaemic stroke. There are some hints of the possible efficacy of very early BP lowering (within 6 h after stroke onset). Nevertheless, the management of BP immediately after stroke onset is largely empiric. It is reasonable to withhold BP-lowering drugs until patients are medically and neurologically stable. Immediately restarting pre-stroke BP-lowering drugs may increase disability. The timing of the BP intervention might be crucial. However, more research is needed to identify patients most likely to benefit from lowering BP in acute stroke, as well as the time window in which the response to treatment is likely to be favourable. Subtyping of stroke according to the underlying cause, advanced neuroimaging tools visualizing tissue at risk of infarction and complete cerebral infarctions, as well as a detailed individual history of the patient’s comorbidities, including identification of signs and symptoms of hypertensive target organ damage, might all help to stratify BP policy in AIS in the future trials that are required.

Hypertension is the major causal factor of neurovascular pathology including both vascular and parenchymal lesions. These lesions are the consequence of large vessel and small vessel ischaemic infarctions, macrohaemorrhages and microbleeds (MBs), as well as vascular and parenchymal brain alterations leading to cerebral tissue disintegration and secondary effects on brain metabolism and function. This chapter includes a description of the images of different brain lesions, silent and clinical, induced by hypertension. Also recent advances in functional neuroimaging for characterizing the effects of hypertension on the brain integrity are described.

The differentiation between ischaemic stroke and haemorrhagic stroke subtype at onset of disease is critical in providing prompt diagnosis and immediate treatment. Although the incidence of haemorrhagic stroke is seven to ten times lower when compared to ischaemic subtypes, severity and associated increased mortality are greater in haemorrhagic stroke. Survival following haemorrhagic stroke is strongly determined by the area of brain bleeding and related tissue damage. Among haemorrhagic stroke, subarachnoid haemorrhage and intracranial haemorrhage are the two major types of haemorrhagic stroke. Although underlying pathophysiology, treatment and prognosis depend on the type of haemorrhage, if not diagnosed and treated promptly, subarachnoid haemorrhage and intracranial haemorrhage result in a loss of cognitive function and subsequent death. While multiple causative factors contribute to this condition, lowering blood pressure and improving adherence to medication can substantially reduce the risk of haemorrhagic stroke.

Hypertension induces subclinical damage in the large elastic arteries and in the small brain arteries. Better understanding of the haemodynamic consequences of hypertension on brain damage is necessary, not only to select the most appropriate therapeutic management but also to optimize prevention, which should be started early in individuals at high risk of developing brain damage. This chapter proposes an integrated pathophysiological approach in order to better understand how large artery damage influences pressure wave transmission, exaggerates subclinical brain damage and leads to cerebrovascular complications. Measurement of arterial stiffness and central blood pressure by non-invasive methods in epidemiological studies and randomized clinical trials may improve our understanding of the haemodynamic consequences of hypertension on the brain, including stroke and cognitive decline.

Introduction: Intracranial carotid artery calcification (ICAC), as a strong contributor to the occurrence of ischemic stroke, might be present in the medial or intimal arterial layer. Traditional cardiovascular risk factors (CVRFs) are associated with ICAC; however, its association with new markers of vascular function is less understood. The paper aimed to evaluate the relationship between carotid-femoral pulse wave velocity (CF-PWV) and ICAC subtypes. Methods: We enrolled 65 patients with ischemic stroke. CF-PWV, systolic, diastolic, mean blood pressure, and pulse pressure were measured within 6 ± 2 days after stroke onset, and CT was performed within 24 h. ICAC on the stroke site was classified by two methods: volume and score based. Tertiles of ICAC volume were determined, and low-grade ICAC (T1) was regarded as a reference. According to the score-based method, (dominant) medial and (dominant) intimal ICAC subtypes were determined. Data were analyzed with multivariate logistic regression. Results: Medial and intimal ICAC subtypes were found in 34 (52%) and 24 (37%) patients, respectively. In 11% of patients, no ICAC calcifications were found. CF-PWV was higher in patients with high-grade ICAC (OR = 1.56, 95% CI = 1.03–2.35, p = 0.035). CF-PWV was higher in patients with the medial ICAC subtype (OR = 1.60, 95% CI = 1.00–2.55, p = 0.049) after adjustment for traditional CVRFs. Conclusion: Our study demonstrates that among patients with ischemic stroke, aortic stiffness is independently associated with ICAC and that medial ICAC, compared with intimal ICAC, is accompanied by more advanced aortic stiffness.

Objective: Blood pressure (BP) after ischemic stroke (IS) may follow various patterns. Post-event acute BP alterations mirror both stroke and patient characteristics, and resolve over time, yet their clinical significance is low or uncertain. Whether individual BP variations, based on a single standardized measurement normalized by a background BP course, have a distinct significance for stroke outcome remains unknown. We hypothesized that the BP difference index (BPD) between daytime supine resting and a series of surrounding BP values (daytime, 24-hour (24h)) in the subacute phase of IS is associated with functional outcome. Design and method: we included 131 IS patients [age 60.8 ± 12.5 years, median (NIHSS) score 5 (3-8)]. Office BP measurements and continuous 24-hour BP monitoring were performed on day 7 after stroke onset. The daytime period was defined as the interval from 6 a.m. to 10 p.m. Functional outcome was evaluated 90 days after stroke using the modified Rankin Scale (mRS) with an mRS score of 3 to 6 (dependency or death) considered as a poor outcome. Results: In a univariate analysis, high BPD was significantly associated with a poor stroke outcome (p = 0.001, 0.003, and 0.002 for systolic, diastolic, and mean BP, respectively, irrespective of the normalization subperiod (daytime, 24h). In a multivariate analysis, the predictive value of BPD remained significant only for systolic BP [SBP] normalized by daytime or 24h mean (OR, 1.06; 95% CI, 1.01-1.11; p = 0.02) after adjustment for covariates. Moreover, the relationship was stronger in a subgroup of patients able to walk independently (mRS 0-2) on day 7 after stroke onset (adjusted OR, 1.08; 95% CI, 1.01-1.17; p = 0.049 for SBP normalized by daytime or adjusted OR, 1.09; 95% CI, 1.01-1.18; p = 0.03 for SBP normalized by 24h mean). Conclusions: We found that the higher difference between supine resting and daytime or diurnal mean BP in patients in the subacute phase of ischemic stroke is independently associated with a poor outcome. This BP index might be useful in clinical practice, including therapeutic decisions, but needs broader studies in patient populations of stroke subtypes.

Patients with non-large vessel occlusion acute ischemic stroke (NL-AIS) on oral anticoagulants (OAC) constitute the biggest portion among those who cannot receive any potential-reperfusion treatment even if they appear early in the hospital. We present the first case of therapy for NL-AIS in a patient with active anti-Xa anticoagulation, combining andexanet alfa and rtPA, who was recruited for STRoke On AntiCoagulants for Thrombolysis (acronym: STROACT), an ongoing therapeutic trial for non-LVO ischemic stroke on a DOAC. This is also the first report of the use of andexanet alfa-rtPA for AIS in a patient on rivaroxaban, which is the most frequently used non-vitamin K antagonist oral anticoagulant. The patient received the intravenous bolus of 800 mg of andexanet (contralateral arm), followed by a bolus of rtPA (10% of the calculated dose; ipsilateral arm), then a continuous infusion of andexanet at 8 mg/min for 120 min (contralateral arm), and rtPA (90% of the calculated dose; ipsilateral arm)—both stopped after completion of 38.9 and 74% of infusion dose, respectively, due to the severe adverse event related to the administration of rtPA. In this schema, both infusions are ongoing concurrently for approximately 60 min, and then andexanet is administered alone until the completion of the dose (altogether lasting approximately 3 h). The therapy was spectacularly effective, with early and complete improvement in NIHSS from 8 to 0 points in 70 min from the initiation of the therapy; mRS = 0. Obviously, a single case cannot drive any standard therapeutic decisions, but the experience we share in this article may help manage selected special clinical problems, especially when a patient's expected outcome is poor and there is no other way to help than experimentally. Additionally, it seems a valuable addition to recent meta-data on thrombolysis in anticoagulated patients.Trial registrationhttps://www.clinicaltrialsregister.eu. Identifier: 2020-004898-41. Date of registration: March 31, 2021.

B a c k g r o u n d: Arterial hypertension (HTN) ranks among the most widespread chronic illnesses that affect adults in industrialized societies.The main goal of this study was to describe the control (inhibition) processes among HTN patients, and to evaluate the dynamics of brain activity while the patients were engaged in tasks measuring the cognitive aspect of self-control.(California Verbal Learning Test, Color Trails Test, The Trail Making Test, Controlled Oral Word Association Test), and a fMRI Stroop test (rapid event design) were administered to 40 persons (20 HTN patients and 20 controls).Groups were matched in terms of age, sex, education, smoking history, and waist-to-hip ratio.R e s u l t s: As revealed by fMRI, the HTN patients demonstrate left-hemisphere asymmetry in inhibitory processes.Also around 90% of patients had problems when completing tasks which rely on verbal and graphomotor aspects of self-control.C o n c l u s i o n s: The results suggest that both cerebral hemispheres must interact correctly in order to provide successful executive control.The deficiencies in control and executive functioning, which were observed among the patients, prove that HTN negatively affects brain processes that control one's cognitive activity. P a r t i c i p a n t s a n d p r o c e d u r e: A set of neuropsychological tests