Introduction: There are no good post-stroke delirium prediction models. Our aim is to investigate whether certain baseline NIHSS-subitem scores might identify patients at risk of developing post-stroke delirium (PSD), next to well-known risk factors such as age and baseline stroke severity.Methods: In a previously published dataset of 514 patients with acute ischemic stroke, 39% developed PSD within the first week after stroke onset using a retrospective chart review based on DSM-5 criteria. We selected those patients with available NIHSS subitems on admission. Multiple logistic regression analysis and receiver operating characteristics (ROC) analysis were used to identify predictors of PSD.Results: Of the 479 included patients with a median age of 75 (IQR 63-84) and NIHSS of 7 (Interquartile range (IQR) 2-14), 190 (39.7%) developed PSD. Based on multiple logistic regression analysis, age, baseline stroke severity (total NIHSS) and known cognitive dysfunction were associated with PSD. Entering all NIHSS subitems, after collinearity check, showed that scores ≥ 1 on "Level of consciousness (LOC)-commands" (subitem 1c) and on "Facial palsy" (subitem 4) were associated with PSD. Score ≥ 1 on "ataxia” (subitem 7) was associated with a lower risk of PSD. ROC curve analysis of a model including age, pre-stroke mRS and NIHSS subitems 1c, 4 and 7 showed an AUC of 0.83. This was not different from a model containing age, pre-stroke mRS and total NIHSS.Discussion and conclusion: Baseline NIHSS subitem scores, particularly impaired consciousness (1c), facial palsy (4) and ataxia (7), in addition to age and pre-stroke disability, are associated with poststroke delirium. However, incorporating these subitems into a predictive model alongside age and pre-stroke mRS, did not improve its predictive value compared to a model based on age, pre-stroke mRS and total baseline NIHSS score.

Abstract Background and aims Delirium is a common complication of ischemic stroke (IS). Its neurophysiological mechanisms remain poorly understood. Ischemic lesions are associated with glutamate-mediated excitotoxicity, and balanced neuronal excitation and inhibition (E/I balance) is crucial for effective neural communication and cognition. We hypothesize that disruption of E/I balance contributes to post-stroke delirium (PSD). Recent computational EEG methods allow non-invasive estimation of E/I balance via the spectral slope of neuronal activity, quantified by the aperiodic exponent (EXP). Methods We analyzed a previously published cohort of 514 patients with IS, of whom 39% developed PSD diagnosed by chart review according to DSM-5 criteria. High-quality EEG recordings and stroke localization were available for 185 patients (50 with PSD, 135 without). Patients were case–control matched for stroke location, admission NIHSS, and age, resulting in 80 patients (40 with PSD, 40 without). For each subject, the first eight artifact-poor 8-second EEG epochs were selected. Aperiodic fitting was performed in the 0.5–40 Hz range, and mean EXP and aperiodic offset (OS) were calculated across all channels excluding Fp1 and Fp2. In a subgroup with middle cerebral artery (MCA) infarction (n=74), EXP and OS were analyzed in ipsi- and contralateral derivations. Group differences were assessed using Welch’s t-test. Results Mean EXP and OS were higher in patients with PSD (Figure 1). In MCA infarction, EXP was increased in both ipsi- and contralateral derivations (Table 1). Conclusions PSD is associated with increased aperiodic exponent, suggesting altered E/I balance as a potential neurophysiological mechanism. Conflict of interest Fenne Vandervorst: nothing to disclose Figure 1 - belongs to Results Figure 2 - belongs to Conclusions

Delirium is a common complication of ischemic stroke (IS). Previous quantitative EEG (qEEG) studies have linked delirium to increased delta and theta power and reduced alpha band functional connectivity. Most excluded patients with structural brain lesions, limiting extrapolation to post-stroke delirium (PSD). This study aims to compare qEEG measures in IS patients with and without PSD. IS patients hospitalized within 24 h after symptom onset were included. The presence of delirium was evaluated by two raters based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria, using a retrospective chart review method. When no consensus was reached, a third rater was consulted. PSD cases were matched to non-PSD patients based on stroke location, severity (NIHSS) and age. Spectral and connectivity EEG results were compared using Mann-Whitney U tests. Relative delta power was significantly higher in PSD patients (n = 40; median(M) = 0,541; IQR = 0,404-0,631) compared to non-PSD patients (n = 40; M = 0,451; IQR = 0,358-0,534; p-value 0,022; r = 0.256). In the alpha band, functional connectivity strength was significantly lower in PSD patients based on phase lag index (PLI M = 0,130 (IQR = 0,118-0,155) versus M = 0,149 (IQR = 0,120-0,174); p-value 0,044; r = 0.157) and amplitude envelope correlation (AEC-c M = 0,517 (IQR = 0,506-0,535) versus M = 0,526 (IQR = 0,514-0,544); p-value 0,029; r = 0.244). PSD is associated with increased delta power and reduced alpha connectivity. Results align with prior qEEG studies in delirium due to other etiologies, suggesting common pathophysiological mechanisms.

Abstract Background and aims Post-stroke fatigue (PSF) is a common, debilitating, and poorly understood complication. Autonomic dysfunction, as reflected by altered heart rate variability (HRV), has been associated with adverse stroke outcomes. This study aimed to investigate the relationship between HRV parameters measured in acute stroke, and PSF at 3 months. Methods HRV was assessed in 35 consecutive acute ischemic stroke patients within 72 hours of admission using 10-minute ECG recordings. To reduce influence of transient environmental fluctuations, the first and last minutes were excluded, and the remaining signal was segmented into overlapping 5-minute windows, averaged to derive stable HRV estimates. After artefact correction and exclusion of atrial fibrillation patients, time- and frequency-domain HRV indices (SDNN, RMSSD, LF, HF, LF/HF) were calculated. PSF was defined as Fatigue Severity Scale (FSS) score ≥4 at 3 months post-stroke. Patients were classified according to the presence or absence of PSF. Owing to small sample size, nonparametric statistical analyses were applied. Results The median age was 65 years, median NIHSS 2, 34% were female and 31% (11/35) developed PSF. LF power (ms2) was significantly lower in patients with PSF compared with those without PSF (median [IQR] 106 [80–330] vs. 246 [142–659]; p = 0.020). HF power also tended to be lower in the PSF group (137 [50–580] vs. 479 [185–1075]; p = 0.067). Conclusions Lower LF and a trend toward lower HF in acute HRV measurements were associated with PSF at 3 months, supporting a role for autonomic imbalance in PSF. Conflict of interest Anissa Ourtani: nothing to disclose; Wout Roelandt: nothing to disclose; Ellen Boels: nothing to disclose; Fernando Esteban Ramirez Barbosa: nothing to disclose; Kurt Barbé: nothing to disclose; Andreea Motoc: nothing to disclose; Robin Gens: nothing to disclose; Marie-Dominique Gazagnes: nothing to disclose; Fenne Vandervorst: nothing to disclose; Sylvie De Raedt: nothing to disclose. Figure 1 - belongs to Results

Background:Delirium is a frequent complication of acute ischemic stroke associated with poor outcome. The complex interplay with post-stroke infections remains to be elucidated. Our study aimed to investigate whether post-stroke delirium (PSD) was a predictor of prolonged hospital stay, poor functional outcome, and mortality after acute ischemic stroke, independent of the development of post-stroke pneumonia (PSP) and post-stroke urinary tract infections (PSU). Methods:In a previously published dataset of 514 patients with acute ischemic stroke, 201 patients (39%) developed delirium within the first week after stroke onset using a chart review method based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition criteria. Fifteen percent developed PSP and 22% PSU, using the modified criteria of the US Centers for Disease Control and Prevention. Logistic regression analyses were used to identify predictors of prolonged hospital stay (>median 9 days), poor functional outcome (modified Rankin Scale >2), and mortality at 3 months after stroke onset. Results:Multiple logistic regression analysis showed that PSD was a predictor of prolonged hospital stay [odds ratio (OR): 4.085, 95% confidence interval (CI): 2.445-6.824] and poor functional outcome [OR: 3.362, 95% CI: 1.851-6.107) at 3 months after stroke onset, even after adjustment for age, premorbid disability, National Institutes of Health Stroke Scale on admission, PSP, and PSU. PSD was no predictor of mortality after stroke. Conclusion:PSD is a predictor of prolonged hospital stay and poor functional outcome at 3 months after ischemic stroke, independent of PSP and PSU.

Abstract Background and aims Delirium is a common complication of stroke. Early identification of post-stroke delirium is essential for guiding targeted interventions. Without structured assessments and serial observations, delirium—particularly the hypoactive subtype—may go undetected. The 4 ‘A’s Test (4AT) is a validated screening tool with high sensitivity and specificity in acute stroke patients. A score ≥ 4 indicates a possible delirium. When used alongside the Richmond Agitation and Sedation Scale (RASS), the specific delirium subtype can be determined. As part of a quality improvement initiative, routine delirium screening using 4AT and RASS was implemented for all patients hospitalized at the Stroke Unit at UZ Brussel. This screening was performed twice daily during stay at Stroke Unit (usually 48hours) and conducted by stroke nurses. Methods Prior to the implementation on 27/05/2024, scales were added to the electronic medical file and nurses underwent individual training in 4AT and RASS. From 27/05/2024 to 30/05/2025, data were collected from the electronic medical records on the number of delirium screenings per patient, and test scores. Results From 27/05/2024 to 30/05/2025, 611 patients were hospitalized at the Stroke Unit of UZ Brussel. Age, gender, NIHSS at admission and diagnosis at discharge are presented in Table 1. On average, four 4AT assessments were performed per patient. Delirium was observed in 27% of patients. Subgroups are described in Table 1. Conclusions 4AT is feasible screening tool in patients hospitalized at the Stroke Unit, applicable across various stroke subtypes and mimics. Overall delirium rate was 27%, with highest prevalence in hemorrhagic strokes. Conflict of interest None Figure 1 - belongs to Results

BACKGROUND AND OBJECTIVES:Contrast-associated acute kidney injury (CA-AKI) is a potentially preventable complication after exposure to iodinated contrast media. In patients undergoing endovascular thrombectomy (EVT) for acute ischemic stroke (AIS), the incidence and clinical impact are poorly characterized, and no validated prediction tool is currently available. The aim of this study was to assess the incidence and prognostic significance of CA-AKI in EVT-treated patients with AIS and to develop and validate a predictive score. METHODS:A retrospective, multicenter cohort study was conducted involving EVT-treated patients across 73 centers in 16 countries (January-December 2023). Inclusion criteria were age ≥18 years, absence of dialysis, availability of preprocedural and 48-hour postprocedural creatinine levels, and available 90-day follow-up (modified Rankin Scale [mRS] score). The primary outcome was CA-AKI, defined by KDIGO (Kidney Disease: Improving Global Outcomes criteria;creatinine increase ≥0.3 mg/dL or ≥1.5 times baseline, within 48 hours). Secondary outcomes were (1) in-hospital mortality, (2) 90-day mRS score, and (3) 90-day severe disability or death (mRS score >3). Logistic models assessing associations with outcomes accounted for within-center clustering by applying robust standard errors. CA-AKI prediction models were developed across imputed data sets using univariable selection (p < 0.20), backward elimination (p < 0.05), and coefficient-based scoring after categorization of continuous predictors, with internal validation by bootstrap to obtain optimism-adjusted estimates. RESULTS:Among 6,638 patients (median age 74 years; 48.7% male), CA-AKI occurred in 326 (4.9%) and was independently associated with in-hospital mortality (adjusted odds ratio [aOR] 2.269; 95% CI 1.615-3.190), higher 90-day mRS scores (adjusted common odds ratio 1.584; 95% CI 1.110-2.258), and 90-day severe disability or death (aOR 1.530; 95% CI 1.057-2.216). A preprocedural risk model including 12 routine clinical variables-sex, ethnicity, arterial hypertension, dyslipidemia, chronic kidney disease, antiplatelet therapy, NIH Stroke Scale score at admission, serum glucose, estimated glomerular filtration rate, hemoglobin, mean arterial pressure, and IV thrombolysis-demonstrated acceptable discrimination (area under the receiver operating characteristic curve 0.710 [95% CI 0.682-0.738]; precision-recall area under the curve 0.13 [95% CI 0.10-0.16]), good calibration (slope 0.870 [95% CI 0.759-0.928]), good overall performance (Brier score 0.045 [95% CI 0.042-0.049]). A second model that included EVT-related variables (e.g., contrast volume) showed similar performances. DISCUSSION:In this large, international cohort, CA-AKI occurred in approximately 1 in 20 EVT-treated patients with AIS and was independently associated with poor outcomes. A simple preprocedural risk score enables early identification of high-risk individuals and may support preventive strategies.

Abstract Background and aims Post-stroke delirium (PSD) is a common complication leading to poor functional outcome. Cerebral small vessel disease (SVD) as a marker for brain frailty and neuro-inflammation may increase vulnerability to delirium. We aimed to investigate whether radiological markers of SVD and neuro-inflammation are associated with the occurrence of delirium. Methods We analyzed a cohort of 211 hospitalized ischemic stroke patients who underwent brain MRI. Delirium, based on DSM-V criteria, was assessed retrospectively the first week of admission using the chart-review method. Markers of SVD and neuro-inflammation (recent small subcortical infarcts (RSSI), lacunes, white matter hyperintensities (WMH), enlarged perivascular spaces (ePVS), cerebral microbleeds, cortical siderosis, global cortical atrophy (GCA), intracranial hemorrhage (hemorrhagic transformation and intracerebral hemorrhage sequelae) and hemorrhagic transformation) were assessed in delirium and non-delirium patients using MRI. Logistic regression analyses were performed with and without adjustment for age, NIHSS, and premorbid cognitive dysfunction to investigate their association with delirium. Results Among the 211 patients (mean age 69, 40% women), 58 developed PSD (27%). In unadjusted analyses, delirium was significantly associated with RSSI, periventricular and total WMH burden, ePVS (centrum semiovale), global cortical atrophy, intracranial hemorrhage and hemorrhagic transformation (Table 1). After adjustment, independent associations remained only for intracranial hemorrhage (aOR 3.50, p=0.004) and hemorrhagic transformation (aOR 2.46, p=0.045) (Table 1). Conclusions Although several MRI markers of SVD and inflammation were associated with PSD, only hemorrhagic transformation of ischemic stroke - with or without intracerebral bleeding sequelae - remained independently associated after adjustment for NIHSS, age and premorbid cognitive dysfunction. Conflict of interest Anne-Lotte Lison: nothing to disclose. Robin Gens: nothing to disclose. Frans Van den Bergh: nothing to disclose. Anne-Marie Van Binst: nothing to disclose. Fran Capitaine: nothing to disclose. Mirte Stiers: nothing to disclose. Yacine Boudiba: nothing to disclose. Anissa Ourtani: nothing to disclose. Fenne Vandervorst: nothing to disclose. Sylvie De Raedt: nothing to disclose. Table 1 - belongs to Results

Direct oral anticoagulants (DOACs) are frequently used for the treatment and prevention of ischaemic stroke in patients with non-valvular atrial fibrillation. Compared to vitamin K antagonists, DOACs have significant advantages, although their drug-drug interaction (DDI) profile may complicate drug efficacy and safety. This narrative review addresses the clinical challenges posed by these DDIs and the potential pharmacological alternatives and monitoring strategies available. A PubMed search was conducted (1 January 2000-31 December 2023) including human DDI studies on DOAC use and CYP3A4/P-gp inducers in adult patients, evaluating patient outcome data and recommendations for DDI management. Twenty-two studies were included. Case reports (n = 6) indicated that antiepileptic drugs such as carbamazepine, phenobarbital and phenytoin may be associated with thromboembolic events. The nested case-control studies (n = 2) and cohort studies (n = 9) found that co-administration of DOACs and CYP3A4/P-gp inducers, particularly carbamazepine and phenytoin, increased the risk of thromboembolic events. Pharmacovigilance database analyses indicated a significant association between DOAC DDIs and increased reported stroke rates. Management recommendations in systematic reviews (n = 5) highlighted monitoring when DOACs were combined with inducers. Strategies included using alternative drugs with a weaker or preferentially absent inducing profile. Limited evidence suggests that edoxaban may be an acceptable option in case of DOAC and CYP3A4/P-gp inducer interactions; however, robust clinical data confirming safety are needed. Present literature indicates a higher thromboembolic risk in patients on DOAC treatment combining CYP3A4- and/or P-gp inducers. DOAC management should be tailored to the individual patient through collaboration between expert healthcare professionals.

Background and ObjectivesCOVID-19-related inflammation, endothelial dysfunction, and coagulopathy may increase the bleeding risk and lower the efficacy of revascularization treatments in patients with acute ischemic stroke (AIS). We aimed to evaluate the safety and outcomes of revascularization treatments in patients with AIS and COVID-19.MethodsThis was a retrospective multicenter cohort study of consecutive patients with AIS receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021 tested for severe acute respiratory syndrome coronavirus 2 infection. With a doubly robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT).ResultsOf a total of 15,128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19; of those, 5,848 (38.7%) patients received IVT-only and 9,280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted OR 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour mortality (OR 2.47; 95% CI 1.58-3.86), and 3-month mortality (OR 1.88; 95% CI 1.52-2.33). Patients with COVID-19 also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60).DiscussionPatients with AIS and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 patients receiving treatment. Current available data do not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in patients with COVID-19 or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring, and establishing prognosis.

Background and Objectives Declines in stroke admission, IV thrombolysis (IVT), and mechanical thrombectomy volumes were reported during the first wave of the COVID-19 pandemic. There is a paucity of data on the longer-term effect of the pandemic on stroke volumes over the course of a year and through the second wave of the pandemic. We sought to measure the effect of the COVID-19 pandemic on the volumes of stroke admissions, intracranial hemorrhage (ICH), IVT, and mechanical thrombectomy over a 1-year period at the onset of the pandemic (March 1, 2020, to February 28, 2021) compared with the immediately preceding year (March 1, 2019, to February 29, 2020). Methods We conducted a longitudinal retrospective study across 6 continents, 56 countries, and 275 stroke centers. We collected volume data for COVID-19 admissions and 4 stroke metrics: ischemic stroke admissions, ICH admissions, IVT treatments, and mechanical thrombectomy procedures. Diagnoses were identified by their ICD-10 codes or classifications in stroke databases. Results There were 148,895 stroke admissions in the 1 year immediately before compared with 138,453 admissions during the 1-year pandemic, representing a 7% decline (95% CI [95% CI 7.1-6.9]; p < 0.0001). ICH volumes declined from 29,585 to 28,156 (4.8% [5.1-4.6]; p < 0.0001) and IVT volume from 24,584 to 23,077 (6.1% [6.4-5.8]; p < 0.0001). Larger declines were observed at high-volume compared with low-volume centers (all p < 0.0001). There was no significant change in mechanical thrombectomy volumes (0.7% [0.6-0.9]; p = 0.49). Stroke was diagnosed in 1.3% [1.31-1.38] of 406,792 COVID-19 hospitalizations. SARS-CoV-2 infection was present in 2.9% ([2.82-2.97], 5,656/195,539) of all stroke hospitalizations. Discussion There was a global decline and shift to lower-volume centers of stroke admission volumes, ICH volumes, and IVT volumes during the 1st year of the COVID-19 pandemic compared with the prior year. Mechanical thrombectomy volumes were preserved. These results suggest preservation in the stroke care of higher severity of disease through the first pandemic year.

Background and Objectives Declines in stroke admission, IV thrombolysis (IVT), and mechanical thrombectomy volumes were reported during the first wave of the COVID-19 pandemic. There is a paucity of data on the longer-term effect of the pandemic on stroke volumes over the course of a year and through the second wave of the pandemic. We sought to measure the effect of the COVID-19 pandemic on the volumes of stroke admissions, intracranial hemorrhage (ICH), IVT, and mechanical thrombectomy over a 1-year period at the onset of the pandemic (March 1, 2020, to February 28, 2021) compared with the immediately preceding year (March 1, 2019, to February 29, 2020). Methods We conducted a longitudinal retrospective study across 6 continents, 56 countries, and 275 stroke centers. We collected volume data for COVID-19 admissions and 4 stroke metrics: ischemic stroke admissions, ICH admissions, IVT treatments, and mechanical thrombectomy procedures. Diagnoses were identified by their ICD-10 codes or classifications in stroke databases. Results There were 148,895 stroke admissions in the 1 year immediately before compared with 138,453 admissions during the 1-year pandemic, representing a 7% decline (95% CI [95% CI 7.1–6.9]; p < 0.0001). ICH volumes declined from 29,585 to 28,156 (4.8% [5.1–4.6]; p < 0.0001) and IVT volume from 24,584 to 23,077 (6.1% [6.4–5.8]; p < 0.0001). Larger declines were observed at high-volume compared with low-volume centers (all p < 0.0001). There was no significant change in mechanical thrombectomy volumes (0.7% [0.6–0.9]; p = 0.49). Stroke was diagnosed in 1.3% [1.31–1.38] of 406,792 COVID-19 hospitalizations. SARS-CoV-2 infection was present in 2.9% ([2.82–2.97], 5,656/195,539) of all stroke hospitalizations. Discussion There was a global decline and shift to lower-volume centers of stroke admission volumes, ICH volumes, and IVT volumes during the 1st year of the COVID-19 pandemic compared with the prior year. Mechanical thrombectomy volumes were preserved. These results suggest preservation in the stroke care of higher severity of disease through the first pandemic year. Trial Registration Information This study is registered under NCT04934020.

Background and Objectives COVID-19–related inflammation, endothelial dysfunction, and coagulopathy may increase the bleeding risk and lower the efficacy of revascularization treatments in patients with acute ischemic stroke (AIS). We aimed to evaluate the safety and outcomes of revascularization treatments in patients with AIS and COVID-19. Methods This was a retrospective multicenter cohort study of consecutive patients with AIS receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021 tested for severe acute respiratory syndrome coronavirus 2 infection. With a doubly robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT). Results Of a total of 15,128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19; of those, 5,848 (38.7%) patients received IVT-only and 9,280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted OR 1.53; 95% CI 1.16–2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20–2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23–1.99), 24-hour mortality (OR 2.47; 95% CI 1.58–3.86), and 3-month mortality (OR 1.88; 95% CI 1.52–2.33). Patients with COVID-19 also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26–1.60). Discussion Patients with AIS and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non–COVID-19 patients receiving treatment. Current available data do not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in patients with COVID-19 or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring, and establishing prognosis. Trial Registration Information The study was registered under ClinicalTrials.gov identifier NCT04895462.

Background Several drugs are available for the preventive treatment of both episodic and chronic migraine. The choice of which therapy to initiate first, second, or third is not straightforward and is based on multiple factors, including general efficacy, tolerability, potential for serious adverse events, comorbid conditions, and costs. Recently, a new class of migraine preventive drugs was introduced, i.e. monoclonal antibodies against calcitonin gene-related peptide (CGRP) or its receptor. Methods The present article summarizes the evidence gathered with this new migraine preventive drug class from randomized placebo-controlled clinical trials. It further puts this into perspective next to the evidence gained by the most widely used agents for the prevention of episodic and chronic migraine with an emphasis on efficacy and the robustness with which this efficacy signal was obtained. Results Although being a relatively new class of migraine preventive drugs, monoclonal antibodies blocking the CGRP pathway have an efficacy which is at least comparable if not higher than those of the currently used preventive drugs. Moreover, the robustness of this efficacy signal is substantiated by several randomized clinical trials each including large numbers of patients. In addition, because of their excellent tolerability and with long-term safety data emerging, they seem to have an unprecedented efficacy over adverse effect profile, clearly resulting in an added value for migraine prevention. Conclusions Balancing the data presented in the current manuscript with additional data concerning long term safety on the one hand and cost issues on the other hand, can be of particular use to health policy makers to implement this new drug class in the prevention of migraine.

BACKGROUND Delirium is an underdiagnosed and possibly preventable complication in acute stroke and is linked to poor outcome. Neutrophil-to-lymphocyte ratio (NLR), a marker of systemic inflammation, is also associated with poor outcome after acute ischemic stroke. AIM To determine whether NLR is a predictor of post-stroke delirium (PSD). METHODS We reviewed the UZ Brussel stroke database and included 514 patients with acute ischemic stroke within 24 hours from stroke onset between February 2009 and December 2014. The presence of delirium was evaluated by two raters based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria, using a retrospective chart review method. When no consensus was reached, a third evaluator was consulted. Patients were divided into two groups: those who developed delirium within the first week after stroke onset (n = 201; 39%) and those who did not (n = 313; 61%). Receiver operating characteristics (ROC) and multiple logistic regression analysis (MLRA) were used to identify predictors of PSD. RESULTS MLRA showed that NLR (odds ratio (OR) 1.14; 95% confidence interval (CI) 1.04-1.26), age (OR 1.05; 95% CI 1.03-1.07), National Institutes of Health Stroke Scale (NIHSS; OR 1.14; 95% CI 1.10-1.18), premorbid modified Rankin Scale (mRS) (OR 1.35; 95% CI 1.05-1.74) and premorbid cognitive dysfunction (OR 3.16; 95% CI 1.26-7.92) predicted PSD. ROC curve of a prediction model including NLR, age, NIHSS and premorbid cognitive dysfunction showed an area under the curve of 0.84 (95% CI = 0.81-0.88). CONCLUSIONS Besides age, stroke severity, premorbid mRS and cognitive impairment, NLR is a predictor of PSD, even independent of the development of pneumonia or urinary tract infection.