Abstract Background and aims The incidence of acute ischemic stroke (AIS) is increasing among young adults, yet data on outcomes in this group remain limited due to small sample sizes. This study aimed to compare functional and safety outcomes after EVT between young adults and older adults in a large international cohort. Methods In this prospective multicenter cohort study, data from the EVA-TRISP registry (17 centers across 9 countries, 2015-2025) were analyzed. Young patients (aged 18–49 years) treated with EVT were compared to those aged ≥50 years using multivariable regression models. Outcomes included favorable functional status (modified Rankin Scale [mRS] 0–2), successful recanalization, symptomatic intracranial hemorrhage (sICH; defined by ECASS II criteria), and all-cause mortality at 3 months. Results Of 12,933 patients treated with EVT, 823 (6.4%) were young adults. Compared to older patients, young adults were more frequently male, had lower admission NIHSS scores, received intravenous thrombolysis more often, and had fewer vascular risk factors except for smoking. Young adults achieved higher rates of favorable functional outcome (67.3% vs 42.4%; adjusted odds ratio aOR 1.84, 95% CI 1.48–2.30) and successful recanalization (77.1% vs 73.4%; aOR 1.39, 95% CI 1.12–1.73), with lower mortality (7.5% vs 24.2%; aOR 0.32, 95% CI 0.22–0.47). Rates of sICH were similar between groups (3.6% vs 4.6%; aOR 0.72, 95% CI 0.47–1.10). Conclusions In this large, international real-world cohort, young adults with AIS treated with EVT more frequently achieved favorable functional outcomes, higher recanalization rates, and lower mortality compared to older adults, with comparable rates of sICH. Conflict of interest Miranda Nybondas: nothing to disclose, Nicolas Martinez-Majander reports funding from the Finnish Medical Foundation, Sami Curtze: nothing to disclose, Annika Nordanstig: nothing to disclose, Susanne Wegener reports speaker honoraria from Amgen, Springer, Teva Pharma, ADVISIS-AG, FOMF, Astra Zeneca, and a consultancy fee from Bayer and Novartis; all outside this work., Patrik Michel: nothing to disclose, Mirjam Heldner reports grants from SITEM Research Support Funds and Swiss National Science Foundation, Swiss Heart Foundation, not directly related to this manuscript., Christian Nolte: reports personal fees from AstraZeneca/Abbot, Alexion,/ (paid to the institution);, Astra-Zeneca, Bristol-Myers Squibb, Daiichi Sankyo, Novartis, Pfizer, Portola and Takeda, all outside the submitted work. Tolga Dittrich: nothing to disclose, Henrik Gensicke: nothing to disclose.

Background: Cervical artery dissection (CeAD) accounts for nearly 25% of all ischemic strokes in young adults. CeAD can lead to the development of dissecting aneurysms (DA). However, the incidence, risk factors and outcomes of CeAD patients with DA is not well established. This study aims to identify risk factors for developing DA, subsequent growth, and impact on patient outcomes. Methods: This is a secondary analysis of the Antithrombotics for Stroke Prevention in Cervical Artery Dissection (STOP-CAD), a multicenter cross-sectional international retrospective study. CeAD patients were stratified for the presence of DA. We used multivariable regression to identify factors associated with DA. Patients with DA were further analyzed for DA growth. The primary outcome was ischemic stroke after CeAD+DA diagnosis. Secondary outcomes included ischemic stroke after CeAD+DA with DA growth. Multivariable logistic regression analysis was used to assess the association between DA and risk factors. We also performed univariate Cox regression and generated Kaplan-Meier survival curves comparing study outcomes based on presence of DA and subsequent growth. Results: Of the 4023 patients included in the STOP-CAD study, 4008 were included in this analysis and 767 (19%) patients had DA (546 with DA on initial presentation). Patients with DA had a mean age of 46 [IQR 37-55] years and 50% (383) were women. In combined adjusted analyses, DA patients were more often non-Hispanic (aOR 0.63, 95% CI 0.41-0.94, p<0.02), more commonly had a history of migraine (aOR 1.27, 95% CI 1.01-1.59, p=0.037), connective tissue disorder (aOR 2.02, 95% CI 1.22-3.36, p=0.007), minor neck trauma (aOR 1.70, 95% CI 1.29-2.26, p<0.001) and were more likely to present with ischemic stroke (aOR 1.73, 95% CI 1.05-2.87, p=0.031). DA growth was noted in 55 out of 546 (10%) patients with DA on presentation. There was no significant difference in the risk of ischemic stroke by day 180 in patients with DA (hazard ratio [HR] 0.92 [95% CI, 0.65-1.30]; P =0.63) or DA growth (HR 2.40, [95% CI, 0.79-7.24]; P =0.12). Conclusion: In this subanalysis of STOP-CAD, nearly one in five patients with CeAD developed a DA. Factors associated with a higher likelihood of DA included non-Hispanic ethnicity, history of migraine, connective tissue disorder, minor neck trauma, and ischemic stroke at presentation. DA diagnosis and DA growth did not impact the risk of subsequent ischemic stroke at 6 months.

Background and Objectives: Cervical artery dissection (CeAD) is a common cause of ischemic stroke in young adults. We aim to identify age-based differences in clinical presentation, imaging findings, and outcomes after CeAD. Methods: This was a sub-study using the STOP-CAD registry, a multicenter cross-sectional international retrospective study of patients diagnosed with CeAD and treated with an antithrombotic from January 1, 2015 to December 31, 2021. Baseline clinical and imaging characteristics were compared between younger and older adults with CeAD (≤45 versus >45 years of age) using multivariable logistic regression. We chose this age cut off due to its frequent usage in stroke in the young literature. Multiple logistic regression models were used to determine association between young age and outcomes after CeAD (ischemic stroke at 180 days, excellent functional outcome with modified Rankin Scale of 0-1 at 90 days, and mortality) after adjusting for sex, vascular risk factors, CeAD characteristics, and NIHSS on presentation. Results: Among 4023 CeAD patients included in the study, 1901 (47.3%) were ≤45 years of age. Patients were followed for a median of 307 days (IQR 102-831). Young adults with CeAD were more likely to be women (Odds Ratio [OR], 2.4; 95% CI, 2.1-2.9; p<0.001), of Hispanic ethnicity (OR, 1.8; 95% CI 1.3-2.5; p<0.001), have a history of migraines (OR, 1.6; 95% CI, 1.3-2.0; p<0.001) and recent neck trauma (OR, 1.6; 95% CI, 1.3-1.9; p<0.001) while having fewer traditional vascular risk factors. Young adults with CeAD had higher odds of a non-ischemic presentation (OR, 1.3; 95% CI, 1.1-1.5; p=0.013), vertebral artery dissection (OR 2.5; 95% CI, 2.2-3.0; p<0.001), and multivessel involvement (OR 1.5; 95% CI, 1.1-1.9; p=0.004). In adjusted analysis, younger age was not associated with an increased risk of recurrent ischemic stroke (adjusted Hazard Ratio [HR], 0.48; 95% CI 0.2-1.2; p=0.119). Younger age was associated with significantly greater odds of excellent functional outcome at 90 days (aOR, 1.48; 1.20-1.84, p<0.001) and lower risk of death at follow up (aHR, 0.37; 95% CI, 0.17-0.81; p=0.012) after CeAD. Conclusion: In a large international cohort, young adults with CeAD had a distinct clinical phenotype with higher odds of non-ischemic presentation, vertebral artery dissection, and multivessel involvement while having fewer traditional vascular risk factors. Young adults had a decreased odds of disability and mortality after CeAD.

INTRODUCTION:Anaemia is an established risk factor for poor outcome in intracerebral haemorrhage and ischaemic stroke. We examined whether anaemia predicts poor outcome in cerebral venous thrombosis (CVT). PATIENTS AND METHODS:We used data of the DOAC-CVT study, which was an international, prospective observational cohort study in adult patients with CVT that ran from January 2021 to January 2024. Anaemia at admission was defined according to World Health Organization criteria. Poor outcome was defined as modified Rankin Scale (mRS) 3-6 at 6-months. Binary logistic regression, adjusted for age, recent delivery/puerperium, income country, cancer and intracranial haemorrhage, was applied. RESULTS:Of 619 patients in DOAC-CVT, 583 patients were included, of whom 157 (27%) had anaemia. Compared to patients without anaemia, patients with anaemia were slightly younger (median age 40 vs. 42 years), more often female (76% vs. 59%), from middle income countries (36% vs. 21%), more often had intracranial haemorrhage (48% vs. 32%) and cancer (5% vs. 2%). Anaemia was associated with poor functional outcome (mRS 3-6, 10% vs. 5%, aOR: 2.20, 95% Cl, 1.01-4.81), but not with mortality (3% vs. 1%, aOR: 3.54, 95% Cl, 0.68-18.31). When stratified by severity, moderate to severe anaemia was associated with poor functional outcome (aOR 2.88, 95% Cl, 1.14-7.38), but mild anaemia was not (aOR 1.64, 95% Cl, 0.60-4.55). DISCUSSION AND CONCLUSION:Anaemia at admission, especially moderate to severe, is a predictor for poor functional outcome in patients with CVT, highlighting the need for further studies on potential interventions.

Abstract Background and aims Endovascular therapy (EVT) is not recommended for acute stroke due to posterior cerebral artery (PCA) occlusion. Perfusion imaging may identify patients who could benefit from EVT. Methods We conducted a multicenter international observational study of consecutive acute stroke patients with isolated PCA occlusion (P1/P2), admitted ≤ 6 hours from symptom onset and with baseline perfusion imaging. Patients received best medical management (BMM) alone or combined with EVT. The primary outcome was good functional outcome (GFO), defined as 3-month modified Rankin Scale score 0–2 or return to baseline mRS. Propensity-score with overlap weighting (PSOW) was used to balance baseline characteristics. Interaction between treatment strategy and perfusion mismatch volume was tested. Results Overall, 295 patients were included (69 BMM + EVT, 226 BMM alone). Median age was 74 years (IQR 64-83), median NIHSS was 6 (3-10), occlusion site was P1 in 21% and P2 in 79%, intravenous thrombolysis used in 70%. Median core volume was 1.5 mL (0-8) and mismatch volume was 15 mL (4-32). The distribution of baseline variables was similar across the 2 groups following PSOW. EVT was not associated with GFO (PSOW-OR 0.99, 95%CI 0.54–1.83; P = 0.97). The association between EVT and GFO was not modified by mismatch volume (Pinteraction = 0.42). Similar results were observed for mRS 0-1. Conclusions In this cohort of acute strokes with PCA occlusion, EVT was not associated with GFO compared to BMM alone. Perfusion mismatch volume did not modify this association and may not be useful to select good EVT candidates in this patient group. Conflict of interest Sabben: Nothing to disclose/Turc reports lecture fees from Guerbert France and consultant services for AI-Stroke and Neurologica/Obadia: Nothing to disclose/Charbonneau: Nothing to disclose/Strambo: Nothing to disclose/Heldner reports grants from SITEM Research Support Funds and Swiss National Science Foundation, Swiss Heart Foundation/Ong: Nothing to disclose/Ter Schiphorst: Nothing to disclose/Sibon: Nothing to disclose/Legris: Nothing to disclose/Carrera: Nothing to disclose/Mione: Nothing to disclose/Bagan-Triquenot: Nothing to disclose/Mazighi reports consulting fees from Acticor Biotech, Boerhinger/Seners speaker fees from Acticor Biotech and Boerhinger-Ingelheim.

Background and Objectives: Cervical artery dissection (CeAD) is a leading cause of ischemic stroke in younger adults, yet sex-specific variations in its clinical presentation, imaging characteristics, and outcomes remain underexplored. We aimed to evaluate these differences using data from a large, multicenter registry. Methods: We analyzed data from the STOP-CAD registry, which includes patients with radiologically confirmed non-traumatic CeAD enrolled between 2015 and 2021 across multiple centers. Clinical and imaging characteristics were compared between men and women using multivariable logistic regression. Outcomes assessed included ischemic stroke recurrence at 180 days, excellent functional outcome (modified Rankin Scale [mRS] 0–1) at 90 days, symptomatic intracerebral hemorrhage (sICH), and mortality. Results: Among 4,023 patients with CeAD, 1,783 (44.6%) were women. Compared to men, women were younger (median age: 42 vs 50 years), more likely to have a history of migraine (26.9% vs 8.3%) and connective tissue disorders (14.3% vs 5.8%), and presented more frequently with non-ischemic symptoms such as headache, neck pain, or tinnitus (adjusted OR [aOR] 2.0; 95% CI, 1.8–2.3; p<0.001). Women had significantly higher odds of vertebral artery dissection (OR, 1.3; 95% CI, 1.2-1.5; p<0.001), multivessel involvement (OR, 2.1; 95% CI, 1.7-2.5; p<0.001), and pseudoaneurysm formation (OR, 1.3; 95% CI, 1.1-1.6; p=0.003). Despite these differences, there was no significant sex-based difference in key clinical outcomes: excellent functional recovery at 90 days (OR 0.94; 95% CI 0.76-1.15 p=0.542), ischemic stroke recurrence at 180 days (OR 0.56 CI 0.23-1.3 p=0.213), or mortality (OR 0.83; 95% CI 0.47-1.48, p=0.529). Conclusion: In this large international cohort, we observed women with CeAD were younger, more likely to present with non-ischemic symptoms with distinct imaging features. These underscore the need for heightened clinical suspicion of CeAD in women presenting with atypical symptoms, even in the absence of ischemic deficits or conventional vascular risk factors, and suggest that sex-specific phenotyping may enhance diagnostic accuracy and early management.

Abstract Background and aims Recent RCTs of EVT in medium- or distal-vessel occlusion (MDVO) strokes (DISTAL, ESCAPE-MeVO) reported neutral outcomes. As trials may not represent patients treated in the real world, we analyzed such patients in a large multicenter registry, comparing outcomes of bridging therapy (IVT+EVT) versus EVT-alone. Methods We retrospectively analyzed registry data from EVA-TRISP (17 stroke centers, 2014-2023). Adults with MDVO (M2–M4 MCA, ACA, PCA) treated with EVT with or without prior IVT were included. The primary outcome was the 90-day mRS distribution, analyzed with a mixed-effects proportional-odds model adjusted for age, pre-stroke mRS, baseline NIHSS, diabetes, hypertension, atrial fibrillation, and treatment year. Secondary outcomes were excellent (mRS0-1) and good (mRS0-2/return-to-premorbid) functional outcome, mortality, symptomatic intracranial haemorrhage, and successful recanalization (mTICI2b-3). Missing data were imputed; sensitivity analyses used complete-case and IPTW approaches. Results Among 3008 patients (median age 76, 45% of female sex, median NIHSS 10), 48% received bridging therapy. Adjusted analysis demonstrated better functional outcome (OR=1.60, 95%-CI 1.38-1.84, p < 0.001), higher odds of excellent (OR=1.75 95%-CI 1.45-2.11) and good (OR=1.63 95%-CI 1.36-1.96) recovery, and lower mortality (OR=0.63 95%-CI 0.50-0.78). Symptomatic intracranial hemorrhage was modestly increased (5% vs. 3%; OR=1.68 95%-CI 1.13-2.51), while recanalization rates were comparable (70% vs. 69%; OR=1.07 95%-CI 0.89-1.28). Findings were consistent across complete-case and IPTW analyses. Conclusions These results suggest that, in real-world practice, adjunctive IVT may add benefit to EVT for MDVO-patients. Conflict of interest The author(s) received no financial support for the research, authorship, and/or publication of this abstract.

Abstract Background and aims Elevated lipoprotein(a) (Lp(a)) is an established risk factor for atherosclerosis. However, its role in intracranial atherosclerotic stenosis (ICAS) remains unclear. 7-Tesla-MRI enables detailed ICAS assessment. Methods We analyzed 162 ≥50%-ICAS patients (n=84 symptomatic) with best medical management from the prospective Bernese Intracranial Stenosis Study, stratified by Lp(a) levels into normal/moderately elevated (<125 nmol/L; n=127) and markedly elevated (≥125 nmol/L; n=35) groups. Associations with risk factors, 3/7T-MRI, and outcome were assessed. Results No significant differences were found between Lp(a) groups and ICAS burden/location (p=0.198/0.709), and most risk factors. Atrial fibrillation was more frequent in the markedly elevated Lp(a) group (16.7% vs.10%; p=0.021) in asymptomatic patients. Markedly elevated Lp(a) was associated with more severe cerebral microangiopathy (p=0.042). Higher Lp(a) levels were linearly associated with poorer functional outcome (mRS) at discharge (p=0.003). 1-year excellent outcome (mRS:0-1) was more frequent in asymptomatic patients (52.1% vs.34.5%; p=0.044), showing a trend (p=0.093) in the normal/moderate Lp(a) group only. 1-year ischaemic strokes (13.6% vs. 0%;p=0.001) occurred in the symptomatic group only. A favorable evolution of 1-year ICAS contrast-enhancement dynamics was more frequent in asymptomatic patients overall (p=0.001) and among patients with normal/moderately elevated Lp(a) levels (p=0.031). Conclusions Markedly elevated Lp(a) in ICAS patients was not associated with ICAS burden/location but with atrial fibrillation, more severe cerebral microangiopathy, and poorer functional outcome at discharge, suggesting Lp(a) may enhance risk stratification in this patient group. Conflict of interest All authors: nothing to disclose.

Introduction: Intracranial atherosclerosis (ICAS) is a leading cause of ischemic stroke (IS) worldwide and carries a high risk of recurrence. Current guidelines favor 90 days of dual antiplatelet therapy (DAPT) for severe symptomatic ICAS, but recurrence remain high. Limited data suggest possible benefit of single antiplatelet plus anticoagulation (SAPT+AC). We compared the effectiveness and safety of DAPT versus SAPT+AC. We hypothesized that DAPT would lower 90-day recurrent IS risk without significantly increasing bleeding. Methods: This substudy of the Biomarkers and Recurrence Risk in Symptomatic Intracranial Arterial Stenosis (BIORISK-ICAS) included patients from 35 centers (Jan 2019–Jun 2024) with symptomatic 50–99% ICAS in the intracranial internal carotid, vertebral, basilar, or M1 segment of the MCA, presenting ≤72 hours from last known well. The primary efficacy outcome was recurrent IS in the same vascular territory at 90 days; the primary safety outcome was severe bleeding (symptomatic intracranial hemorrhage or major extracranial bleeding). Categorical variables were compared using χ 2 and continuous variables with the Student's t test; multivariable Cox regression adjusted for key covariates. Results: Of 2050 BIORISK-ICAS patients, 1658 met criteria (DAPT n=1499; SAPT+AC n=159). Mean age was 67 vs. 73 years, and 44% were women. At 90 days, recurrent IS occurred in 121 DAPT patients (8.07%) vs. 13 SAPT+AC patients (8.17%); unadjusted HR 0.83 (95% CI, 0.50–1.36; p=0.46). After adjustment for age, diabetes, coronary heart disease, atrial fibrillation, active smoking, and borderzone infarct, the adjusted HR was 0.99 (95% CI, 0.52–1.86; p=0.97). Severe bleeding occurred in 34 DAPT patients (2.26%) and 5 SAPT+AC patients (3.14%); unadjusted HR 0.79 (95% CI, 0.28–1.85; p=0.50), adjusted HR 0.66 (95% CI, 0.21–2.09; p=0.47). Conclusions: In patients with symptomatic ICAS, DAPT and SAPT+AC were associated with similar risks of 90-day recurrent ischemic stroke and severe bleeding. Well-powered randomized trials are needed to determine the optimal antithrombotic regimen in this high-risk population.

Abstract Background and aims Patients with active cancer are at increased risk of ischaemic stroke. Smaller studies of endovascular thrombectomy (EVT) in such stroke patients indicate worse clinical outcomes despite similar recanalization rates as patients without active cancer. However, evidence from larger multicentre cohorts is lacking. Methods We used data from the EVA-TRISP registry comprising stroke patients treated with EVT (11 centres, 8 countries, 2014−2023). Using multivariable regressions adjusting for prognostic variables and propensity score weighting we compared patients with active cancer to patients without cancer regarding early neurological improvement (ENI), defined as NIHSS improvement of -4 points or score 0−1 at 24h after EVT, successful recanalization (mTICI 2b−3), symptomatic intracranial haemorrhage (sICH), functional independence (modified Rankin Scale [mRS] 0−2) and death at 3 months. Results We included 526 EVT patients with active cancer and 6,894 without cancer. ENI (47.5 vs 45.3%, weighted OR [wOR] 1.05, 95%CI 0.87−1.26) and successful recanalization (78.8 vs 70.4%, wOR 0.86, 95%CI 0.68-1.08) did not differ significantly. However, patients with active cancer showed higher rates of sICH (7.2 vs 4.0%, wOR 1.88, 95%CI 1.30−2.70), less functional independence at 3 months (30.1 vs 44.0%, wOR 0.56, 95%CI 0.45−0.69) and higher death rates (42.8 vs 22.3%, wOR 2.60, 95%CI 1.14−3.17). Conclusions In this large observational multicentre study, recanalization rates and ENI after EVT were comparable in stroke patients with and without active cancer. Still, worse 3−month outcomes in patients with active cancer may have to be considered in EVT-decision making in such patients. Conflict of interest Malin Woock: nothing to disclose, Katarina Jood: nothing to disclose, Turgut Tatlisumak: nothing to disclose, Gianluca Costamagna: nothing to disclose, Christian Nolde: nothing to disclose, Mirjam Heldner: nothing to disclose, Nicolas Martinez-Majander: nothing to disclose, Ronen Leker: nothing to disclose, Anton Schmick: nothing to disclose and Joâo Pedro Marto: nothing to disclose.

Abstract Background and aims In acute stroke due to large vessel occlusion (AIS-LVO), identifying a core-perfusion mismatch guides reperfusion therapy in extended time windows, but perfusion imaging is not universally available. We assessed whether the ASPECTS score is associated with core-perfusion mismatch and could serve as a surrogate imaging marker. Methods We retrospectively analyzed a large multicenter international cohort of consecutive AIS-LVO (ICA or M1) imaged 4.5-24 hours from last time seen well, with baseline CT- or MR-perfusion imaging. Core-perfusion mismatch was defined as a volume ≥ 15 mL and ratio ≥ 1.8 using automated software. Receiver operating characteristic (ROC) analyses were performed to identify optimal ASPECTS cutoffs for mismatch classification. Results Overall, 531 patients were included (CT, n = 182; MRI, n = 349). Core-perfusion mismatch was present in 86% of the CT cohort and 62% of the MRI cohort. In the MRI cohort, ASPECTS predicted mismatch with an AUC-ROC of 0.843 (95%CI, 0.797-0.890), with an optimal cutoff of ≥6, yielding a sensitivity, specificity, positive and negative predictive value (PPV and NPV) of 0.87, 0.72, 0.84, and 0.77, respectively. In the CT cohort, the AUC-ROC was 0.801 (95%CI, 0.698-0.904), with an optimal cutoff of ≥7, yielding a sensitivity, specificity, PPV and NPV of 0.74, 0.81, 0.96, and 0.34, respectively. Conclusions The high PPV of ASPECTS≥6 on MRI and ≥ 7 on CT supports their potential use as pragmatic inclusion criteria for patient selection in future late-window AIS-LVO trials when perfusion imaging is unavailable, as surrogate markers of salvageable tissue. Conversely, low ASPECTS values –especially on CT– do not exclude core-perfusion mismatch. Conflict of interest Nothing to disclose.

Background and Objectives: Pregnancy and the postpartum period increase the risk of cervical artery dissection (CEAD), a notable cause of stroke in young women. We aimed to describe the clinical presentation, imaging findings, and outcomes of CEAD occurring during pregnancy or shortly after delivery. Methods: We analyzed data from the STOP-CAD registry, a large international multicenter study of patients treated with antithrombotic therapy for non-traumatic CEAD between 2015 and 2021. This sub-study focused on women who were pregnant or within 12 weeks postpartum at the time of symptom onset. We assessed baseline clinical features, imaging results, acute stroke treatments, and functional outcomes. Results: Among 1,783 women in the registry, 62 (3.5%) had pregnancy-associated CEAD, with a median age of 34 years (IQR, 30-38). One-third had a history of migraine (33.9%), one-fifth had hypertension (21.0%), while other vascular risk factors were rare. Recent minor neck trauma was reported in 17.7%. Ischemic stroke symptoms occurred in 25 (40.3%) patients, and 23 (37.1%) had acute infarcts on imaging. However, most (59.7%) presented with non-ischemic symptoms. Vertebral artery dissections were more common than carotid dissections (62.9% vs. 48.4%), and 33.9% had multivessel involvement. Among patients presenting with ischemic stroke symptoms, 4 received thrombolysis and 7 underwent thrombectomy. Remarkably, 92% had excellent functional recovery (modified Rankin Score 0–1) at 90 days, and there were no stroke recurrences at 180 days. Conclusion: Pregnancy- and postpartum-associated CEAD is uncommon and associated with ischemic stroke in nearly half of patients. A history of migraine and hypertension may be potential risk factors. Despite the severity of presentation, most patients had favorable outcomes with timely treatment.

Background: The clinical characteristics and complications associated with de novo pseudoaneurysm formation beyond the acute phase of cervical artery dissection remain poorly defined. In this study, we examined the incidence, risk factors, and related ischemic and hemorrhagic events of post-acute de novo pseudoaneurysm formation. Methods: We analyzed data from the STOP-CAD study (Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection). A de novo pseudoaneurysm was defined as a new (not present on initial imaging) focal enlargement in the diameter of the artery, greater than the native lumen. The incidence of de novo pseudoaneurysm was assessed at 90 days, 180 days, and beyond 180 days of follow-up. Univariate and multivariate regression analyses were conducted to identify risk factors for post-acute de novo pseudoaneurysm formation. Kaplan-Meier survival estimates were used to compare ischemic and hemorrhagic events between patients with and without de novo pseudoaneurysms. Results: Among 4008 patients, 546 were excluded as they had dissecting pseudoaneursyms on initial presentation. Therefore, 3,462 patients were included in this analysis of whom 220 patients (6.35%) developed a de novo pseudoaneurysm over a maximum follow-up of 4.4 years. Of these, 127 (57.72%) were detected within the first 90 days, and 172 (78.18%) within the first 180 days. In multivariate regression analyses, in addition to hypertension, active smoking and Hispanic ethnicity, fibromuscular dysplasia (FMD) was an independent risk factor for post-acute de novo pseudoaneurysm formation (adjusted OR: 2.160; 95% CI: 1.408–3.315; p < 0.001). Notably, the presence of a de novo pseudoaneurysm was not associated with a significant increase in ischemic (hazard ratio [HR] 1.43 [95% CI, 0.89–2.30]; P=0.14) or hemorrhagic events (hazard ratio [HR] 1.42 [95% CI, 0.43–4.69]; P=0.57). Conclusion: De novo pseudoaneurysm formation following a diagnosis of a cervical artery dissection is not uncommon and most frequently occurs within the first 180 days. FMD was independently associated with this complication. The development of a de novo pseudoaneurysm did not significantly increase the risk of subsequent ischemic or hemorrhagic events.

Introduction: Migraine has been reported to be associated with an increased risk of spontaneous cervical artery dissection (sCeAD), a leading cause of ischemic stroke, particularly in young adults. Migraine may increase vulnerability to ischemia, making brain tissue more susceptible to ischemic injury. Nevertheless, migraine patients have been reported to have higher Calcitonin Gene-Related Peptide (CGRP) levels which has a vasodilatory effect that may protect against ischemia. We aim to determine if a history of migraine influences clinical presentation and outcome of sCeAD. Methods: We performed a post-hoc analysis of the STOP-CAD registry, a large international multicenter study of patients with sCeAD. Clinical, demographic, and imaging data were compared between patients with and without history of migraine applying statistical tests as appropriate for continuous variables (t-tests) and for categorical variables (Chi-square/Fisher’s exact test). Logistic regression, Kaplan-Meier survival analysis, and Cox regression with clustered standard errors were used to assess associations between migraine, sCeAD features and outcome adjusting for potential confounders. Results: STOP-CAD included 668 participants (16.6%) with a history of migraine and 3,355 (83.4%) without migraine. Patients with migraine were younger and more frequently female. In a univariate analysis, patients with migraine compared to patients without migraine had significantly fewer presentations with ischemic stroke, a higher rate of transient ischemic attacks, lower NIHSS scores at admission and better functional outcomes at discharge (mRankin<2). These results remained significant after adjusting for potential confounders: ischemic stroke (OR 0.53, 95% CI 0.42–0.67, p<0.001); NIHSS admission (OR 0.60, 95% CI 0.47–0.76, p<0.001) and mRankin<2 at discharge (OR 1.65, 95%CI 1.34-0.23, p=0.001). Conclusion: In this cohort study, migraine patients with sCeAD were significantly less likely to have an ischemic stroke at admission and had better functional outcome at discharge. Migraine might influence the clinical presentation of sCeAD and modulate the severity of cerebral ischemia. Future research should evaluate the role of potential pathophysiological mechanisms, particularly of CGRP.

Abstract Background and aims Within the international CERES-TANDEM cohort, emergent carotid stenting (eCAS) during thrombectomy improved 90-day outcomes for anterior circulation tandem lesions overall. Whether this benefit extends to the subgroup with cervical carotid dissection remains uncertain. Methods This is a predefined CERES-TANDEM substudy including consecutive patients with extracranial carotid dissection–related tandem occlusions treated with endovascular thrombectomy at 49 comprehensive stroke centres worldwide (2018–2024). Patients were classified as eCAS (n=288) or no-stenting (n=194); IPTW balanced >20 baseline and procedural covariates, and the primary estimand was 90-day mRS shift. Secondary outcomes were good functional outcome (mRS 0–2), mortality, and safety; we also provide a meta-analysis of eCAS in dissection-related tandem occlusions, including multicentre studies with n>100 patients. Results Patients were middle-aged (median 55 years) with severe stroke at baseline (NIHSS 15–17) and similar imaging profiles across strategies. After IPTW, eCAS was associated with a non-significant trend toward lower disability (common OR 1.10, 95% CI 0.80–1.51) and no excess in sICH or mortality versus no-stenting. Distribution of 90-day mRS suggested numerically more favourable outcomes with eCAS, but good outcome did not differ significantly between strategies. In the updated meta-analysis (3 studies, 892 patients), eCAS yielded a marginal increase in good functional outcome (pooled OR 1.20, 95% CI 0.92–1.57). Conclusions In this CERES-TANDEM substudy, eCAS in cervical dissection–related tandem lesions conferred only a non-significant benefit on functional outcome after rigorous adjustment. Pooled evidence from our meta-analysis suggests a modest treatment effect that supports RCTs. Conflict of interest

INTRODUCTION:Data on safety of endovascular therapy (EVT) in the very elderly are scarce. Using data from a large prospective EVT registry, we aimed at providing better evidence for EVT decision-making in patients aged 90 years and older. PATIENTS AND METHODS:In this multicentre observational study from the EVA-TRISP collaboration outcomes were compared between patients aged ⩾90 years with those aged <90 years using multivariate logistic regression analysis and reporting odds ratios and 95% confidence intervals. Outcomes were occurrence of poor functional outcome in survivors (modified Rankin Scale (mRS) 3-5 if pre-stroke mRS 0-2 and mRS higher than pre-stroke mRS if pre-stroke mRS 3-5), mortality at 3 months after stroke, unsuccessful recanalization (mTICI 0-2a) and symptomatic intracranial hemorrhage (sICH, defined by ECASS-II-/III-criteria). RESULTS:Of 13,306 eligible patients, 892 were ⩾90 years old (6.7%). The very elderly had a higher median National Institutes of Health Stroke Scale (NIHSS) on admission (16 vs 14) and were more likely to have a pre-stroke mRS of 3-5 (38.0% vs 8.7%). The odds of poor functional outcome (ORadjusted 2.35 (95%-CI 1.87-2.97); 61.6% vs 38.7%), death (ORadjusted 3.04 (95%-CI 2.60-3.55); 53.9% vs 21.3%) and unsuccessful recanalization (ORadjusted 1.34 (95%-CI 1.14-1.57); 32.4% vs 27.2%) were higher in patients aged ⩾90 years. The odds of sICH did not differ (ORadjusted 0.92 (95%-CI 0.66-1.28); 5.1% vs 5.0%). DISCUSSION AND CONCLUSION:EVT-treated stroke patients ⩾90 years had higher odds of poor functional outcome, mortality and unsuccessful recanalization than younger patients. However, the probability of sICH after EVT was not increased. The decision in favor of or against EVT in the very elderly should not be based on age alone.