ESO Voice of Stroke

Embolic stroke of undetermined source (ESUS) accounts for a substantial proportion of ischaemic strokes. But could new imaging techniques help uncover the causes that conventional investigations have missed?

In the latest Voice of Stroke podcast episode, we explore three recent studies examining how advanced imaging, carotid plaque assessment and thrombus composition may help identify the underlying mechanisms of cryptogenic stroke.

This episode discusses:

• A novel PET imaging technique that may directly identify the source of thrombosis in patients with ischaemic stroke
• Whether CT angiography and Plaque-RADS can identify high-risk non-stenotic carotid plaques associated with ESUS
• How the composition of thrombi retrieved during thrombectomy may reveal distinct stroke mechanisms
• Featuring discussion of recent research published in Circulation, Neurology, and Neurological Sciences.

Written by: Voice of Stroke Podcast Editor Robert Hurford from University of Oxford, and Voice of Stroke Editor-in-Chief Linxin Li from University of Oxford.

Read the full transcript: https://eso-stroke.org/wp-content/uploads/ESOPodacst_EP9_Transcript.pdf

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This podcast series is supported by an unrestricted educational grant from Bayer

Medium or distal vessel occlusions account for up to a third of ischaemic stroke, but recent randomised trials have raised important questions about the role of thrombectomy in these patients.

In the latest Voice of Stroke podcast episode, we explore new evidence searching for the "green flags" that could help identify patients with medium or distal vessel occlusion who may benefit from thrombectomy.

This episode discusses:

• The ORIENTAL-MeVO trial and thrombectomy in patients with moderate-to-severe neurological deficits

• Whether baseline imaging and collateral status may help identify differences in treatment response

• Evidence from DISTAL examining whether thrombectomy can preserve threatened brain tissue

Featuring discussion of recent research published in:

· New England Journal of Medicine

· Radiology

· JAMA Neurology

Written by: Umberto Pensato, Voice of Stroke Podcast Editor, and Linxin Li, Voice of Stroke Editor-in-Chief.

Read the full transcript.

1. Liu J, Cui T, Wen J, et al. Endovascular Treatment of Medium-Vessel-Occlusion Strokes. N Engl J Med. 2026;394:1894-1904.

2. Ospel JM, Diprose WK, Uchida K, et al. Reperfusion Therapy in ESCAPE-MeVO Trial Participants: Imaging Characteristics and Clinical Outcomes. Radiology. 2026;319:e251769.

3. Anastasiou A, Corbaz H, Christodoulou E, et al. Mechanical Thrombectomy and Final Infarct Volume in Medium or Distal Vessel Occlusion Stroke: A Post Hoc Analysis of a Randomized Clinical Trial. JAMA Neurol. 2026;83:537-543.

4. Goyal M, Ospel JM, Ganesh A, et al. Endovascular Treatment of Stroke Due to Medium-Vessel Occlusion. N Engl J Med. 2025;392:1385-1395.

5. Psychogios M, Brehm A, Ribo M, et al. Endovascular Treatment for Stroke Due to Occlusion of Medium or Distal Vessels. N Engl J Med. 2025;392:1374-1384.

6. Clarençon F, Bala F, Baptiste A, et al. Mechanical Thrombectomy in Ischemic Stroke With a Medium or Distal Arterial Occlusion: The DISCOUNT Randomized Clinical Trial. JAMA. 2026;336:755–764.

7. Prabhakaran S, et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke. Stroke. 2026;57:e316–e436.

Endovascular thrombectomy has transformed the treatment of large vessel occlusion stroke. But as its use expands, important questions remain about where its boundaries lie.

In this episode of Voice of Stroke, we explore three recent studies examining patient selection and treatment intensity at the margins of thrombectomy practice.

This episode discusses:

• The CHOICE-2 trial and adjunctive intra-arterial alteplase after successful thrombectomy

• Whether ischaemic core volume may refine patient selection beyond ASPECTS in large-core stroke

• The AURORA pooled analysis examining the role of time in imaging-selected patients treated in the extended 6–24-hour window

Featuring discussion of recent research published in JAMA, Stroke, and Neurology.

Written by: Robert Hurford, Voice of Stroke Podcast Editor, and Linxin Li, Voice of Stroke Editor-in-Chief.

Read the full transcript here

· Renú A, Fernández-Couto MD, de la Riva P, et al. Adjunctive Intra-Arterial Alteplase After Successful Thrombectomy for Acute Ischemic Stroke: The CHOICE-2 Randomized Clinical Trial. JAMA. 2026.

· Jiang X, Zhao Z, Zhang Y, et al. Intra-arterial thrombolysis following endovascular recanalization for large vessel occlusion stroke: a systematic review and meta-analysis. Neurology. 2025.

· Kim H, Ryu WS, Inoue M, et al. Defining the Therapeutic Ceiling of Endovascular Thrombectomy in Large-Core Stroke: Beyond the Limits of ASPECTS. Stroke. 2026.

· Sarraj A, Hassan AE, Abraham MG, et al. Endovascular thrombectomy for large ischemic stroke across ischemic injury and penumbra profiles. JAMA. 2024.

· Sarraj A, Thomalla G, Yoshimura S, et al. Endovascular thrombectomy for patients with large-core ischaemic stroke presenting up to 24 h after onset (ATLAS). Lancet. 2026.

· Nogueira RG, Jovin TG, Lansberg MG, et al. Time to Treatment in Stroke Thrombectomy and Outcomes in the Extended Time Window: A Meta-Analysis. Neurology. 2026.

Cerebral small vessel disease is increasingly recognised as one of the leading causes of stroke, cognitive impairment and dementia worldwide. Despite its enormous clinical impact, disease-modifying therapies remain limited.

In this episode of Voice of Stroke, we explore how advances in biomarker discovery and cerebrovascular physiology are reshaping our understanding of cSVD and identifying promising new therapeutic targets.

This episode discusses:

• The global burden of cerebral small vessel disease
• Cerebrospinal fluid and blood biomarkers for disease characterisation and progression
• Cerebral autoregulation as an emerging physiological biomarker
• The potential role of phosphodiesterase-5 inhibitors and other therapies targeting cerebral vascular function

Featuring discussion of recent research published in:

• International Journal of Stroke
• Nature Aging
• Alzheimer's Research & Therapy
• Frontiers in Neurology

Written by: Annemijn Algra, Voice of Stroke Podcast Editor, and Linxin Li, Voice of Stroke Editor-in-Chief.

Read the full transcript

1. Lam BYK, et al. Global burden of cerebral small vessel disease determined from large MRI studies: A systematic review and meta-analysis. International Journal of Stroke. 2026.

2. Hristovska I, et al. Identification of distinct and shared biomarker panels in different manifestations of cerebral small-vessel disease through proteomic profiling. Nature Aging. 2026.

3. Yang D, et al. Plasma extracellular vesicle proteins biomarker for cerebral small vessel disease related cognitive impairment. Alzheimer's Research & Therapy. 2026.

4. Webb AJS, et al. The role of impaired autoregulation in cerebral small vessel disease and vascular cognitive impairment. International Journal of Stroke. 2026.

5. Yan L, et al. Phosphodiesterase-5 inhibitors for cerebral small vessel disease-related ischemic stroke and cognitive decline: Systematic review and meta-analysis. Frontiers in Neurology. 2026.

How should clinicians think about hypertension in 2026?

In this episode of Voice of Stroke, we explore recent evidence addressing one of the most important questions in vascular prevention: not simply whether to lower blood pressure, but which treatments work best, who should be treated, and how hypertension-related vascular disease may influence stroke mechanisms and secondary prevention.

This episode discusses:

• Meta-analyses evaluating the efficacy and tolerability of antihypertensive drugs and combinations
• Blood pressure lowering in isolated diastolic hypertension
• An exploratory analysis of the ARCADIA trial examining high-risk hypertension features and recurrent stroke prevention

Featuring discussion of recent studies published in The Lancet, JAMA, European Heart Journal and JAMA Neurology.

Written by Voice of Stroke Podcast Editor-In-Chief Linxin Li and Co-Editor Maria Magdalena Gabriel.

Read the full transcript here.

• Ridha M et al. Hypertension With High-Risk Features in Cryptogenic Stroke: An Exploratory Analysis of the ARCADIA Randomized Clinical Trial. JAMA Neurology. 2026.
• Bidel Z et al. Blood pressure lowering in isolated diastolic hypertension and cardiovascular risk: an individual patient data meta-analysis. European Heart Journal. 2026.
• Wang N et al. Blood pressure-lowering efficacy of antihypertensive drugs and their combinations. The Lancet. 2025.
• Wang N et al. Adverse Effects and Treatment Discontinuation of Blood Pressure-Lowering Drugs and Combinations. JAMA. 2026.
• Blood Pressure Treatment Efficacy Calculator: https://www.bpmodel.org/blood-pressure-treatment-efficacy-calculator/

In this episode of Voice of Stroke we explore major recent advances in intracerebral haemorrhage research.

This episode discusses:

• The TRIDENT trial and long-term blood pressure lowering after ICH
• Perihaematomal oedema growth as a biomarker of secondary brain injury
• Translational neuroimmunology and inflammatory signalling after haemorrhage
• Highlights from the ESO ICH Academy Meeting in Maastricht

Featuring discussion of recent publications in the New England Journal of Medicine, Stroke, and Annals of Neurology.

Written by Voice of Stroke Podcast Editor-in-Chief Linxin Li and Co-editor Annemijn Algra.

Listen on Spotify, Apple Podcasts, and via the European Stroke Organisation website.

Read the full transcript here.

References

1. The Trident Research Group. Three Low-Dose Antihypertensive Agents in a Single Pill after Intracerebral Hemorrhage. N Engl J Med. 2026; 394: 1571-1582. doi: 10.1056/NEJMoa2515043. https://www.nejm.org/doi/full/10.1056/NEJMoa2515043

2. Samarasekera N et al. Perihematomal Edema and Functional Outcome After Intracerebral Hemorrhage: A Meta-Analysis of Individual Participant Data. Stroke 2026; 57: 1310-1324. doi: 10.1161/STROKEAHA.125.053991. https://www.ahajournals.org/doi/epdf/10.1161/STROKEAHA.125.053991

3. Parry-Jones A et al. Hematoma Interleukin-1 ReceptorAntagonist Concentrations PredictLong-Term Outcome in AcuteHuman Intracerebral Hemorrhage. Ann Neurol 2026; 00: 1-16. doi: 10.1002/ana.78237. https://onlinelibrary.wiley.com/doi/epdf/10.1002/ana.78237

4. ICH Academy Meeting: https://eso-stroke.org/resources/eso-ich-academy-meeting-iam/

In this episode of Voice of Stroke, we explore the latest evidence shaping stroke prevention in atrial fibrillation (AF) – a condition responsible for up to a quarter of all ischaemic strokes.

This episode examines emerging strategies and unresolved questions in AF management, including:

• Whether left atrial appendage closure (LAAC) can replace anticoagulation in patients eligible for oral therapy
• The role of catheter ablation in reducing recurrent stroke risk after AF-related stroke
• New population data on blood pressure control and stroke risk, particularly in younger AF patients

• Anticoagulation remains the cornerstone of stroke prevention, but limitations persist
• LAAC may reduce bleeding risk but does not yet clearly outperform anticoagulation in eligible patients
• Catheter ablation did not reduce recurrent stroke risk in current trial evidence
• Blood pressure is a critical—and potentially under-recognised—driver of stroke risk in AF, especially in younger populations

Together, these findings refine how we approach AF stroke prevention, balancing procedural interventions, pharmacological therapy, and risk factor management.

This episode was written by Voice of Stroke Podcast editor Umberto Pensato and Editor-in-Chief Linxin Li.

Read the full transcript here.

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References

Landmesser U et al. Left Atrial Appendage Closure or Medical Therapy in Atrial Fibrillation. N Endl J Med. 2026; 394: 1270-1280. doi: 10.1056/NEJMoa2513310. https://www.nejm.org/doi/full/10.1056/NEJMoa2513310

Doshi SK et al. Left Atrial Appendage Closure or Anticoagulation for Atrial Fibrillation. N Engl J Med. 2026 Mar 28. doi: 10.1056/NEJMoa2517213 https://www.nejm.org/doi/full/10.1056/NEJMoa2517213

Kimura K et al. Catheter Ablation and Oral Anticoagulation for Secondary Stroke Prevention in Atrial Fibrillation: The STABLED Randomized Clinical Trial. JAMA Neurol. 2026 Mar 2:e260155. doi: 10.1001/jamaneurol.2026.0155. https://jamanetwork.com/journals/jamaneurology/fullarticle/2845745

Jeong MH et al. Impact of blood pressure on the risk of stroke and all-cause mortality in patients with atrial fibrillation across different age groups: a nationwide population-based study. Heart Rhythm. 2026 Mar 24:S1547-5271(26)02172-7. doi: 10.1016/j.hrthm.2026.03.1917. https://www.heartrhythmjournal.com/article/S1547-5271(26)02172-7/fulltext

In this episode of Voice of Stroke, we explore new evidence shaping how lipid management can reduce stroke risk across both primary and secondary prevention.

This episode explores:

• Reassessing statin side effects using large-scale randomised trial data
• The role of PCSK9 inhibition (VESALIUS-CV) in reducing vascular events in high-risk patients without prior stroke
• Long-term data linking LDL, lipoprotein(a), and inflammation to stroke risk decades later

Together, these findings clarify safety concerns, expand preventive options, and highlight the importance of long-term risk prediction in stroke care.

This episode was written by Linxin Li, Editor-in-Chief of the Voice of Stroke Podcast, and Co-Editor Ahmad Nehme.

Note: Full transcript available here.

The following publications were mentioned in this podcast:

• NEJM paper on the VESALIUS-CV trial
• Lancet paper on statin side effects
• Lancet Neurology paper on prediction of long-term stroke risk
• 2026 AHA/ACC guideline on lipid management
• International Journal of Stroke review on lipid management

In this first episode of Voice of Stroke, we examine three key trials presented at ISC 2026 that challenge how we define time boundaries in acute stroke care.

This episode explores:

· Extending intravenous thrombolysis beyond 4.5 hours in non-large vessel occlusion stroke (OPTION)

· Tenecteplase within 24 hours for basilar artery occlusion (TRACE-5)

· Ultra-early recombinant factor VIIa in intracerebral haemorrhage (FASTEST)

Together, these trials refine our understanding of patient selection, risk, and benefit across ischaemic and haemorrhagic stroke.

This month's Voice of Stroke episode was written by Linxin Li, Editor-in-Chief of the Voice of Stroke Podcast.

Read the full transcript here.

Welcome to Voice of Stroke, brought to you by the European Stroke Organisation. Your fast, reliable update on the science driving stroke care forward.

Each month, we spotlight key papers from the world's leading journals and discuss how it can inform and refine clinical practice.

From breakthrough randomised controlled trials to cross-disciplinary insights, Voice of Stroke brings you concise, evidence-based takeaways — straight from the front lines of research.