diff --git a/CHANGELOG.md b/CHANGELOG.md index feef9eb2..d67ec797 100644 --- a/CHANGELOG.md +++ b/CHANGELOG.md @@ -1,5 +1,19 @@ # CHANGELOG +## v7.11.0 — 2026-11-07 — Accessibility, layout and search fixes (outside the Protocols tab) + +From a read-only audit of accessibility (axe-core across 136 page states plus keyboard, zoom, forced-colors and reflow checks), layout (690 captured states at six widths in both themes) and performance. The Protocols tab is unchanged. + +- **Trials:** on phones and tablets, "View N possible candidates" opened the Retired destination page (its `#trial-results` link was read as a route); it now scrolls to the results and focuses the result summary. The trial-criteria dialog keeps its title and Close button visible while its body scrolls (on screens taller than 440 px). Registry links show one external-link marker instead of two. The database search's accessible name now starts with its visible label (WCAG 2.5.3). +- **Case bar:** the thrombolytic "Dose table" link is shown only for acute ischemic stroke, a recorded administration, or before a diagnosis is chosen, no longer in ICH, SAH, TIA or other encounters. +- **Short screens (phone landscape, 200–400% zoom):** at 440 px tall or less, the header and case bar scroll with the page instead of covering most of it, so content and keyboard focus stay visible (WCAG 1.4.10, 2.4.11). The Protocols surface keeps its sticky chrome. +- **More panel:** closes when focus moves outside it, so it no longer covers the focused control; a press inside the install sheet no longer closes it; Escape in the install sheet closes only the sheet; Escape returns focus to More only when focus was inside the panel. +- **Global search:** the search field shows a focus indicator and its placeholder meets 4.5:1 contrast. +- **Forced colors (Windows High Contrast):** selected, pressed and current states, external-link markers and the case bar's Copy button stay visible. +- **Evidence:** search no longer re-normalizes every record on each keystroke (typing "thrombectomy" letter by letter: 229 → 2.5 ms of search work unthrottled; identical results and order for 2,061 queries in every care setting). The wide index separates each section's topic count from its heading, for sight and for screen readers. +- **Polish:** Trials, Evidence, Calculators, search and install-option failure states are styled like the rest of the app (the Protocols and Quick reference fallbacks are unchanged); checklist selects line up from 481 px; reference tiles keep the same ink in dark mode. +- **Tests:** the smoke check that compares `--case-bar-h` with the case bar's height now waits for a rendering opportunity instead of a fixed 150 ms. + ## v7.10.3 — 2026-11-04 — Trial criteria and registry-reference update - **MINUTE:** the stored full criteria now include all eight registry inclusions and 17 exclusions, checked against the official protocol-training materials. Consent, bleeding diathesis, active infection, follow-up-limiting conditions and concurrent interventional trials remain explicit manual confirmations; no automated eligibility rule changes. diff --git a/README.md b/README.md index 01c4b20f..e1da4f6e 100644 --- a/README.md +++ b/README.md @@ -56,6 +56,6 @@ Required guards cover clinical-source tracing, bounded schemas/citations, leak p Open the site, then **More → Install App**, or use the browser's installation menu. Shortcuts open Encounter or Protocols. Offline core use requires a successful complete online cache installation; an uncached first visit requires network. Updates never automatically reload an active session. See [PWA behavior](docs/pwa-and-app.md). Existing optional Capacitor distributions remain in the repository; native builds were not changed or certified by this redesign. -The immediate rollback point is commit `0dde1f96c65ed5c21a99326036036c3e59c29199` (7.10.1) on `main`; 7.10.0 is `0ba15529f38f884d1484eded2f73921271ab2059`, 7.9.0 is `9b3464f4844ab1c93e978aa128afa622a647ab96`, 7.8.3 is `88f53b927e268219f572a43254bb8f3c29e08dfd`, 7.8.0 is `af21b0777067f9683c9612472777e1c4f173230f`; 7.7.13 is `dc9b87fa741d4867d5812a0914a3663314427ed1`, 7.7.12 is `c15b80714c1b7cbfdbc1c21709fb50949f851087`, 7.7.11 is `17076aad3ac61c0222c55d9e17a72b23fe5cec77`, 7.7.10 is `43fb1a5021d9d7b7763d28ec21a3da22baa8eec3`, 7.7.9 is `07e270f3a701c551cb09093e462b10d197fb21c7`, 7.7.8 is `1b261e7931e371640a8150b64e9ddeccefaf2323`, 7.7.7 is `741658276aa86fe957882e05202cfd8dbe917576`, 7.7.6 is `6a1774f8bce14e1612472df4830800b7bd3b34de`, 7.7.5 is `f2fac1cc5e1bdfe6e7c54e67ee409e46c7b14422`, 7.7.4 is `36febd79aeea1af6f097e913f3ef7d766a62c3ab`, 7.7.3 is `fa475f6908d7c8a342556caed8eb09485308287b`, 7.7.2 is `d04df878c5cb3b7bd833e5be4a9325dd8f260c64`, 7.7.1 is `509d012f7eb2c088ed5ba86dc796a87604ed3a00`, 7.7.0 is `6472d236d3910ae8b6caf4dbf8097122171a9dd5`, and the pre-review point `c48733186f3f81f690dee3c582bf4d8f5d5da899` (7.6.5) and the earlier ref **`archive/pre-timing-review-20261002-adb81c2`** (7.6.4) remain available. +The immediate rollback point is commit `c54e142e60f7764ddd0e2304feec21e384277ab8` (7.10.4) on `main`; 7.10.2 is `9f099b767d386cdfcf2e7e9668a248f39047aff4`, 7.10.1 is `0dde1f96c65ed5c21a99326036036c3e59c29199`, 7.10.0 is `0ba15529f38f884d1484eded2f73921271ab2059`, 7.9.0 is `9b3464f4844ab1c93e978aa128afa622a647ab96`, 7.8.3 is `88f53b927e268219f572a43254bb8f3c29e08dfd`, 7.8.0 is `af21b0777067f9683c9612472777e1c4f173230f`; 7.7.13 is `dc9b87fa741d4867d5812a0914a3663314427ed1`, 7.7.12 is `c15b80714c1b7cbfdbc1c21709fb50949f851087`, 7.7.11 is `17076aad3ac61c0222c55d9e17a72b23fe5cec77`, 7.7.10 is `43fb1a5021d9d7b7763d28ec21a3da22baa8eec3`, 7.7.9 is `07e270f3a701c551cb09093e462b10d197fb21c7`, 7.7.8 is `1b261e7931e371640a8150b64e9ddeccefaf2323`, 7.7.7 is `741658276aa86fe957882e05202cfd8dbe917576`, 7.7.6 is `6a1774f8bce14e1612472df4830800b7bd3b34de`, 7.7.5 is `f2fac1cc5e1bdfe6e7c54e67ee409e46c7b14422`, 7.7.4 is `36febd79aeea1af6f097e913f3ef7d766a62c3ab`, 7.7.3 is `fa475f6908d7c8a342556caed8eb09485308287b`, 7.7.2 is `d04df878c5cb3b7bd833e5be4a9325dd8f260c64`, 7.7.1 is `509d012f7eb2c088ed5ba86dc796a87604ed3a00`, 7.7.0 is `6472d236d3910ae8b6caf4dbf8097122171a9dd5`, and the pre-review point `c48733186f3f81f690dee3c582bf4d8f5d5da899` (7.6.5) and the earlier ref **`archive/pre-timing-review-20261002-adb81c2`** (7.6.4) remain available. The complete committed prior application is preserved at **`archive/pre-encounter-first-20261001-4f8e99d`**, commit `4f8e99de9f605327bb901d0585f279cc7ebcd12e` (6.30.7). Rollback requires a reviewed forward commit restoring that tree, then a *new* coherent app/cache version, production build and normal checks/release. Reusing an old worker version is insufficient for clients already running 7.x. This deployment rollback has not been executed; the baseline-to-new-version update/failure path is tested separately. An already-open old page or permanently offline device cannot be remotely guaranteed to update. diff --git a/app-assets.json b/app-assets.json index 265a6413..eecf6f59 100644 --- a/app-assets.json +++ b/app-assets.json @@ -1,6 +1,6 @@ { "schemaVersion": 1, - "appVersion": "7.10.4", + "appVersion": "7.11.0", "buildTarget": "public", "entry": "app.js", "initial": [ @@ -19,9 +19,9 @@ "files": [ { "path": "app.js", - "bytes": 109040, - "gzipBytes": 34242, - "sha256": "63674a1e455bd2557073a57f6b822fcb12c0d972faff07212eb4f04cae2bfa83" + "bytes": 110183, + "gzipBytes": 34397, + "sha256": "8b73f284ac4256f9899143b97c6d4cdcc47a8f62797a2e5d952829b5ad654c35" }, { "path": "chunks/chunk-3C5ZDFRN.js", @@ -53,6 +53,12 @@ "gzipBytes": 628, "sha256": "e53b76097ab7b6ad561bdc6a921075c340a55a623f41f405af1698cc971118aa" }, + { + "path": "chunks/chunk-FI3I7QSW.js", + "bytes": 4774, + "gzipBytes": 2376, + "sha256": "d1a9dff2172d4049be80b27736db4dad02e7a412340522f671bb1d94d657078a" + }, { "path": 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diff --git a/data/atlas/active-trials.json b/data/atlas/active-trials.json index 199fffb5..ef8a347f 100644 --- a/data/atlas/active-trials.json +++ b/data/atlas/active-trials.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/atlas/active-trials.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/atlas/citations.json b/data/atlas/citations.json index 58871c93..bcec900a 100644 --- a/data/atlas/citations.json +++ b/data/atlas/citations.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "citations", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:7df7539161214e503ebdb9e3b3ab04af", "count": 43, "source": "Maintained Encounter/protocol evidence dependency closure", diff --git a/data/atlas/claims.json b/data/atlas/claims.json index 976623fa..d109c55d 100644 --- a/data/atlas/claims.json +++ b/data/atlas/claims.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "claims", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:d67377827a118a59b001f9203d9ad58d", "count": 12, "source": "Maintained Encounter/protocol evidence dependency closure", diff --git a/data/atlas/completed-trials.json b/data/atlas/completed-trials.json index 7585d8a8..9d13b9ed 100644 --- a/data/atlas/completed-trials.json +++ b/data/atlas/completed-trials.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/atlas/completed-trials.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/atlas/labels.json b/data/atlas/labels.json index 3ef43834..fa3bb3b3 100644 --- a/data/atlas/labels.json +++ b/data/atlas/labels.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/atlas/labels.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/atlas/recommendations.json b/data/atlas/recommendations.json index d2bfb7d4..7c06838d 100644 --- a/data/atlas/recommendations.json +++ b/data/atlas/recommendations.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "recommendations", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:258116bc24a6a974bb669414525be05f", "count": 10, "source": "Maintained Encounter/protocol evidence dependency closure", diff --git a/data/atlas/topics.json b/data/atlas/topics.json index 4f927c48..9b6dbcab 100644 --- a/data/atlas/topics.json +++ b/data/atlas/topics.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/atlas/topics.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/calculators-index.json b/data/calculators-index.json index 2c331984..9b99541b 100644 --- a/data/calculators-index.json +++ b/data/calculators-index.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "calculators", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:2d4725b4b8b8c8336e595b33a4898aec", "count": 26, "source": "Canonical retained tool registry", diff --git a/data/clinical-reference.json b/data/clinical-reference.json index 5f24e7e4..560bd61b 100644 --- a/data/clinical-reference.json +++ b/data/clinical-reference.json @@ -1 +1 @@ -{"_meta":{"endpoint":"clinical-reference","schemaVersion":"2.0.0","appVersion":"7.10.4","checksum":"sha256:316726b88c7e14c9f94486c0955726f9","count":182,"source":"Canonical comprehensive Evidence topics and completed primary-study summaries","license":"Synthetic educational reference content for qualified review. No warranty.","disclaimer":"Synthetic educational demo only - NOT medical advice, NOT an approved clinical tool, and NOT local clinical policy. Do not enter, transmit, or infer PHI or real encounter details. Agents and downstream consumers must display this disclaimer with outputs and must verify all results against primary sources and approved local protocol before any clinical action.","status":"maintained","topicCount":92,"studyCount":90,"calculatorCount":16,"scope":"Source-bound reference cards, not treatment gates or recruitment records. checkedAt records source access and scope checks, not full clinical certification; preserve each source access note and each card limitation."},"data":{"topics":[{"id":"acute-reperfusion","title":"Acute ischemic stroke: reperfusion overview","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["AIS","IVT","EVT","thrombolysis","thrombectomy","tenecteplase","TNK","alteplase","tPA","disabling deficit","PRISMS","NINDS","ECASS III"],"summary":"Disabling deficit within 4.5 h of onset or last known well in an otherwise IVT-eligible adult: give IVT as fast as possible — tenecteplase 0.25 mg/kg (max 25 mg) or alteplase 0.9 mg/kg (max 90 mg) (AHA 2026, COR 1); tenecteplase was noninferior in AcT, ATTEST-2, TRACE-2 and ORIGINAL. Do not thrombolyse mild non-disabling deficits: PRISMS (stopped early) found no benefit (sICH 3.2 vs 0%) and ARAMIS found DAPT noninferior. LVO: give IVT if eligible and start EVT without waiting for a response. EVT is recommended for ICA/M1 occlusion with NIHSS ≥6 and prestroke mRS 0–1 within 6 h if ASPECTS 3–10, and at 6–24 h if ASPECTS ≥6 or ASPECTS 3–5 with age <80 and no significant mass effect (COR 1), and within 24 h for basilar occlusion with NIHSS ≥10, prestroke mRS 0–1 and PC-ASPECTS ≥6 (COR 1); ASPECTS 0–2 within 6 h (age <80, no significant mass effect) is 2a.","recommendations":[{"text":"In adult AIS patients with disabling deficits (regardless of NIHSS score) who are eligible for IVT, faster treatment is recommended as it improves functional outcomes.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-84 · p. 38","id":"ais-2026-84"},{"text":"In adult AIS patients presenting within 4.5 hours of symptom onset or last known well who are eligible for IVT, tenecteplase 0.25 mg/kg (max 25 mg) or alteplase 0.9 mg/kg (max 90 mg) is recommended to improve functional outcomes.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-98 · p. 42","id":"ais-2026-98"},{"text":"In eligible adult AIS patients presenting with mild, non-disabling stroke deficits (e.g., isolated sensory syndrome) within 4.5 hours of symptom onset or last known well, IVT is not recommended as it has not shown superiority over dual antiplatelet treatment for improving functional outcomes.","cor":"3: No Benefit","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-91 · p. 38","id":"ais-2026-91"},{"text":"In AIS patients eligible for both IVT and EVT, IVT is recommended to be administered as rapidly as possible without waiting to observe clinical response or delaying EVT initiation, to improve treatment times and clinical outcomes.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-113 · p. 48","id":"ais-2026-113"}],"consider":["Is the deficit disabling regardless of the NIHSS total? If not (e.g., isolated sensory symptoms), IVT is not recommended (COR 3: No Benefit); use antithrombotics instead: DAPT is COR 1 for noncardioembolic minor stroke (NIHSS ≤3) within 24 h, and NIHSS 4–5 options carry lower grades (see the minor-stroke card).","Do not wait for coagulation results unless an abnormality is suspected, or for MRI to count microbleeds (AHA 2026).","Minor stroke with a visible occlusion: TEMPO-2 found no benefit from tenecteplase and more deaths (5 vs 1%). 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July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"SELECT2 — Trial of Endovascular Thrombectomy for Large Ischemic Strokes.","url":"https://pubmed.ncbi.nlm.nih.gov/36762865/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ANGEL-ASPECT — Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct.","url":"https://pubmed.ncbi.nlm.nih.gov/36762852/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"RESCUE-Japan LIMIT — Endovascular Therapy for Acute Stroke with a Large Ischemic Region.","url":"https://pubmed.ncbi.nlm.nih.gov/35138767/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"TENSION — Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37837989/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"LASTE — Trial of Thrombectomy for Stroke with a Large Infarct of Unrestricted Size.","url":"https://pubmed.ncbi.nlm.nih.gov/38718358/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ATLAS — Endovascular thrombectomy for patients with large-core ischaemic stroke presenting up to 24 h after onset (ATLAS): a systematic review and individual patient data meta-analysis with central imaging adjudication.","url":"https://pubmed.ncbi.nlm.nih.gov/42107392/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"DIRECT ANGIO — Safety and efficacy of direct versus conventional transfer to angiography suite in patients with severe acute stroke treated with thrombectomy (DIRECT ANGIO) in France: a multicentre, open-label, blinded-endpoint, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41864232/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"TEMPO-2 — Tenecteplase versus standard of care for minor ischaemic stroke with proven occlusion (TEMPO-2): a randomised, open label, phase 3 superiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38768626/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ARAMIS — Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke: The ARAMIS Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37367978/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"MR CLEAN — A randomized trial of intraarterial treatment for acute ischemic stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25517348/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ESCAPE — Randomized assessment of rapid endovascular treatment of ischemic stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25671798/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"EXTEND-IA — Endovascular therapy for ischemic stroke with perfusion-imaging selection.","url":"https://pubmed.ncbi.nlm.nih.gov/25671797/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SWIFT PRIME — Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25882376/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"REVASCAT — Thrombectomy within 8 hours after symptom onset in ischemic stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25882510/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"HERMES — Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.","url":"https://pubmed.ncbi.nlm.nih.gov/26898852/","year":2016,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"TESLA — Thrombectomy for Stroke With Large Infarct on Noncontrast CT: The TESLA Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39374319/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"TENSION antithrombotic analysis — Large Core Stroke Thrombectomy Is Safe and Effective Regardless of Prior Antithrombotic or Thrombolytic Treatment: A Secondary Analysis of the Randomized TENSION Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42261979/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. Secondary analysis; prior antithrombotic treatment was not the randomized intervention."},{"title":"LASTE ASPECTS 0-2 — Endovascular Thrombectomy in Patients With Largest Baseline Infarcts (ASPECTS 0-2): An Ancillary Analysis of the LASTE Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41979451/","year":2026,"type":"Report","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. Ancillary analysis of the randomized trial population."},{"title":"ANGEL-ASPECT HMCAS analysis — Effects of Computed Tomography Hyperdense Middle Cerebral Artery Sign on the Efficacy of Endovascular Therapy in Acute Ischemic Stroke With Large Infarcts: A Subgroup Analysis of the ANGEL-ASPECT Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41914357/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. Subgroup analysis; the imaging sign was not a randomized exposure."},{"title":"EVA-TRISP prior-APT analysis — Previous Antiplatelet Therapy and Outcomes of Acute Ischemic Stroke With Large Vessel Occlusion Treated With Direct Endovascular Therapy.","url":"https://pubmed.ncbi.nlm.nih.gov/41671526/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Minor-stroke IVT meta-analysis — Meta-Analysis of Randomized Controlled Trials on IV Thrombolysis in Patients With Minor Acute Ischemic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/40674672/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."}],"related":[{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"},{"label":"Current NIHSS","href":"#/encounter/nihss"},{"label":"Thrombectomy selection","href":"#/evidence/evt-selection"},{"label":"Wake-up and late-window IVT","href":"#/evidence/extended-window-ivt"},{"label":"Minor stroke DAPT","href":"#/evidence/minor-stroke-antiplatelets"}]},{"id":"code-stroke-activation","title":"Code stroke activation and prehospital LVO scales","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["code stroke","stroke alert","RACE","LVO scale","prehospital","EMS","mobile stroke unit","RACECAT","triage","transfer","door to needle"],"summary":"Activate the stroke team for any acute focal deficit — EVT can be offered up to 24 h from last known well. Check glucose, and do not wait for creatinine before CTA/CTP. EMS should use a validated scale, pre-notify, and go to the closest stroke-capable hospital (AHA 2026, COR 1). RACE (face 0–2, arm 0–2, leg 0–2, gaze 0–1, aphasia or agnosia 0–2) ≥5 detected LVO with 85% sensitivity and 68% specificity in its 2013 validation, but 75% and 76% pooled across EMS studies (2026 meta-analysis). In nonurban Catalonia, bypassing the local stroke center for a thrombectomy center did not improve outcome (RACECAT, cOR 1.03): fewer received IVT (47.5 vs 60.4%) and more had EVT (48.8 vs 39.4%).","recommendations":[{"text":"For patients with suspected stroke transported by ambulance, use of a brief validated stroke assessment tool by prefacility personnel is recommended to improve early stroke identification, including detection of large vessel occlusion.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-9 · p. 12","id":"ais-2026-9"},{"text":"For patients with suspected acute stroke, EMS transport is recommended to the closest appropriate stroke-capable facility (ASRH, PSC, TSC, or CSC) to minimize time to treatment, rather than to a non-stroke-capable facility.","cor":"1","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-15 · p. 14","id":"ais-2026-15"}],"consider":["Aim to image as fast as possible (for example within 25 minutes).","Children: suspect stroke with any sudden focal deficit, including a first seizure.","Where available, mobile stroke units are recommended over conventional EMS for thrombolytic-eligible patients: faster treatment and better outcome (COR 1, LOE A). On one Melbourne MSU (MSU-TELEMED, n=275, randomized by day; published after the AHA 2026 literature cutoff, not graded), a telemedicine neurologist versus an onboard neurologist had similar safety events (13 vs 12%) and a longer scene-to-decision time (median 19 vs 13 min; adjusted difference 4 min); the prespecified composite of safety, decision time and neurologist time favored telemedicine (win odds 3.5).","A seizure, hypoglycemia or apparent mimic can coexist with stroke; keep the stroke pathway open until a clinician has reassessed."],"caution":"Prehospital scales triage; they neither exclude LVO nor decide treatment.","sources":[{"title":"RACE scale: design and prospective validation to predict large arterial occlusion","url":"https://pubmed.ncbi.nlm.nih.gov/24281224/","year":2013,"type":"Observational study","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"RACECAT: direct transport to a thrombectomy center vs local stroke center","url":"https://pubmed.ncbi.nlm.nih.gov/35510397/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"Prehospital LVO scales applied by EMS: systematic review and meta-analysis","url":"https://pubmed.ncbi.nlm.nih.gov/42333681/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed (43 studies, October 2016–July 2024; RACE ≥5 pooled)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"MSU-TELEMED — A Randomized Trial of Telemedicine Models of Care on a Mobile Stroke Unit.","url":"https://pubmed.ncbi.nlm.nih.gov/41429047/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Single Melbourne MSU per the ClinicalTrials.gov registry record NCT05991310."}],"related":[{"label":"Current NIHSS","href":"#/encounter/nihss"},{"label":"Stroke mimics","href":"#/evidence/stroke-mimics-ivt"},{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"}]},{"id":"stroke-mimics-ivt","title":"Suspected stroke mimics and thrombolysis","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["mimic","FABS","seizure","Todd paralysis","migraine","functional","hypoglycemia","conversion"],"summary":"Do not delay IVT for a disabling, otherwise eligible deficit to exclude every mimic: in 9 series (392 mimics among 8,942 IVT-treated patients), sICH was 0.5% and orolingual edema 0.3% in mimics, a lower sICH risk than in true stroke (RR 0.33). Check glucose first; if a disabling deficit persists after correcting hypo- or hyperglycemia, IVT is recommended (AHA 2026, COR 1). FABS ≥3 (no facial droop, no AF history, age <50, SBP <150, seizure history, isolated sensory symptoms) identified mimics with 90% sensitivity and 91% specificity after a negative CT.","recommendations":[{"text":"In suspected ischemic stroke patients with severe hypoglycemia or hyperglycemia, if disabling stroke symptoms persist despite correction to normoglycemia, IVT administration is recommended to improve functional outcomes.","cor":"1","loe":"C-LD","source":"AHA/ASA AIS 2026 · ais-2026-89 · p. 38","id":"ais-2026-89"}],"consider":["Look for seizure onset, prior identical episodes, migraine aura, functional signs and toxic-metabolic causes.","If the diagnosis stays uncertain and the deficit is disabling, the low harm in mimics favors treatment within standard eligibility.","Obtain MRI DWI afterwards and record whether stroke was confirmed."],"caution":"Mimic data are observational and mostly alteplase-era; they do not override contraindications or a structural lesion on imaging.","sources":[{"title":"Safety of IVT in stroke mimics: prospective study and meta-analysis","url":"https://pubmed.ncbi.nlm.nih.gov/25791717/","year":2015,"type":"Meta-analysis","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"FABS: screening tool for stroke mimics in the emergency department","url":"https://pubmed.ncbi.nlm.nih.gov/27491733/","year":2016,"type":"Observational study","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."}],"related":[{"label":"Functional seizures","href":"#/evidence/functional-seizures"},{"label":"Stroke chameleons","href":"#/evidence/stroke-chameleons"},{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"}]},{"id":"stroke-chameleons","title":"Stroke chameleons: commonly missed presentations","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["chameleon","missed stroke","misdiagnosis","cerebellar","decreased consciousness","coma","dizziness"],"summary":"In one university emergency department (Lausanne), 47 of 2,200 ischemic strokes (2.1%) were missed, more often in younger patients and in cerebellar, very mild or very severe strokes. Missed patients also had fewer vascular risk factors and less eye deviation. They were labeled as another neurological illness (43%), a non-neurological illness (17%), unexplained decreased consciousness (21%) or a coexisting disease (19%), and had worse 12-month outcomes and higher mortality.","consider":["Acute dizziness or imbalance: examine gait and eye movements; cerebellar strokes are over-represented among misses.","Unexplained decreased consciousness was a common label — image the brain and vessels, including the posterior circulation.","A coexisting illness masked about one in five misses: a persistent deficit still needs a stroke review."],"caution":"These are single-center retrospective data; the absence of these features does not exclude stroke.","sources":[{"title":"Acute stroke chameleons in a university hospital: risk factors, circumstances and outcomes","url":"https://pubmed.ncbi.nlm.nih.gov/26180146/","year":2015,"type":"Observational study","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"related":[{"label":"Acute dizziness","href":"#/evidence/dizziness"},{"label":"Code stroke activation","href":"#/evidence/code-stroke-activation"},{"label":"Stroke mimics","href":"#/evidence/stroke-mimics-ivt"}]},{"id":"post-ivt-complications","title":"Post-thrombolysis hemorrhage and angioedema","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["sICH","hemorrhagic transformation","post-lytic","cryoprecipitate","fibrinogen","angioedema","orolingual"],"summary":"Neurological worsening during or after IVT: stop any running thrombolytic and get an emergent CT. If hemorrhage is suspected or seen, follow the post-lytic ICH protocol: send urgent labs including fibrinogen, and correct the fibrinolytic coagulopathy early — the mainstay of treatment, though based on expert opinion (AHA 2017). Angioedema occurred in about 1% (6 patients per arm) with tenecteplase or alteplase in ATTEST-2; assess the airway first. Teams must be ready to treat bleeding and angioedema (AHA 2026, COR 1).","recommendations":[{"text":"Healthcare professionals are recommended to be prepared to treat potential emergent adverse effects of IVT, including bleeding complications and angioedema (which may cause partial airway obstruction), to reduce poor clinical outcomes.","cor":"1","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-86 · p. 38","id":"ais-2026-86"}],"consider":["Take cryoprecipitate, antifibrinolytic and angioedema drug doses from the protected protocol; this card adds no doses.","Angioedema: protect the airway early, hold ACE inhibitors and follow the angioedema protocol.","Involve neurosurgery and hematology early; manage BP, glucose and temperature as for ICH."],"caution":"No randomized evidence supports a specific sICH reversal regimen.","sources":[{"title":"AHA/ASA statement: treatment and outcome of hemorrhagic transformation after IV alteplase","url":"https://pubmed.ncbi.nlm.nih.gov/29097489/","year":2017,"type":"Scientific statement","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed; dosing tables not reproduced."},{"title":"ATTEST-2: tenecteplase vs alteplase within 4.5 h","url":"https://pubmed.ncbi.nlm.nih.gov/39424558/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."}],"related":[{"label":"Post-lytic ICH protocol","href":"#/protocols/ischemic/post-lytic"},{"label":"Angioedema protocol","href":"#/protocols/ischemic/angioedema"},{"label":"Reversal","href":"#/evidence/antithrombotic-reversal"}]},{"id":"ct-perfusion","title":"CT perfusion and collateral imaging for late-window selection","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["CT perfusion","CTP","Tmax","rCBF","core","penumbra","mismatch","RAPID","collaterals","MR CLEAN-LATE","DAWN","DEFUSE 3","PRACTISE"],"summary":"Perfusion maps estimate hypoperfused tissue (Tmax >6 s) and core (markedly reduced relative CBF; below about 31% of the contralateral side best matched DWI in the derivation study), but within 4.5 h IVT must not wait for them (AHA 2026, COR 1). DEFUSE 3 target mismatch at 6–16 h: core <70 mL, hypoperfused-to-core ratio ≥1.8 and mismatch volume ≥15 mL. DAWN used clinical–core mismatch instead: core <21 mL at age ≥80 with NIHSS ≥10; <31 mL under 80 with NIHSS ≥10; <51 mL under 80 with NIHSS ≥20. Collateral flow on CTA alone selected patients who still benefited from EVT at 6–24 h in MR CLEAN-LATE (cOR 1.67; sICH 7 vs 2%).","recommendations":[{"text":"In adult AIS patients eligible for IVT within 4.5 hours of symptom onset, treatment is recommended to be initiated as quickly as possible while ensuring safe administration, avoiding potential delays from additional multimodal neuroimaging (CTA/MRA, CT/MR perfusion).","cor":"1","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-85 · p. 38","id":"ais-2026-85"},{"text":"In patients with suspected AIS who awaken with symptoms or have unknown time of onset 4.5 to 24 hours from last known well, CTP or MR DWI-PWI selection with automated postprocessing software can be useful to determine eligibility for extended-window IVT.","cor":"2a","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-53 · p. 27","id":"ais-2026-53"}],"consider":["Check for artifact: a poor contrast bolus or leukoaraiosis can make non-infarcted white matter look like core.","EVT at 6–24 h can be selected on NCCT ASPECTS (AHA 2026, COR 1); perfusion is adjunctive when immediately available (2a).","AHA 2026 grades perfusion-selected IVT for EVT-ineligible patients at 4.5–9 h from LKW or within 9 h of the sleep midpoint (2a, ais-2026-101); up to 24 h from onset or LKW, wake-up included, only LVO with salvageable penumbra that cannot receive EVT is graded (2b, ais-2026-102; TRACE-III). The 2a for CTP or DWI-PWI after wake-up or unknown onset (ais-2026-53) grades imaging selection, not IVT itself. Large-core trials also accepted CTP cores (e.g., SELECT2 ≥50 mL).","Within 4.5 h, adding CTA and CTP to non-contrast CT (PRACTISE: 11 UK sites, 2015–2018, stopped at 271 of 400 planned; published after the AHA 2026 literature cutoff) lowered thrombolysis use (49.1 vs 67.6% of patients without a CT contraindication). Among treated patients, decision and needle times did not differ (decisions not to treat took longer); 90-day outcomes did not differ significantly, but the trial was not powered for them, and whether untreated patients were mimics or missed strokes is uncertain."],"caution":"Software thresholds estimate tissue fate; they are not exact infarct volumes or stand-alone exclusions.","sources":[{"title":"DEFUSE 3: perfusion-selected thrombectomy at 6–16 h (methods: Tmax >6 s, mismatch criteria)","url":"https://pubmed.ncbi.nlm.nih.gov/29364767/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Full text (PMC) read for imaging definitions."},{"title":"Cerebral blood flow is the optimal CT perfusion parameter for infarct core","url":"https://pubmed.ncbi.nlm.nih.gov/21980202/","year":2011,"type":"Observational study","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"MR CLEAN-LATE: collateral-selected EVT at 6–24 h","url":"https://pubmed.ncbi.nlm.nih.gov/37003289/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"ESO annual stroke evidence update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41706824/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PMC full text (PMC12915583) read 2026-10-31. ESO Guideline Board evidence review; its practice implications are the authors' interpretation, not guideline recommendations."},{"title":"PRACTISE — Randomised, controlled Trial of CT perfusion and angiography compared to CT alone in thrombolysis-eligible acute ischaemic stroke patients: The penumbra and recanalisation acute computed tomography in ischaemic stroke evaluation (PRACTISE) trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41614492/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PMC full text (PMC12866261) read 2026-10-31; bibliographic record checked; first published online 2025-09-19 (PMID 40970508)."}],"related":[{"label":"DAWN screen","href":"#/encounter/dawn"},{"label":"DEFUSE 3 screen","href":"#/encounter/defuse3"},{"label":"Thrombectomy selection","href":"#/evidence/evt-selection"},{"label":"Large core","href":"#/evidence/large-core-evt"}]},{"id":"tia-evaluation","title":"TIA: evaluation and disposition","category":"Acute ischemic stroke","settings":["on-call","hospital","clinic"],"keywords":["transient ischemic attack","ABCD2","transient symptoms","DWI","vascular imaging","rapid follow-up"],"summary":"Treat TIA as a stroke warning: MRI with DWI ideally within 24 h (about 40% show infarction, which makes it a stroke), head-and-neck vessel imaging in the ED regardless of ABCD2, and ECG, telemetry and troponin for all. Admit presumed symptomatic >50% extracranial or intracranial stenosis. Noncardioembolic high-risk TIA (ABCD2 ≥4) or minor stroke (NIHSS ≤3) within 24 h, without IVT: aspirin plus clopidogrel with a loading dose for 21 days, then one agent (AHA 2026, COR 1). Discharge only with the workup arranged and TIA-clinic review, preferably within 48 h.","recommendations":[{"text":"Multimodal brain MRI is the preferred method to evaluate for acute ischemic infarct and ideally should be obtained within 24 hours of symptom onset. In cases where MRI with DWI can be obtained without delay, NCCT can be safely avoided in a stable patient with completely resolved symptoms.","cor":"Statement","loe":"Ungraded","source":"AHA TIA Statement 2023 · tia-ed-2023-12","id":"tia-ed-2023-12"},{"text":"Vessel imaging in the emergency department is warranted regardless of ABCD2 score or likelihood of admission.","cor":"Statement","loe":"Ungraded","source":"AHA TIA Statement 2023 · tia-ed-2023-44","id":"tia-ed-2023-44"},{"text":"Presumed symptomatic (>50%) extracranial or intracranial stenosis warrants hospital admission.","cor":"Statement","loe":"Ungraded","source":"AHA TIA Statement 2023 · tia-ed-2023-50","id":"tia-ed-2023-50"}],"consider":["Does the story fit focal ischemia (abrupt, maximal at onset, usually <60 min) or a mimic (marching symptoms, positive visual phenomena, migraine, seizure)?","ABCD2 omits posterior-circulation signs and stenosis; dual or crescendo TIA is high risk and may warrant admission whatever the score.","Suspected cardioembolism: arrange prolonged rhythm monitoring (30 days) within 6 months."],"caution":"A normal CT does not exclude infarction; persisting or recurrent deficits need acute stroke reassessment.","sources":[{"title":"AHA 2023 TIA diagnosis, workup and risk reduction statement — official summary","url":"https://professional.heart.org/en/science-news/diagnosis-workup-risk-reduction-of-transient-ischemic-attack-in-the-emergency-department-setting/top-things-to-know","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack","url":"https://pubmed.ncbi.nlm.nih.gov/34414299/","year":2021,"type":"Guideline","checkedAt":"2026-10-17","access":"PubMed abstract verified; full recommendations not reviewed. Interpret with newer evidence."},{"title":"Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/36655570/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Key-point statements (ungraded) from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards."}],"related":[{"label":"DAPT calculator","href":"#/encounter/dapt"},{"label":"ABCD2","href":"#/tools/abcd2"},{"label":"Carotid revascularization timing","href":"#/evidence/carotid"},{"label":"Minor stroke DAPT","href":"#/evidence/minor-stroke-antiplatelets"},{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"}]},{"id":"ich-management","title":"Spontaneous ICH: first-hour targets","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital"],"keywords":["intracerebral hemorrhage","hematoma expansion","anticoagulation reversal","blood pressure","neurocritical care","DNAR"],"summary":"Run the care bundle in the first hours (INTERACT3: better 6-month mRS, cOR 0.86): SBP <140 started early and reached within 1 h (stop lowering at 130); glucose 6.1–7.8 mmol/L (≈110–140 mg/dL; 7.8–10.0 mmol/L ≈140–180 mg/dL with diabetes); temperature ≤37.5 °C; INR <1.5 after warfarin. Do not acutely lower SBP below 130 in mild-to-moderate ICH presenting with SBP >150 (AHA 2022, harm; ATACH-2 at 110–139 gave no benefit and more renal adverse events, 9.0 vs 4.0%). Reverse anticoagulation immediately (see the reversal card). Severity scores frame discussion but must not alone limit care; defer new DNAR orders until at least the second full day.","recommendations":[{"text":"Initiating acute BP treatment within 2 hours of ICH onset and reaching the target within 1 hour can be beneficial to reduce hemorrhage expansion risk and improve functional outcome.","cor":"2a","loe":"C-LD","source":"AHA/ASA ICH 2022 · ich-2022-22 · p. 16","id":"ich-2022-22"},{"text":"For patients with mild to moderate spontaneous ICH presenting with SBP 150-220 mm Hg, acutely lowering SBP to a target of 140 mm Hg (maintaining 130-150 mm Hg range) is safe and may be reasonable for improving functional outcomes.","cor":"2b","loe":"B-R","source":"AHA/ASA ICH 2022 · ich-2022-23 · p. 17","id":"ich-2022-23"},{"text":"Acute lowering of SBP to <130 mm Hg is potentially harmful in patients with mild to moderate spontaneous ICH presenting with SBP >150 mm Hg.","cor":"3: Harm","loe":"B-R","source":"AHA/ASA ICH 2022 · ich-2022-25 · p. 17","id":"ich-2022-25"},{"text":"For patients with spontaneous ICH who lack preexisting documented wishes to limit life-sustaining therapy, aggressive care with postponement of new DNAR orders or withdrawal of support until at least the second full day of inpatient stay is reasonable to decrease mortality and improve functional outcome.","cor":"2a","loe":"B-NR","source":"AHA/ASA ICH 2022 · ich-2022-95 · p. 45","id":"ich-2022-95"}],"consider":["Repeat CT within 24 h, sooner if the GCS falls, for expansion, hydrocephalus or swelling; early CTA can flag expansion risk. Vascular imaging (CTA ± venography) for lobar ICH <70 y, deep/posterior fossa ICH <45 y, or 45–70 y without hypertension (AHA 2022, COR 1).","Cerebellar ICH, hydrocephalus or a large hematoma: call neurosurgery now (see the ICH surgery card).","No prophylactic antiseizure drugs; continuous EEG for unexplained or fluctuating mental status.","Post-guideline pooled analyses (hypothesis-generating; AHA 2022 grades unchanged): in INTERACT1–4 (11,312 patients; INTERACT3 tested a care bundle), intensive SBP lowering (<140 within 1 h) reduced mRS 3–6 (OR 0.85); in its CT substudy (2,921) the effect declined with time from onset and crossed no effect at 3 h. Whether the effect differs by hematoma location is unsettled: an individual-patient pool of INTERACT1–4 and ATACH-2 (11,288; 81.5% deep, 10.1% lobar) found effect modification by location (interaction P=0.033), with clear benefit only in deep ICH (aOR 0.81, 0.74–0.89), whereas a study-level meta-analysis of ATACH-2, INTERACT2 and INTERACT3 (7,917 deep, 1,105 lobar) found no significant benefit in deep (OR 0.82, 0.57–1.18; I² 60%) or lobar ICH (OR 0.97, 0.76–1.24). Neither tested location-specific BP targets, and the AHA 2022 recommendations above do not differ by location."],"caution":"Intensive targets are less certain with SBP >220 mm Hg, hematomas >30 mL or planned evacuation; avoid SBP drops >70 mm Hg or below 110 (ESO 2025 consensus).","sources":[{"title":"AHA/ASA 2022 spontaneous ICH guideline — official summary","url":"https://professional.heart.org/en/science-news/2022-guideline-for-the-management-of-patients-with-spontaneous-intracerebral-hemorrhage/top-things-to-know","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"2025 update to European Stroke Organisation (ESO) guideline on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/42095756/","year":2026,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (against intensive SBP lowering <140 in the first 24 h after successful thrombectomy, high certainty); other recommendations from the archived full-text transcription (reviewed 2026-09-30). Published in 2026 under a 2025-update title."},{"title":"European Stroke Organisation (ESO) and European Association of Neurosurgical Societies (EANS) guideline on stroke due to spontaneous intracerebral haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/40401775/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"NLM title, PMID, DOI and abstract checked; abstract and plain-language summary re-read 2026-10-31 from the PMC record (PMC12098356), whose body is empty, so recommendation tables and individual strengths were not read; the ICH surgery line uses the abstract's list of interventions with weaker evidence. The BP consensus on the ICH card (>70 mm Hg, 110, >220, >30 mL, evacuation) is from the archived transcription. Interpret with newer evidence."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"Treatment of Antithrombotic-Associated Intracranial Hemorrhage in Adults: A Focused Guideline Update from the Neurocritical Care Society and the Society of Critical Care Medicine","url":"https://pubmed.ncbi.nlm.nih.gov/42786382/","year":2026,"type":"Guideline","checkedAt":"2026-10-17","access":"Recommendations with GRADE strength and certainty from the archived full publisher text (reviewed 2026-09-30); quoted in the topic cards. Abstract rechecked 2026-10-17."},{"title":"INTERACT3 — The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37245517/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ANNEXA-I — Andexanet for Factor Xa Inhibitor-Associated Acute Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/38749032/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"INTERACT2 — Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/23713578/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ATACH-2 — Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/27276234/","year":2016,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"TRIDENT — Three Low-Dose Antihypertensive Agents in a Single Pill after Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/42019018/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"Hyponatremia & ICH — Severity-Stratified Hyponatremia Is Associated with Increased Mortality and Complications in Nontraumatic Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/42194925/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ANNEXA-4 — Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors.","url":"https://pubmed.ncbi.nlm.nih.gov/30730782/","year":2019,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"INTERACT1-4 pooled — Effects of blood pressure lowering in relation to time in acute intracerebral haemorrhage: a pooled analysis of the four INTERACT trials.","url":"https://pubmed.ncbi.nlm.nih.gov/40541207/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; individual-patient pooled analysis of four randomized trials, not a new trial. INTERACT3 (7,036 of 11,312 patients) tested a care bundle, and the time-from-onset effect comes from the CT substudy (2,921 patients)."},{"title":"Deep vs lobar ICH BP meta-analysis — Functional Outcomes After Intensive Blood Pressure Reduction in Deep and Lobar Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/41962119/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked. Study-level stepwise meta-analysis (ATACH-2 individual data; INTERACT2 and INTERACT3 published pooled results); poor outcome was mRS 4–6 in ATACH-2 and INTERACT3 and 3–6 in INTERACT2, and INTERACT3 tested a care bundle."},{"title":"BP lowering by hematoma location (INTERACT1–4 and ATACH-2 IPD) — Effects of Blood Pressure Lowering by Hematoma Location in Acute Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/42848972/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; individual-patient pooled analysis of five randomized trials, not a new trial; full text not reviewed."},{"title":"Andexanet vs 4F-PCC meta-analysis — Efficacy and Safety of Andexanet Alfa Versus Four Factor Prothrombin Complex Concentrate for Emergent Reversal of Factor Xa Inhibitor Associated Intracranial Hemorrhage: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/39379749/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"RECAP-ICH — Intensive blood pressure lowering after spontaneous intracerebral haemorrhage for secondary stroke prevention (RECAP-ICH): a systematic review and individual participant data meta-analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42586098/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (2,944 participants; recurrent stroke HR 0.62, recurrent ICH HR 0.39); bibliographic record checked; full text not read. Individual-participant meta-analysis of 4 trials of BP-lowering treatment vs placebo or standard care, not a test of the <130/80 target. Included trials are not named in the abstract; overlap with TRIDENT not confirmed."}],"related":[{"label":"ICH protocol","href":"#/protocols/ich"},{"label":"Reversal","href":"#/evidence/antithrombotic-reversal"},{"label":"ICH volume","href":"#/encounter/ich-volume"},{"label":"GCS","href":"#/encounter/gcs"}]},{"id":"ich-surgery","title":"ICH: when to revisit surgical options","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital"],"keywords":["minimally invasive surgery","MIS","ENRICH","MIND","lobar","deep hemorrhage","cerebellar","hydrocephalus"],"summary":"Cerebellar ICH with deterioration, brainstem compression, hydrocephalus or volume ≥15 mL: immediate evacuation with or without EVD (AHA 2022, COR 1). Supratentorial ICH >20–30 mL with GCS 5–12: minimally invasive evacuation can reduce mortality (2a). ENRICH (lobar or anterior basal ganglia, 30–80 mL, within 24 h) improved 180-day utility-weighted mRS, mainly in lobar ICH; MIND (mostly deep, within 72 h) and SWITCH (decompression for severe deep ICH) were not conclusive. Large IVH with reduced consciousness: EVD (COR 1).","recommendations":[{"text":"For patients with cerebellar ICH who are deteriorating neurologically, have brainstem compression and/or hydrocephalus from ventricular obstruction, or have cerebellar ICH volume ≥15 mL, immediate surgical removal of the hemorrhage with or without EVD is recommended in preference to medical management alone to reduce mortality.","cor":"1","loe":"B-NR","source":"AHA/ASA ICH 2022 · ich-2022-89 · p. 42","id":"ich-2022-89"},{"text":"Minimally invasive hematoma evacuation (endoscopic or stereotactic aspiration, with or without thrombolytic use) can be useful to reduce mortality compared with medical management alone for patients with supratentorial ICH >20-30 mL and GCS 5-12.","cor":"2a","loe":"B-R","source":"AHA/ASA ICH 2022 · ich-2022-79 · p. 37","id":"ich-2022-79"},{"text":"EVD is recommended over medical management alone for patients with spontaneous ICH, large IVH, and impaired level of consciousness to reduce mortality.","cor":"1","loe":"B-NR","source":"AHA/ASA ICH 2022 · ich-2022-82 · p. 39","id":"ich-2022-82"}],"consider":["Location, volume, GCS, premorbid function and hours from onset decide which trial applies. Agree on realistic goals with the family before surgery.","Craniotomy is a lifesaving option for deteriorating supratentorial ICH (2b); decompressive craniectomy may be considered to reduce mortality in supratentorial ICH with coma, a large hematoma with significant midline shift, or refractory ICP (2b).","Cochrane 2025 (24 RCTs): minimally invasive evacuation may improve good function (RR 1.36, low certainty) and probably lowers mortality (RR 0.71, moderate certainty); most trials had high risk of bias.","ESO/EANS 2025 (GRADE-based) places craniotomy or minimally invasive surgery for supratentorial ICH, decompressive surgery for deep supratentorial ICH and evacuation of cerebellar ICH >15 mL among treatments with weaker supporting evidence; it made strong recommendations for only a few interventions. Individual recommendation strengths are in the full guideline."],"caution":"Lower mortality is not the same as better function; do not extend lobar-ICH results to deep or infratentorial bleeds.","sources":[{"title":"AHA 2026 minimally invasive ICH evacuation advisory — official summary","url":"https://professional.heart.org/en/science-news/evidence-update-for-minimally-invasive-surgical-evacuation-of-supratentorial-spontaneous-intracerebr/top-things-to-know","year":2026,"type":"Science advisory","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"AHA/ASA 2022 spontaneous ICH guideline — official summary","url":"https://professional.heart.org/en/science-news/2022-guideline-for-the-management-of-patients-with-spontaneous-intracerebral-hemorrhage/top-things-to-know","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"Surgery for spontaneous supratentorial ICH (Cochrane review)","url":"https://pubmed.ncbi.nlm.nih.gov/40673401/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-17","access":"Primary abstract checked via PubMed."},{"title":"Evidence Update for Minimally Invasive Surgical Evacuation of Supratentorial Spontaneous Intracerebral Hemorrhage: A Science Advisory From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/42634945/","year":2026,"type":"Science advisory","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"European Stroke Organisation (ESO) and European Association of Neurosurgical Societies (EANS) guideline on stroke due to spontaneous intracerebral haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/40401775/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"NLM title, PMID, DOI and abstract checked; abstract and plain-language summary re-read 2026-10-31 from the PMC record (PMC12098356), whose body is empty, so recommendation tables and individual strengths were not read; the ICH surgery line uses the abstract's list of interventions with weaker evidence. The BP consensus on the ICH card (>70 mm Hg, 110, >220, >30 mL, evacuation) is from the archived transcription. Interpret with newer evidence."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"ENRICH — Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/38598795/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"MISTIE III — Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/30739747/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"MIND — Minimally Invasive Surgery vs Medical Management Alone for Intracerebral Hemorrhage: The MIND Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40892424/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SWITCH — Decompressive craniectomy plus best medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracerebral haemorrhage: a randomised controlled clinical trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38761811/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 2 corrections or notices; check them before applying results."},{"title":"STICH — Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/15680453/","year":2005,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"STICH II — Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/23726393/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 2 corrections or notices; check them before applying results."}],"related":[{"label":"ICH protocol","href":"#/protocols/ich"},{"label":"ICH volume","href":"#/encounter/ich-volume"}]},{"id":"sah","title":"Aneurysmal SAH: coordinated specialist care","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital","clinic"],"keywords":["subarachnoid hemorrhage","aneurysm","thunderclap","DCI","vasospasm","nimodipine","hydrocephalus"],"summary":"Secure the aneurysm as early as feasible, preferably within 24 h (AHA 2023, COR 1; ESO 2026 consensus), at a high-volume center. Start enteral nimodipine early (COR 1). Until it is secured: frequent BP checks with short-acting agents, avoiding hypotension, hypertension and swings; ESO 2026 expert consensus suggests targeting about 160 if SBP stays >160–180 after analgesia and nimodipine. Good grade and equally suitable for both: coil rather than clip. No routine antifibrinolytics, statins, magnesium, endothelin-receptor antagonists or prophylactic hypervolemia. Urgent CSF diversion (EVD and/or lumbar drain) for acute symptomatic hydrocephalus (COR 1).","recommendations":[{"text":"Surgical or endovascular treatment of the ruptured aneurysm is recommended as early as feasible after presentation, preferably within 24 hours of onset, to improve outcome.","cor":"1","loe":"B-NR","source":"AHA/ASA aSAH 2023 · sah-2023-16 · p. 14","id":"sah-2023-16"},{"text":"Early initiation of enteral nimodipine is recommended in aSAH patients to prevent DCI and improve functional outcomes.","cor":"1","loe":"A","source":"AHA/ASA aSAH 2023 · sah-2023-54 · p. 26","id":"sah-2023-54"},{"text":"Frequent blood pressure monitoring and management with short-acting agents is recommended in aSAH patients with an unsecured aneurysm, targeting avoidance of severe hypotension, hypertension, and BP variability.","cor":"1","loe":"C-EO","source":"AHA/ASA aSAH 2023 · sah-2023-13 · p. 13","id":"sah-2023-13"},{"text":"For good-grade aSAH from anterior circulation aneurysms equally suitable for primary coiling and clipping, primary coiling is recommended over clipping to improve 1-year functional outcome.","cor":"1","loe":"A","source":"AHA/ASA aSAH 2023 · sah-2023-24 · p. 14","id":"sah-2023-24"}],"consider":["New decline: think rebleeding, hydrocephalus, DCI/vasospasm or seizures — urgent CT ± CTA/CTP.","Seizure prophylaxis: AHA 2023 allows it only with high-risk features (MCA aneurysm, high grade, ICH, hydrocephalus, cortical infarct; 2b) and lists phenytoin as harmful; NCS 2026 is conditional (ASM or no ASM; either agent and duration), its expert guidance favoring levetiracetam for ≤3 days unless seizures or EEG features suggest ongoing risk. Seizure at onset: AHA 2023 supports treatment for no more than 7 days (2a).","Keep euvolemia; liberal transfusion (Hb ≤10 g/dL) did not improve 12-month outcome (SAHaRA).","In a Stockholm register cohort of 544 aSAH survivors younger than 40 (index events 1967–2014; observational), de novo aneurysms reached a cumulative incidence of 30% at 40 years without a plateau; female sex, smoking and family history raised the risk, and stopping smoking was associated with lower risk. Of 158 de novo aneurysms, 23 ruptured, none under systematic surveillance."],"caution":"Prophylactic hemodynamic augmentation and induced hypervolemia are harmful.","sources":[{"title":"AHA/ASA 2023 aneurysmal SAH guideline — official summary","url":"https://professional.heart.org/en/science-news/2023-guideline-for-the-management-of-patients-with-aneurysmal-subarachnoid-hemorrhage/top-things-to-know","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"European Stroke Organisation (ESO), European Association of Neurosurgical Societies (EANS) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on aneurysmal subarachnoid haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/42095754/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendations from the archived full-text transcription (reviewed 2026-09-30); cited in topic summaries."},{"title":"Guidelines for Seizure Prophylaxis in Patients with Aneurysmal Subarachnoid Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society","url":"https://pubmed.ncbi.nlm.nih.gov/42552475/","year":2026,"type":"Guideline","checkedAt":"2026-10-17","access":"PMC full text (PMC13642444) read 2026-10-17; supplementary tables not reviewed."},{"title":"2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/37212182/","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 38011240 (Stroke 2023;54:e516) is indexed; its body was not re-read."},{"title":"ISAT (18-year) — The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial (ISAT).","url":"https://pubmed.ncbi.nlm.nih.gov/25465111/","year":2015,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results. Long-term follow-up of a randomized trial cohort."},{"title":"De novo aneurysms after aSAH in young survivors — Lifelong De Novo Aneurysm Risk After Aneurysmal Subarachnoid Hemorrhage in Young Survivors.","url":"https://pubmed.ncbi.nlm.nih.gov/42636016/","year":2026,"type":"Observational study","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Single-region (Stockholm) cohort with index events 1967–2014."}],"related":[{"label":"GCS","href":"#/encounter/gcs"},{"label":"Hunt and Hess","href":"#/tools/hunt-hess"},{"label":"WFNS","href":"#/tools/wfns"},{"label":"aSAH critical care","href":"#/evidence/sah-critical-care"}]},{"id":"cvt","title":"Cerebral venous thrombosis","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["CVST","venous sinus thrombosis","headache","pregnancy","postpartum","papilledema","venography"],"summary":"Anticoagulate on diagnosis, even with venous hemorrhage: parenteral heparin (LMWH favored; nonheparin agents if VITT is suspected), then oral anticoagulation for 3–12 months, or indefinitely with chronic major risk factors or recurrent VTE (AHA 2024); in pregnancy, LMWH only. DOACs are a reasonable alternative to warfarin after the lead-in: RE-SPECT CVT (dabigatran) had no recurrent VTE and major bleeding 1.7 vs 3.3%; ACTION-CVT (observational) found similar recurrence and less major hemorrhage (aHR 0.35). A 2026 meta-analysis (8 RCTs and 6 observational studies; 3,698 patients) found no significant difference between DOACs and VKAs in recurrent VTE (RR 0.92, 95% CI 0.55–1.53) or major bleeding (RR 0.74, 0.44–1.25). Endovascular therapy is rescue only (TO-ACT: no benefit); decompressive craniectomy is lifesaving with impending herniation.","recommendations":[{"text":"The mainstream initial treatment of cerebral venous thrombosis includes parenteral heparin followed by transition to oral vitamin K antagonists for 3 to 12 months, depending on the underlying cause, or indefinitely in the presence of chronic major risk factors or recurrent venous thromboembolism. [Editorial note: the statement's abbreviated key point refers broadly to thrombophilia; its treatment section specifies chronic major risk factors. An isolated thrombophilia result is not, by itself, a universal indication for indefinite treatment.]","cor":"Statement","loe":"Ungraded","source":"AHA CVT Statement 2024 · cvt-2024-5","id":"cvt-2024-5"},{"text":"The presence of venous hemorrhage does not constitute a contraindication for anticoagulation. Whether degree of venous recanalization should inform duration of anticoagulation remains an area of uncertainty.","cor":"Statement","loe":"Ungraded","source":"AHA CVT Statement 2024 · cvt-2024-25","id":"cvt-2024-25"},{"text":"Given the lack of controlled studies (and poorer outcomes in meta-analyses), endovascular therapies are reserved for patients with evidence of thrombus propagation, for individuals with neurological deterioration despite medical therapy, or for those with contraindications to anticoagulation.","cor":"Statement","loe":"Ungraded","source":"AHA CVT Statement 2024 · cvt-2024-8","id":"cvt-2024-8"}],"consider":["Confirm with MRI/MRV (CT/CTV is a reasonable alternative); add GRE/SWI or contrast MRV for cortical vein thrombosis.","Look for pregnancy/puerperium, estrogen, obesity, APS, myeloproliferative disease, malignancy and infection; headache with thrombocytopenia after an adenoviral vaccine suggests VITT — avoid heparin and involve hematology.","Watch vision, seizures and consciousness; escalate for deterioration or propagation despite anticoagulation."],"caution":"DOACs are contraindicated in pregnancy and breastfeeding and carry more thrombotic events in APS.","sources":[{"title":"AHA 2024 CVT diagnosis and management statement — official summary","url":"https://professional.heart.org/en/science-news/diagnosis-and-management-of-cerebral-venous-thrombosis/top-things-to-know","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"Diagnosis and Management of Cerebral Venous Thrombosis: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/38284265/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Key-point statements (ungraded) from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards."},{"title":"European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - Endorsed by the European Academy of Neurology","url":"https://pubmed.ncbi.nlm.nih.gov/31008314/","year":2017,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"TO-ACT — Effect of Endovascular Treatment With Medical Management vs Standard Care on Severe Cerebral Venous Thrombosis: The TO-ACT Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/32421159/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ACTION-CVT — Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT): A Multicenter International Study.","url":"https://pubmed.ncbi.nlm.nih.gov/35143325/","year":2022,"type":"Observational study","checkedAt":"2026-10-01","access":"PubMed bibliographic identity and primary-abstract study design checked: retrospective observational cohort, not random treatment allocation. Outcomes not reviewed here."},{"title":"CVT DOAC vs VKA meta-analysis — Comparison of DOAC Versus VKA for Cerebral Venous Thrombosis: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42910429/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. 8 RCTs and 6 observational studies; the RCT-only estimates were also imprecise (recurrent VTE RR 1.06, 0.35–3.24)."},{"title":"RE-SPECT CVT — Safety and Efficacy of Dabigatran Etexilate vs Dose-Adjusted Warfarin in Patients With Cerebral Venous Thrombosis.","url":"https://pubmed.ncbi.nlm.nih.gov/31479105/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed; bibliographic record checked."}],"related":[{"label":"Maternal stroke","href":"#/evidence/maternal-stroke"},{"label":"Antiphospholipid syndrome","href":"#/evidence/antiphospholipid-syndrome"},{"label":"Follow-up imaging","href":"#/evidence/imaging-follow-up"}]},{"id":"dizziness","title":"Acute dizziness: HINTS and when to image","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["vertigo","HINTS","HINTS plus","GRACE-3","posterior circulation","acute vestibular syndrome","skew deviation","head impulse","nystagmus","BPPV","Dix-Hallpike"],"summary":"Sort dizziness by timing and triggers (GRACE-3). In acute vestibular syndrome (continuous vertigo with nystagmus, nausea, head-motion intolerance, unsteady gait) and vascular risk, a trained examiner's HINTS beats early MRI: any central sign — normal head impulse, direction-changing nystagmus or skew deviation — was 100% sensitive and 96% specific for stroke; adding new hearing loss (HINTS plus) reached 99.2% sensitivity for central causes. Early DWI missed 12–14% of infarcts within 48 h. Central or equivocal findings: MRI/MRA. ABCD2 is not a dizziness screen (sensitivity 61%).","consider":["Head impulse: a corrective saccade suggests a peripheral lesion; a normal head impulse in continuous vertigo is a central sign.","Nystagmus: direction-changing nystagmus on eccentric gaze is central.","Test of skew (cross-cover): any vertical misalignment is central and points to the brainstem.","Hearing: new hearing loss is the \"plus\" that raises sensitivity for central causes; triggered positional episodes are not a HINTS situation."],"caution":"HINTS needs continuous vertigo with nystagmus and a trained examiner; routine CT is not the GRACE-3 way to exclude a central cause. Not every stroke causing dizziness shows nystagmus: in a prospective single-centre ED cohort of 75 patients with MRI-proven stroke causing vertigo, dizziness or imbalance, 59% had no spontaneous nystagmus but postural or gait imbalance (acute imbalance syndrome), a presentation HINTS was not designed for.","sources":[{"title":"SAEM GRACE-3 acute dizziness and vertigo — official recommendations","url":"https://www.saem.org/publications/grace/grace-3","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Official SAEM recommendations page."},{"title":"HINTS to diagnose stroke in the acute vestibular syndrome (Kattah 2009)","url":"https://pubmed.ncbi.nlm.nih.gov/19762709/","year":2009,"type":"Observational study","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"HINTS outperforms ABCD2 in acute continuous vertigo (HINTS plus)","url":"https://pubmed.ncbi.nlm.nih.gov/24127701/","year":2013,"type":"Observational study","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"GRACE-3 — Guidelines for reasonable and appropriate care in the emergency department 3: acute dizziness and vertigo in the emergency department.","url":"https://pubmed.ncbi.nlm.nih.gov/37166022/","year":2023,"type":"Guideline","checkedAt":"2026-10-03","access":"PubMed bibliographic record checked; recommendations summarized from the official SAEM page."},{"title":"Acute imbalance syndrome cohort — Acute Imbalance Syndrome vs Acute Vestibular Syndrome: Clinical and Topographical Differentiation.","url":"https://pubmed.ncbi.nlm.nih.gov/42848973/","year":2026,"type":"Observational study","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Prospective single-centre ED cohort."}],"related":[{"label":"Stroke chameleons","href":"#/evidence/stroke-chameleons"},{"label":"Basilar occlusion","href":"#/evidence/basilar-occlusion"},{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"}]},{"id":"inpatient-care","title":"Inpatient stroke: complication review","category":"Inpatient care and complications","settings":["hospital"],"keywords":["stroke unit","dysphagia","aspiration","fever","glucose","DVT","VTE","pressure injury","urinary retention","post-thrombectomy","HeadSOAR","ZODIAC","head position"],"summary":"Stroke-unit care with protocols: bedside swallow screen before any oral intake; treat fever to normothermia and look for its source; treat glucose <60 mg/dL and keep persistent hyperglycemia at 140–180 mg/dL (not 80–130); oxygen only for hypoxia, to keep SpO2 >94%; intermittent pneumatic compression for immobile patients and no elastic stockings; no routine bladder catheters or prophylactic antibiotics; no high-dose very early mobilization within 24 h (AHA 2026).","recommendations":[{"text":"In AIS patients, a bedside swallow screening prior to any oral intake is recommended to identify patients at increased aspiration risk.","cor":"1","loe":"C-EO","source":"AHA/ASA AIS 2026 · ais-2026-160 · p. 74","id":"ais-2026-160"},{"text":"In AIS patients, it is reasonable to treat persistent hyperglycemia to achieve blood glucose levels of 140-180 mg/dL with close monitoring to prevent worse functional outcomes.","cor":"2a","loe":"C-LD","source":"AHA/ASA AIS 2026 · ais-2026-82 · p. 37","id":"ais-2026-82"},{"text":"In inpatient AIS patients with hyperglycemia, IV insulin targeting blood glucose of 80-130 mg/dL is not recommended as it does not improve 3-month functional outcomes.","cor":"3: No Benefit","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-83 · p. 37","id":"ais-2026-83"},{"text":"In AIS patients with hyperthermia, targeting normothermia (including nurse-initiated fever management protocols) is recommended to improve functional outcomes and reduce mortality.","cor":"1","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-78 · p. 37","id":"ais-2026-78"},{"text":"In AIS patients with impaired mobility and no contraindications, intermittent pneumatic compression (IPC) in addition to routine care is recommended over routine care alone to reduce DVT risk.","cor":"1","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-169 · p. 76","id":"ais-2026-169"}],"consider":["After IVT: BP <180/105 for at least 24 h; antiplatelets in the first 24 h only when a strong indication outweighs the uncertain risk.","Screen nutrition within 48 h and depression with a structured tool; start enteral feeding within 7 days if the patient cannot swallow.","After EVT: neurological checks, access site, the BP plan and urgent imaging for any decline.","Awaiting thrombectomy for LVO: in ZODIAC (12 US hospitals; 92 of 182 planned, enrollment halted by the DSMB at the second interim analysis; published after the AHA 2026 literature cutoff), a 0° vs 30° head position reduced ≥2-point NIHSS worsening before EVT (1 vs 26 patients); 90-day deaths were 2 vs 10, but 90-day mRS did not differ significantly. AHA 2026's COR 3: No Benefit for routine 24-h flat positioning (ais-2026-66) addresses AIS patients overall, not LVO awaiting EVT. Head position after successful EVT (anterior LVO, eTICI ≥2b): in HeadSOAR (BMJ 2026; 67 centres in China; 1,368 patients), 72 h at 30–40° vs flat at 0–10° did not significantly improve 90-day mRS (adjusted generalized OR 1.12, 95% CI 0.97–1.29); 90-day mortality was 18.3 vs 20.3% (aRR 0.86, 0.69–1.07), and the authors could not exclude a modest benefit of elevation. ZODIAC's flat-positioning result before EVT should not be extended to the period after reperfusion, where flat positioning showed no advantage."],"caution":"Intensive targets backfire here: targeting SBP <140 for 72 h after successful anterior-LVO EVT is harmful (AHA 2026, COR 3: Harm); after successful LVO EVT, a 24-h <140 target also lowered functional independence (OPTIMAL-BP 39.4 vs 54.4%), and ESO 2025 recommends against intensive lowering below 140 in the first 24 h; IV insulin to 80–130 mg/dL adds hypoglycemia without benefit.","sources":[{"title":"AHA 2024 systemic complications of acute stroke statement — official summary","url":"https://professional.heart.org/en/science-news/addressing-systemic-complications-of-acute-stroke/top-things-to-know","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"AHA 2021 acute stroke nursing care statements — official summary","url":"https://professional.heart.org/en/science-news/2021-update-care-of-the-patient-with-acute-ischemic-stroke/top-things-to-know","year":2021,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"AHA/ASA 2026 acute ischemic stroke guideline — official summary","url":"https://professional.heart.org/en/science-news/2026-guideline-for-the-early-management-of-patients-with-acute-ischemic-stroke/top-things-to-know","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"OPTIMAL-BP randomized trial","url":"https://pubmed.ncbi.nlm.nih.gov/37668619/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22: LVO with mTICI ≥2b after EVT; SBP <140 vs 140–180 for 24 h; stopped early for safety."},{"title":"HeadSOAR — head positioning after endovascular thrombectomy (BMJ 2026)","url":"https://pubmed.ncbi.nlm.nih.gov/42624516/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; full text and registry NCT06115707 not reviewed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"2025 update to European Stroke Organisation (ESO) guideline on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/42095756/","year":2026,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (against intensive SBP lowering <140 in the first 24 h after successful thrombectomy, high certainty); other recommendations from the archived full-text transcription (reviewed 2026-09-30). Published in 2026 under a 2025-update title."},{"title":"SO2S — Effect of Routine Low-Dose Oxygen Supplementation on Death and Disability in Adults With Acute Stroke: The Stroke Oxygen Study Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/28973619/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"HeadPoST — Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/28636854/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SHINE — Intensive vs Standard Treatment of Hyperglycemia and Functional Outcome in Patients With Acute Ischemic Stroke: The SHINE Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/31334795/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"AVERT dose-response — Prespecified dose-response analysis for A Very Early Rehabilitation Trial (AVERT).","url":"https://pubmed.ncbi.nlm.nih.gov/26888985/","year":2016,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic identity and primary-abstract design checked: observational secondary dose-response analysis of AVERT, irrespective of randomized treatment assignment. This is not a randomized comparison of mobilization doses; Outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"OPTIMISTmain — Safety and efficacy of low-intensity versus standard monitoring following intravenous thrombolytic treatment in patients with acute ischaemic stroke (OPTIMISTmain): an international, pragmatic, stepped-wedge, cluster-randomised, controlled non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40412428/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked: clinically stable with NIHSS <10 within 2 h of IVT; mRS 2–6 31.7 vs 30.9% (RR 1.03, 95% CI 0.92–1.15; margin 1.15; p=0.057); authors report weak evidence of noninferiority."},{"title":"ZODIAC — Optimal Head-of-Bed Positioning Before Thrombectomy in Large Vessel Occlusion Stroke: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40465238/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PMC full text (PMC12138796) read 2026-10-31; bibliographic record checked."}],"related":[{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"},{"label":"ICH protocol","href":"#/protocols/ich"},{"label":"Follow-up imaging","href":"#/evidence/imaging-follow-up"},{"label":"Acute BP context","href":"#/evidence/acute-bp"}]},{"id":"imaging-follow-up","title":"Follow-up imaging by diagnosis","category":"Inpatient care and complications","settings":["on-call","hospital","clinic"],"keywords":["follow-up imaging","repeat CT","DSA","CTA","MRI","vasospasm","TCD","coil follow-up","MRV","recanalization"],"summary":"TIA, and by extension minor stroke: brain MRI with DWI, ideally within 24 h of onset, plus head-and-neck vessel imaging in the ED (AHA 2023 TIA statement, ungraded). ICH: repeat CT within 24 h (sooner with decline) for expansion; CTA ± venography for lobar ICH <70 y, deep or posterior fossa ICH <45 y, or 45–70 y without hypertension; DSA if CTA suggests a macrovascular cause or for primary IVH; MRI/MRA if CTA is negative; repeat DSA at 3–6 months may be reasonable after a negative first study. aSAH: CTA/CTP and TCD for vasospasm (AHA 2023, 2a; ESO 2026 makes no TCD recommendation); after adequately occluded coiling, image again at ≥12 months (ESO 2026 consensus). CVT: MRI/MRV (CT/CTV acceptable); whether recanalization should guide anticoagulation duration is uncertain.","consider":["Any neurological decline: urgent CT first (hemorrhage, swelling, hydrocephalus), then CTA if reocclusion or vasospasm is possible.","Ischemic stroke: noninvasive intracranial and vertebrobasilar imaging (CTA or MRA) identifies atherosclerosis, dissection and moyamoya (AHA 2021, 2a).","Established FMD: at least one brain-to-pelvis CTA or MRA (consensus)."],"caution":"Schedules are examples; image sooner whenever the examination changes.","sources":[{"title":"ESH/SVM 2019 first international consensus on fibromuscular dysplasia","url":"https://journals.sagepub.com/doi/pdf/10.1177/1358863X18821816","year":2019,"type":"Consensus statement","checkedAt":"2026-10-02","access":"Selected primary PDF passages read (brain-to-pelvis imaging)."},{"title":"Diagnosis and Management of Cerebral Venous Thrombosis: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/38284265/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Key-point statements (ungraded) from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards."},{"title":"European Stroke Organisation (ESO), European Association of Neurosurgical Societies (EANS) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on aneurysmal subarachnoid haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/42095754/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendations from the archived full-text transcription (reviewed 2026-09-30); cited in topic summaries."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/37212182/","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 38011240 (Stroke 2023;54:e516) is indexed; its body was not re-read."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/36655570/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Key-point statements (ungraded) from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards."}],"related":[{"label":"ICH first-hour targets","href":"#/evidence/ich-management"},{"label":"aSAH critical care","href":"#/evidence/sah-critical-care"},{"label":"CVT","href":"#/evidence/cvt"}]},{"id":"anticoagulant-labels","title":"Anticoagulants: label and interaction review","category":"Prevention and antithrombotics","settings":["on-call","hospital","clinic"],"keywords":["DOAC","apixaban","Eliquis","rivaroxaban","Xarelto","dabigatran","Pradaxa","edoxaban","Savaysa","warfarin","renal","P-gp","CYP3A4"],"summary":"Before procedures or switching, confirm the exact drug, dose, indication, last intake and current renal function against the U.S. label; in anticoagulant-associated ICH, identify the drug and last dose but do not delay reversal (AHA 2022, COR 1). AF and VTE dosing differ. Apixaban's AF dose adjustment combines age, weight and serum creatinine; edoxaban carries an upper creatinine-clearance restriction for AF; warfarin needs INR monitoring. Check P-gp/CYP3A4 interactions and feeding-tube or swallowing constraints.","consider":["Are the indication, current formulation, last dose, adherence and any planned procedure established?","Are current renal function, weight, age and hepatic status appropriate for the specific label?","Have P-gp/CYP interactions, other antithrombotics and nonprescription products been checked?","Do food, swallowing or feeding-tube requirements affect reliable administration?"],"caution":"Creatinine clearance alone does not select a dose; check the full label with a pharmacist and use the ICH protocol for urgent reversal.","sources":[{"title":"Eliquis (apixaban) U.S. prescribing information","url":"https://packageinserts.bms.com/pi/pi_eliquis.pdf","year":2026,"type":"Drug label","checkedAt":"2026-10-01","access":"Full primary label accessed, revision 08/2026; indications, adult adjustment, renal and interaction sections spot-checked, not a complete label review."},{"title":"Xarelto (rivaroxaban) U.S. prescribing information","url":"https://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/XARELTO-pi.pdf","year":2026,"type":"Drug label","checkedAt":"2026-10-01","access":"Full primary label accessed, revision 03/2026; indications, renal, interaction and administration sections spot-checked, not a complete label review."},{"title":"Pradaxa (dabigatran) capsules — U.S. label on DailyMed","url":"https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=ba74e3cd-b06f-4145-b284-5fd6b84ff3c9","year":2025,"type":"Drug label","checkedAt":"2026-10-01","access":"Full primary label accessed, revision 06/2025; indication-specific renal and interaction sections spot-checked, not a complete label review."},{"title":"Savaysa (edoxaban) — U.S. label on DailyMed","url":"https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e77d3400-56ad-11e3-949a-0800200c9a66","year":2023,"type":"Drug label","checkedAt":"2026-10-01","access":"Full primary label accessed, revision 10/2023 (DailyMed updated 07/2025); boxed warning, indications, renal and interaction sections spot-checked."},{"title":"Warfarin sodium — U.S. label on DailyMed","url":"https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=541c9a70-adaf-4ef3-94ba-ad4e70dfa057","year":2026,"type":"Drug label","checkedAt":"2026-10-01","access":"Full primary label accessed, revision 09/2026; boxed warning, indications, INR monitoring and interaction sections spot-checked, not a complete label review."}],"related":[{"label":"Creatinine clearance","href":"#/encounter/crcl"},{"label":"Reversal","href":"#/evidence/antithrombotic-reversal"},{"label":"ICH protocol","href":"#/protocols/ich"}]},{"id":"af-timing","title":"AF after ischemic stroke: anticoagulation timing","category":"Prevention and antithrombotics","settings":["on-call","hospital","clinic"],"keywords":["atrial fibrillation","DOAC","ELAN","OPTIMAS","CATALYST","restart anticoagulation","apixaban","rivaroxaban","edoxaban","dabigatran","when to start","start timing","TIMING","START"],"summary":"Early oral anticoagulation is reasonable and low risk versus a delayed start in carefully selected (e.g., milder) AF-associated ischemic stroke (AHA 2026, 2a), although its efficacy against early recurrence is not established. CATALYST (5,441 patients from 4 trials; published after the AHA 2026 evidence-review cutoff): starting within 4 days vs day 5 or later reduced 30-day recurrent ischemic stroke, sICH or unclassified stroke (2.1 vs 3.0%; OR 0.70), with identical sICH (0.4%). ELAN schedule: within 48 h for minor or moderate and day 6–7 for major imaging-defined infarcts. OPTIMAS: within 4 days was noninferior to days 7–14 (3.3% each).","recommendations":[{"text":"In carefully selected (e.g., milder severity) AIS patients with atrial fibrillation, a strategy of early oral anticoagulation post-stroke is low risk and is reasonable compared with delayed anticoagulation, although the efficacy of early anticoagulation for preventing early recurrent stroke is not established.","cor":"2a","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-154 · p. 68","id":"ais-2026-154"},{"text":"In stroke or TIA patients with AF who do not have moderate-to-severe mitral stenosis or a mechanical heart valve, a DOAC (apixaban, dabigatran, edoxaban, or rivaroxaban) is recommended over warfarin to reduce recurrent stroke risk.","cor":"1","loe":"B-R","source":"AHA/ASA Secondary Prevention 2021 · secondary-prevention-2021-82 · p. 38","id":"secondary-prevention-2021-82"}],"consider":["Size the infarct on imaging (ELAN categories), not by NIHSS alone; brain imaging before starting may be considered (AHA 2021, 2b). ELAN infarct size: minor ≤1.5 cm; moderate involves a cortical superficial branch of the MCA, ACA or PCA, a deep MCA branch or the internal border zone; major involves an entire MCA, ACA or PCA territory, two or more MCA cortical branches, cortical plus deep MCA branches, or a brainstem or cerebellar lesion >1.5 cm (ELAN, NEJM 2023).","Larger infarcts: in a prespecified OPTIMAS analysis (3,572 participants; segmented infarct volume), the effect of starting a DOAC within 4 days vs days 7–14 did not vary with infarct volume, and sICH with infarcts >25 mL was 3/238 early vs 5/239 delayed; only 187 had infarcts >50 mL. In ELAN, prior IVT or thrombectomy did not modify the early-vs-late effect. Both are secondary analyses within each trial's selected patients.","Hemorrhagic transformation: starting or continuing anticoagulation may be considered case by case (AHA 2026, 2b).","TIA with nonvalvular AF: starting anticoagulation immediately is reasonable (AHA 2021, 2a, expert opinion)."],"caution":"Trial schedules guide but do not set an individual start date for very large infarcts or significant hemorrhagic transformation.","sources":[{"title":"ELAN: imaging-based analysis of the randomized trial","url":"https://pubmed.ncbi.nlm.nih.gov/38805207/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed (post hoc imaging analysis of ELAN)."},{"title":"OPTIMAS randomized trial","url":"https://pubmed.ncbi.nlm.nih.gov/39491870/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"CATALYST individual-participant meta-analysis","url":"https://pubmed.ncbi.nlm.nih.gov/40570866/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"ELAN — Early versus Later Anticoagulation for Stroke with Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/37222476/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ELAN prior reperfusion analysis — Prior Reperfusion Strategy Does Not Modify Outcome in Early Versus Late Start of Anticoagulants in Patients With Ischemic Stroke: Prespecified Subanalysis of the Randomized Controlled ELAN Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40402090/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. 1,973 of 2,013 ELAN patients; the title says prespecified and the abstract post hoc."},{"title":"TIMING — Early Versus Delayed Non-Vitamin K Antagonist Oral Anticoagulant Therapy After Acute Ischemic Stroke in Atrial Fibrillation (TIMING): A Registry-Based Randomized Controlled Noninferiority Study.","url":"https://pubmed.ncbi.nlm.nih.gov/36065821/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"OPTIMAS infarct volume and location analysis — Early versus delayed anticoagulation in acute ischemic stroke with atrial fibrillation according to infarct volume and location: A prespecified subgroup analysis of the OPTIMAS randomized controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41906919/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; PMC full text (PMC13392158) not read. Prespecified analysis of 3,572 participants (98.6% of the trial)."},{"title":"STABLED — Catheter Ablation and Oral Anticoagulation for Secondary Stroke Prevention in Atrial Fibrillation: The STABLED Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41770549/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract and PMC full text (PMC12954600) read 2026-10-31; bibliographic record checked; the major-bleeding and hemorrhagic-stroke figures appear in both the Results text and Table 3. A JAMA Neurol 'Clarification to Table 3' (PMID 41973432, same issue; PMC13077508 has no text) could not be read and is not reconciled."}],"related":[{"label":"Renal function worksheet","href":"#/encounter/crcl"}]},{"id":"stroke-workup","title":"Stroke mechanism, ESUS and rhythm monitoring","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["etiology","TOAST","cryptogenic","ESUS","AF","telemetry","loop recorder","echocardiography"],"summary":"Complete or start the etiologic workup within 48 h of onset to guide prevention: brain CT or MRI, ECG, and CBC, coagulation, glucose, HbA1c, creatinine and lipids (AHA 2021, COR 1), plus carotid imaging for revascularization candidates (COR 1) and intracranial and vertebrobasilar imaging (2a). Cryptogenic stroke: echocardiography and prolonged rhythm monitoring are reasonable (2a) — CRYSTAL AF found AF in 12.4 vs 2.0% at 12 months with an implantable monitor. ESUS: antiplatelet, not empiric anticoagulation — NAVIGATE ESUS (rivaroxaban), RE-SPECT ESUS (dabigatran) and ARCADIA (apixaban for atrial cardiopathy) were neutral.","consider":["Classify the mechanism (TOAST); an incomplete workup leaves it undetermined and does not establish ESUS.","ESUS: TEE, cardiac CT or cardiac MRI might be reasonable to find cardioaortic sources (2b).","Who reviews the monitor and acts on AF?"],"caution":"A brief negative ECG does not exclude paroxysmal AF.","sources":[{"title":"AHA/ASA secondary prevention: diagnostic and mechanism-based approach","url":"https://professional.heart.org/en/science-news/2021-guideline-for-the-prevention-of-stroke-in-patients-with-stroke-and-transient-ischemic-attack/top-things-to-know","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin","url":"https://pubmed.ncbi.nlm.nih.gov/36082257/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 37021192 not reconciled."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"NAVIGATE ESUS — Rivaroxaban for Stroke Prevention after Embolic Stroke of Undetermined Source.","url":"https://pubmed.ncbi.nlm.nih.gov/29766772/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"RE-SPECT ESUS — Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source.","url":"https://pubmed.ncbi.nlm.nih.gov/31091372/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ARCADIA — Apixaban to Prevent Recurrence After Cryptogenic Stroke in Patients With Atrial Cardiopathy: The ARCADIA Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38324415/","year":2024,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ARCADIA hemorrhage analysis — Apixaban Versus Aspirin and Risk of Hemorrhage in the ARCADIA Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41741942/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Secondary analysis; primary safety sample censored at permanent study-drug discontinuation, with an intention-to-treat sensitivity analysis."},{"title":"Jefferson Inherited Thrombophilia Audit — Low value of inherited thrombophilia testing among patients with stroke or transient ischemic attack: A three-year retrospective study.","url":"https://pubmed.ncbi.nlm.nih.gov/37633204/","year":2023,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"sifap — Acute cerebrovascular disease in the young: the Stroke in Young Fabry Patients study.","url":"https://pubmed.ncbi.nlm.nih.gov/23306324/","year":2013,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"UKYSS — Demographics, risk factor profiles and etiologies in young ischemic and hemorrhagic stroke - the United Kingdom Young Stroke Study (UKYSS).","url":"https://pubmed.ncbi.nlm.nih.gov/42640350/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Illicit Drug Use and Stroke (meta-analysis + Mendelian randomization) — Does illicit drug use increase stroke risk? A systematic review, meta-analyses, and Mendelian randomization analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/41566428/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"2024 ACC Expert Consensus Decision Pathway on Practical Approaches for Arrhythmia Monitoring After Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/39692645/","year":2024,"type":"Consensus statement","checkedAt":"2026-10-03","access":"PubMed bibliographic record checked (no abstract); pathway details not reproduced."}],"related":[{"label":"TOAST classification","href":"#/evidence/stroke-classification"},{"label":"PFO","href":"#/evidence/pfo"},{"label":"Encounter","href":"#/encounter"}]},{"id":"stroke-classification","title":"TOAST classification and stroke mechanism","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["TOAST","stroke subtype","etiology","large artery atherosclerosis","cardioembolism","small vessel occlusion","lacunar","undetermined","lateral medullary","Wallenberg"],"summary":"TOAST sorts ischemic stroke into five subtypes (large-artery atherosclerosis, cardioembolism, small-vessel occlusion, other determined etiology and undetermined etiology), with possible or probable diagnoses by the clinician's certainty; in its original test two neurologists agreed in 19 of 20 patients. Assign the subtype after brain imaging, vessel imaging and cardiac evaluation, because the mechanism decides prevention (antiplatelet or anticoagulant, revascularization, PFO closure).","consider":["An incomplete workup leaves the mechanism undetermined; it does not establish ESUS.","DWI pattern helps: a single deep lacune suggests small-vessel disease, scattered emboli in several territories a cardiac source, and a watershed pattern large-artery disease (AHA TIA statement).","Pure lateral medullary infarction (n=130; angiography in 123): vertebral artery disease in 67% and PICA disease in 10%; presumed mechanisms included large-vessel 50%, dissection 15%, small-vessel 13% and cardioembolic 5%."],"caution":"TOAST was built to classify trial participants; it does not replace an individual mechanism review.","sources":[{"title":"TOAST: classification of subtype of acute ischemic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/7678184/","year":1993,"type":"Report","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"Pure lateral medullary infarction: clinical-radiological correlation of 130 patients","url":"https://pubmed.ncbi.nlm.nih.gov/12805095/","year":2003,"type":"Observational study","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/36655570/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Key-point statements (ungraded) from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards."}],"related":[{"label":"Stroke mechanism workup","href":"#/evidence/stroke-workup"},{"label":"Lacunar stroke","href":"#/evidence/lacunar-small-vessel"}]},{"id":"pfo","title":"PFO: attribution and closure discussion","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["patent foramen ovale","RoPE","PASCAL","atrial septal aneurysm","shunt","cryptogenic stroke"],"summary":"PFO closure with long-term antiplatelet therapy is reasonable for ages 18–60 with nonlacunar stroke of undetermined cause after a full evaluation and a PFO with high-risk anatomic features (AHA 2021, 2a); without them AHA rates the benefit uncertain (2b), but ESO 2024 recommends closure when PASCAL rates the PFO possibly or probably causal. RESPECT: recurrent ischemic stroke 0.58 vs 1.07 per 100 patient-years (HR 0.55) over a median 5.9 years; CLOSE: 0/238 vs 14/235 strokes over a mean 5.3 years. Closure adds AF (CLOSE 4.6 vs 0.9%) and venous thromboembolism (RESPECT).","consider":["Exclude competing causes first: vessel imaging, prolonged rhythm monitoring and echocardiography with a bubble study.","Use RoPE and PASCAL to judge causality: in pooled trial data (SCOPE), closure reduced stroke when PASCAL rated the PFO possible or probable (HR 0.38 and 0.10) but not unlikely (HR 1.14); AF beyond day 45 rose with closure in unlikely (+4.4%) and possible (+1.5%) categories.","Discuss procedural risk, AF and the long-term antiplatelet plan with the closure team. ESO 2024 suggests closure plus antiplatelet therapy over long-term anticoagulation alone (possible or probable PASCAL; low certainty); if closure is declined, individualize antiplatelet versus anticoagulant therapy (expert consensus)."],"caution":"Evidence over age 60 and for an incidental PFO is limited.","sources":[{"title":"AAN PFO advisory: patient and family summary","url":"https://www.aan.com/Guidelines/home/GetGuidelineContent/1008","year":2020,"type":"Guideline","checkedAt":"2026-10-01","access":"AAN patient and family summary."},{"title":"SCOPE pooled trial data: PASCAL categories and closure benefit","url":"https://pubmed.ncbi.nlm.nih.gov/34905030/","year":2021,"type":"Meta-analysis","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (individual-participant data, 6 RCTs; stroke HR and AF beyond day 45 by PASCAL category)."},{"title":"European Stroke Organisation (ESO) Guidelines on the diagnosis and management of patent foramen ovale (PFO) after stroke","url":"https://pubmed.ncbi.nlm.nih.gov/38752755/","year":2024,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22; PMC copy has no body text. The anticoagulation statements (PICO 3 conditional, low certainty; PICO 4 expert consensus if closure is refused) are from the archived full-text transcription (Table 12); other recommendations not reviewed."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"RESPECT — Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/28902590/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"CLOSE — Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/28902593/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"REDUCE — Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/28902580/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."}],"related":[{"label":"RoPE worksheet","href":"#/tools/rope"},{"label":"PASCAL worksheet","href":"#/tools/pascal"}]},{"id":"carotid","title":"Carotid stenosis: symptoms, severity and referral","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["CEA","CAS","endarterectomy","carotid stenting","NASCET","CREST-2","revascularization","timing","within 2 weeks","symptomatic stenosis","CREST-H"],"summary":"TIA or nondisabling stroke within 6 months with ipsilateral 70–99% stenosis: endarterectomy if perioperative stroke or death risk is <6% (AHA 2021, COR 1), ideally within 2 weeks (2a); 50–69%: endarterectomy depending on patient factors (COR 1); <50%: no revascularization (COR 3: No Benefit). At age ≥70 or within the first week, endarterectomy is preferred over stenting (2a). Asymptomatic: for >70% stenosis, AHA 2024 recommends shared decision-making on revascularization versus medical management (COR 1); at low perioperative risk, adding revascularization to intensive medical therapy may be reasonable (2b). ESO 2021 recommends endarterectomy for 60–99% stenosis at increased stroke risk on best medical therapy (moderate-quality evidence). Postdating both, CREST-2 (≥70%) found fewer 4-year events with stenting plus intensive medical management (2.8 vs 6.0%) but no significant benefit from endarterectomy (3.7 vs 5.3%); ACST-2 (2021) found stenting and endarterectomy similar (5-year non-procedural stroke 5.3 vs 4.5%).","recommendations":[{"text":"CEA is recommended for patients with TIA or nondisabling ischemic stroke within the past 6 months and ipsilateral severe (70-99%) carotid stenosis to reduce future stroke risk, provided the estimated perioperative morbidity and mortality is below 6%.","cor":"1","loe":"A","source":"AHA/ASA Secondary Prevention 2021 · secondary-prevention-2021-60 · p. 32","id":"secondary-prevention-2021-60"},{"text":"When carotid revascularization is indicated for TIA or nondisabling stroke, it is reasonable to perform the procedure within 2 weeks of the index event rather than delaying surgery, to increase the likelihood of a stroke-free outcome.","cor":"2a","loe":"C-LD","source":"AHA/ASA Secondary Prevention 2021 · secondary-prevention-2021-66 · p. 32","id":"secondary-prevention-2021-66"}],"consider":["How was the stenosis measured (NASCET), and does the lesion explain the event?","Large or disabling infarct, hemorrhage or near-occlusion: individualize timing with vascular surgery.","Everyone gets intensive medical therapy: antiplatelet, statin and BP control (COR 1).","Revascularizing to improve cognition: in CREST-2 (≥70% asymptomatic stenosis), neither stenting nor endarterectomy added to intensive medical management improved cognition over up to 4 years (prespecified secondary outcome; 2,165 US patients). In the CREST-H substudy (51 patients with reduced baseline cognition), revascularization did not improve 1-year cognition, and the effect did not differ by baseline hemodynamic impairment (JAMA 2026)."],"caution":"CREST-2 ran two separate trials, so it does not compare stenting directly with endarterectomy.","sources":[{"title":"ESO carotid endarterectomy and stenting guideline","url":"https://pubmed.ncbi.nlm.nih.gov/34414302/","year":2021,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (asymptomatic and symptomatic recommendations); full text not reviewed."},{"title":"2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/39429201/","year":2024,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (literature searched May–November 2023); no PMC copy. The asymptomatic carotid grades (shared decision-making >70%, COR 1; revascularization at low perioperative risk, 2b) are from the archived full-text transcription. Interpret with newer evidence (CREST-2). Indexed correction(s) 39585937, 39869715 not reconciled."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"CREST — Stenting versus endarterectomy for treatment of carotid-artery stenosis.","url":"https://pubmed.ncbi.nlm.nih.gov/20505173/","year":2010,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 2 corrections or notices; check them before applying results."},{"title":"CREST-2 — Medical Management and Revascularization for Asymptomatic Carotid Stenosis.","url":"https://pubmed.ncbi.nlm.nih.gov/41269206/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"PubMed bibliographic record checked; PMC full text (PMC13148431) read 2026-10-21."},{"title":"CREST-2 cognitive outcomes — Revascularization of Asymptomatic Carotid Artery Stenosis: Cognitive Results of the CREST-2 Randomized Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42747844/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked; prespecified secondary outcomes of both randomized trials."},{"title":"CREST-H — Revascularization in Asymptomatic Carotid Artery Stenosis With Hemodynamic Impairment and Cognitive Outcomes: The CREST-H Substudy of the CREST-2 Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42747834/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked; randomized substudy of CREST-2."},{"title":"ECST-2 — Optimised medical therapy alone versus optimised medical therapy plus revascularisation for asymptomatic or low-to-intermediate risk symptomatic carotid stenosis (ECST-2): 2-year interim results of a multicentre randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40252662/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ACST-2 — Second asymptomatic carotid surgery trial: a randomised comparison of carotid artery stenting versus carotid endarterectomy.","url":"https://pubmed.ncbi.nlm.nih.gov/34469763/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed; bibliographic record checked."}],"related":[{"label":"NASCET","href":"#/tools/nascet"},{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"}]},{"id":"sicas","title":"Symptomatic intracranial atherosclerosis","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["sICAS","intracranial stenosis","SAMMPRIS","BASIS","angioplasty","DAPT"],"summary":"Severe (70–99%) intracranial stenosis with stroke or TIA within 30 days: aspirin plus clopidogrel for up to 90 days (AHA 2021, 2a; AAN 2022, when hemorrhagic-transformation risk is low), plus high-intensity statin with LDL <70 mg/dL, long-term SBP <140 and exercise (COR 1). No angioplasty or stenting as first treatment (COR 3: Harm) — SAMMPRIS: 30-day stroke or death 14.7 vs 5.8% with stenting. BASIS (China, 2024; after AHA 2021 and AAN 2022): at ages 35–80 with TIA within 90 days or stroke 14–90 days earlier, submaximal balloon angioplasty plus medical therapy lowered a 1-year composite that included later revascularization of the qualifying artery (4.4 vs 13.5%), but 30-day stroke or death was 3.2 vs 1.6% and dissection occurred in 14.5%. AAN 2022 advises against routine angioplasty alone outside trials, and ESO 2022 against first-line angioplasty or stenting.","consider":["Confirm the stenosis is symptomatic and in the right territory; 50–69% stenosis gets medical therapy (stenting is harmful).","Write the DAPT stop date and the single agent to continue.","Recurrent events despite therapy: recheck adherence and mechanism; the usefulness of angioplasty or stenting is unknown (2b)."],"caution":"Long-term BP targets do not apply in the acute, perfusion-dependent phase.","sources":[{"title":"AAN symptomatic intracranial atherosclerosis advisory","url":"https://www.aan.com/Guidelines/home/GetGuidelineContent/1069","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"AAN practice advisory."},{"title":"BASIS randomized trial","url":"https://pubmed.ncbi.nlm.nih.gov/39235816/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract re-read 2026-10-21: population, primary result, 30-day risk and dissection rate; protocol not reviewed."},{"title":"Stroke Prevention in Symptomatic Large Artery Intracranial Atherosclerosis Practice Advisory: Report of the AAN Guideline Subcommittee","url":"https://pubmed.ncbi.nlm.nih.gov/35314513/","year":2022,"type":"Practice advisory","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (systematic review through November 2020); full advisory not reviewed. Interpret with newer evidence (BASIS 2024)."},{"title":"European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease","url":"https://pubmed.ncbi.nlm.nih.gov/36082254/","year":2022,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (endovascular therapy not recommended as first choice in high-grade symptomatic ICAD, moderate-level evidence); full recommendations not reviewed. Interpret with newer evidence (BASIS 2024)."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"CASSISS — Effect of Stenting Plus Medical Therapy vs Medical Therapy Alone on Risk of Stroke and Death in Patients With Symptomatic Intracranial Stenosis: The CASSISS Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35943472/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SAMMPRIS — Stenting versus aggressive medical therapy for intracranial arterial stenosis.","url":"https://pubmed.ncbi.nlm.nih.gov/21899409/","year":2011,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."}],"related":[{"label":"DAPT source screen","href":"#/encounter/dapt"}]},{"id":"dissection","title":"Cervical artery dissection","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["carotid dissection","vertebral dissection","neck pain","arteriopathy","antithrombotic"],"summary":"Extracranial carotid or vertebral dissection with stroke or TIA: give antithrombotic therapy for at least 3 months (AHA 2021, COR 1) — antiplatelet or anticoagulant are both reasonable (AHA 2026, 2a), but a large infarct, hemorrhagic transformation or intradural extension may favor antiplatelet therapy (AHA 2024). CADISS found no difference (stroke or death 3/126 vs 1/124); TREAT-CAD did not show aspirin noninferior to a vitamin K antagonist (composite 23 vs 15%; 7 ischemic strokes vs none). Pooled CADISS/TREAT-CAD participant data (444 patients): 90-day ischemic stroke, death or major bleeding 1.4% with anticoagulation vs 4.4% with antiplatelets (P=0.06, not significant), with fewer strokes (OR 0.14) but 2 vs 0 bleeding events. AHA 2024 suggests individualizing the choice for at least 3–6 months.","recommendations":[{"text":"In AIS patients with extracranial carotid or vertebral arterial dissection, treatment with either antiplatelet or anticoagulant therapy for at least 3 months is reasonable to prevent recurrent stroke.","cor":"2a","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-142 · p. 62","id":"ais-2026-142"}],"consider":["Confirm on CTA or MRI/MRA and separate cervical from intracranial or aortic dissection.","Recurrent events despite antithrombotics: endovascular therapy may be considered (AHA 2021, 2b).","Look for an underlying arteriopathy such as FMD when the history suggests it."],"caution":"Neither trial was powered to prove equivalence, and DOACs were not tested.","sources":[{"title":"AHA cervical artery dissection statement: overview","url":"https://professional.heart.org/en/science-news/treatment-and-outcomes-of-cervical-artery-dissection-in-adults/top-things-to-know","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/38299330/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (literature 1990–2022); full statement not reviewed. Interpret with newer evidence (2024 CADISS/TREAT-CAD participant-data meta-analysis; AHA 2026 AIS guideline)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"ESO guideline for the management of extracranial and intracranial artery dissection","url":"https://pubmed.ncbi.nlm.nih.gov/34746432/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 37021160 not reconciled."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"CADISS — Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/25684164/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"TREAT-CAD — Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/33765420/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CAD antithrombotic IPD meta-analysis — Antithrombotic Treatment for Cervical Artery Dissection: A Systematic Review and Individual Patient Data Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/38739383/","year":2024,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"PubMed bibliographic record and abstract checked 2026-10-21."},{"title":"STOP-CAD — Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection: The STOP-CAD Study.","url":"https://pubmed.ncbi.nlm.nih.gov/38335240/","year":2024,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"Ischemic protocol","href":"#/protocols/ischemic"}]},{"id":"secondary-prevention","title":"Secondary prevention and medication review","category":"Prevention and antithrombotics","settings":["hospital","clinic"],"keywords":["blood pressure","LDL","lipids","statin","diabetes","adherence","smoking","DAPT transition"],"summary":"Noncardioembolic stroke or TIA: antiplatelet rather than anticoagulant (COR 1); DAPT only short term (minor stroke [NIHSS ≤3] or high-risk TIA [ABCD2 ≥4] without IVT, started within 24 h: 21 days, AHA 2026 COR 1; severe intracranial stenosis: up to 90 days). BP <130/80 for most (AHA 2021, COR 1). Atherosclerotic stroke: statin ± ezetimibe to LDL <70 mg/dL (COR 1); no known coronary disease or major cardiac source and LDL >100: atorvastatin 80 mg (SPARCL). Diabetes: glucose-lowering drugs with proven cardiovascular benefit (AHA 2021, COR 1). Recheck lipids 4–12 weeks after a change, then every 3–12 months.","recommendations":[{"text":"Antiplatelet therapy is recommended over oral anticoagulation for patients with noncardioembolic ischemic stroke or TIA to reduce recurrent ischemic stroke and other cardiovascular events while minimizing bleeding risk.","cor":"1","loe":"A","source":"AHA/ASA Secondary Prevention 2021 · secondary-prevention-2021-144 · p. 64","id":"secondary-prevention-2021-144"},{"text":"An office BP goal of less than 130/80 mmHg is recommended for most hypertensive stroke or TIA patients to reduce recurrent stroke and vascular events.","cor":"1","loe":"B-R","source":"AHA/ASA Secondary Prevention 2021 · secondary-prevention-2021-28 · p. 20","id":"secondary-prevention-2021-28"},{"text":"For ischemic stroke or TIA patients with atherosclerotic disease (intracranial, carotid, aortic, or coronary), lipid-lowering therapy with a statin (plus ezetimibe if needed) to achieve an LDL-C goal below 70 mg/dL is recommended to reduce major cardiovascular events.","cor":"1","loe":"A","source":"AHA/ASA Secondary Prevention 2021 · secondary-prevention-2021-32 · p. 21","id":"secondary-prevention-2021-32"}],"consider":["Is the mechanism settled, and does it change the drug (AF, PFO, dissection, intracranial stenosis)? Check adherence, cost, smoking, diet and activity at every visit.","Very high risk (stroke plus another major ASCVD event, or ≥2 high-risk conditions): ACC/AHA 2026 goal LDL-C <55 mg/dL; add ezetimibe and/or a PCSK9 antibody as needed (COR 1).","Noncardioembolic stroke while taking aspirin: over a median of about 19 months, switching to another antithrombotic was not clearly better than continuing aspirin (network meta-analysis of 9 RCTs, 5,459 patients; recurrent ischemic stroke RR 0.88, 95% CI 0.76–1.03). Trials with only ≤90-day outcomes were excluded, so this does not address short-term DAPT after minor stroke or high-risk TIA.","Type 2 diabetes with minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4): in LAMP (China, open-label with blinded end points; 636 patients randomized within 24 h), 90 days of liraglutide reduced 90-day stroke recurrence (7.9 vs 13.8%; HR 0.56); its authors call the trial underpowered. It postdates AHA 2021 and does not establish an acute indication. A 2026 meta-analysis of four randomized trials of early GLP-1 receptor agonists after ischemic stroke or high-risk TIA (LAMP, GALLOP-1, GALLOP-2, TEXAIS; 1,514 patients) found only a fragile gain in 90-day mRS 0–2 (RR 1.06, 1.01–1.11) that was not significant without LAMP (RR 1.07, 0.92–1.24)."],"caution":"Avoid indefinite DAPT or antiplatelet-plus-anticoagulant combinations without a separate indication.","sources":[{"title":"AHA/ASA secondary stroke prevention guideline: overview","url":"https://professional.heart.org/en/science-news/2021-guideline-for-the-prevention-of-stroke-in-patients-with-stroke-and-transient-ischemic-attack/top-things-to-know","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"2026 multisociety dyslipidemia guideline: overview","url":"https://professional.heart.org/en/science-news/2026-guideline-on-the-management-of-dyslipidemia/top-things-to-know","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack","url":"https://pubmed.ncbi.nlm.nih.gov/36082250/","year":2022,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract read 2026-10-21; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"ATIS-NVAF — Optimal Antithrombotics for Ischemic Stroke and Concurrent Atrial Fibrillation and Atherosclerosis: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41051787/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CHANCE — Clopidogrel with aspirin in acute minor stroke or transient ischemic attack.","url":"https://pubmed.ncbi.nlm.nih.gov/23803136/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"POINT — Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA.","url":"https://pubmed.ncbi.nlm.nih.gov/29766750/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"THALES — Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA.","url":"https://pubmed.ncbi.nlm.nih.gov/32668111/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"INSPIRES — Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/38157499/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CHANCE-2 — Ticagrelor versus Clopidogrel in CYP2C19 Loss-of-Function Carriers with Stroke or TIA.","url":"https://pubmed.ncbi.nlm.nih.gov/34708996/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"TAPIS — Ticagrelor with aspirin dual antiplatelet therapy combined with intravenous thrombolysis in patients with ischaemic stroke in China (TAPIS): a multicentre, double-blind, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42114550/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"MATCH — Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/15276392/","year":2004,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"RESTART — Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial.","url":"https://pubmed.ncbi.nlm.nih.gov/31128924/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CMOSS — Extracranial-Intracranial Bypass and Risk of Stroke and Death in Patients With Symptomatic Artery Occlusion: The CMOSS Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37606672/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. This report concerns bypass for symptomatic artery occlusion, not intracranial stenting."},{"title":"Switching from aspirin network meta-analysis — Switching From Aspirin Monotherapy After Noncardioembolic Stroke: A Systematic Review and Network Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/41347302/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked."},{"title":"LAMP — Liraglutide in Acute Minor Ischemic Stroke or High-Risk Transient Ischemic Attack With Type 2 Diabetes: The LAMP Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41182740/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked."},{"title":"Early GLP-1RA meta-analysis — Early GLP-1 Receptor Agonist Therapy in Acute Ischemic Stroke and High-Risk Transient Ischemic Attack: A Systematic Review and Meta-analysis of Randomized Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42878597/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31 (Ann Indian Acad Neurol 2026;29(5):685-696); bibliographic record checked; full text not reviewed."},{"title":"RESTART extended follow-up — Effects of Antiplatelet Therapy After Stroke Caused by Intracerebral Hemorrhage: Extended Follow-up of the RESTART Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/34477823/","year":2021,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record and notices checked; outcomes not reviewed here. Extended follow-up of the original randomized population."}],"related":[{"label":"DAPT source screen","href":"#/encounter/dapt"},{"label":"Encounter","href":"#/encounter"}]},{"id":"recovery","title":"Recovery, rehabilitation and follow-up","category":"Recovery and rehabilitation","settings":["hospital","clinic"],"keywords":["rehabilitation","function","mood","depression","anxiety","caregiver","participation","telehealth"],"summary":"AHA/ASA AIS 2026: formal inpatient interdisciplinary assessment and rehabilitation matched to the patient (COR 1); no high-dose, very early mobilization within 24 h of stroke onset (COR 3: Harm); screen for depression with a structured inventory and treat diagnosed depression (COR 1). CSBPR 2025 (Canada) adds: begin mobilization once medically stable, ideally 24–48 h after stroke, with caution and clinical judgment (strong recommendation; moderate-quality evidence). SSRIs are not recommended for motor or functional recovery (COR 3: No Benefit): fluoxetine 20 mg daily for 6 months did not improve mRS and increased fractures (FOCUS, AFFINITY, EFFECTS), when started 2–15 days after stroke; this does not apply to treating diagnosed depression. Levodopa/carbidopa 100/25 mg three times daily for 39 days, added to task-oriented inpatient rehabilitation after acute ischemic or hemorrhagic stroke with hemiparesis, did not improve 3-month Fugl-Meyer scores, with similar serious adverse events (ESTREL RCT, Switzerland, 610 patients: −0.9 points, 95% CI −3.8 to 2.0; postdates the AIS 2026 evidence review, not graded). Reassess function, mood and goals at follow-up.","consider":["Which impairments, daily activities and participation goals need assessment or renewed therapy?","Have the patient and care partner received education, training and support?","Is follow-up feasible (transport, access, telehealth), and who reassesses progress?"],"caution":"A screening score is not a diagnosis, and this card gives no driving, work or travel clearance. Grades are from AHA/ASA AIS 2026 (acute ischemic stroke) unless labelled CSBPR 2025; the August 2026 AHA/ASA rehabilitation guideline was not reviewed.","sources":[{"title":"2026 AHA/ASA adult stroke rehabilitation and recovery guideline: overview","url":"https://professional.heart.org/en/science-news/2026-guideline-for-adult-stroke-rehabilitation-and-recovery/top-things-to-know","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page; not used for this card's grades."},{"title":"FOCUS trial of fluoxetine after stroke","url":"https://pubmed.ncbi.nlm.nih.gov/30528472/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract read."},{"title":"AFFINITY trial of fluoxetine after stroke","url":"https://pubmed.ncbi.nlm.nih.gov/32702334/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract read."},{"title":"EFFECTS trial of fluoxetine after stroke","url":"https://pubmed.ncbi.nlm.nih.gov/32702335/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract read."},{"title":"2026 Guideline for Adult Stroke Rehabilitation and Recovery: A Guideline From the American Heart Association and American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/42657476/","year":2026,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed record and abstract read: published online 2026-08-27 (Stroke 2026;57(10):e514–e658); replaces the 2016 guideline; literature since 2016 searched June–October 2025, so later evidence is not reflected. No PMC copy; recommendations not reviewed or quoted. A correction was published 2026-10-26 (PMID 42932410; Stroke 2026;57(11):e700–e701); its content was not reviewed. Archive held only an access placeholder."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery and Community Participation Following Stroke. Part One: Stroke Rehabilitation Planning for Optimal Care Delivery, 7th Edition Update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41257448/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PMC full text (PMC12871428) read 2026-10-31; only the mobilization-timing recommendations (section 3) are used, with strength and evidence quality as published."},{"title":"ESTREL — Levodopa Added to Stroke Rehabilitation: The ESTREL Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40982270/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; PMC full text (PMC12455486) not read."}],"related":[{"label":"PHQ-2 worksheet","href":"#/tools/phq2"},{"label":"mRS descriptors","href":"#/tools/mrs-descriptors"},{"label":"Encounter","href":"#/encounter"}]},{"id":"maternal-stroke","title":"Pregnancy and postpartum stroke","category":"Stroke in specific populations","settings":["on-call","hospital","clinic"],"keywords":["maternal","pregnancy","postpartum","preeclampsia","eclampsia","breastfeeding"],"summary":"Pregnancy should not delay evidence-based treatment of acute stroke, and CT, CTA and noncontrast MRI are safe (AHA 2026 maternal statement), but IVT needs an individual risk–benefit review (ESO 2022 consensus). No reperfusion RCT included pregnant or postpartum patients; ESO 2022 expert consensus supports thrombectomy for LVO (preferred over IVT whenever possible) and IVT (in pregnancy by majority), not withheld if thrombectomy is unavailable; ESO found no IVT data within 10 days of delivery. Severe hypertension (systolic ≥160 or diastolic ≥110 mm Hg, confirmed within 15 minutes) is an emergency; magnesium and antihypertensives are the cornerstones for preeclampsia and eclampsia. Consider ICH, SAH, CVT, RCVS and PRES as well as ischemic stroke, especially postpartum.","consider":["Establish the pregnancy or postpartum stage, blood pressure and likely mechanism.","Involve vascular neurology and maternal-fetal medicine early; a transradial approach is preferred for endovascular procedures when possible.","Plan for infant care, breastfeeding and rehabilitation support."],"caution":"Acute stroke alone is not an indication for immediate delivery; stabilize the mother first, and the statement supplies no universal antithrombotic choice.","sources":[{"title":"Prevention and Treatment of Maternal Stroke in Pregnancy and Postpartum: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/41603019/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-22","access":"Primary abstract read; full statement not accessible. The severe-hypertension threshold, magnesium and transradial details come from the archived transcription (incomplete fragments) and were not verified against the full statement."},{"title":"European Stroke Organisation guidelines on stroke in women: Management of menopause, pregnancy and postpartum","url":"https://pubmed.ncbi.nlm.nih.gov/35647308/","year":2022,"type":"Guideline","checkedAt":"2026-10-22","access":"PMC body text read (PMC9134774; recommendation and vote tables not in the retrieved text): no RCTs of IVT or MT in pregnancy or postpartum; expert consensus, not evidence-based recommendations; no IVT data <10 days after delivery. Search to 2020; interpret with newer evidence (AHA 2026 maternal statement). Erratum 37021188 not reconciled (PMC copy has no body)."},{"title":"Finnish Subsequent-Pregnancy Cohort — Stroke Recurrence and Pregnancy Outcomes in the Subsequent Pregnancies After Maternal Ischemic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/40970275/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"},{"label":"RCVS and PRES","href":"#/evidence/rcvs-pres"},{"label":"CVT","href":"#/evidence/cvt"}]},{"id":"cancer-stroke","title":"Stroke with active cancer","category":"Stroke in specific populations","settings":["on-call","hospital","clinic"],"keywords":["malignancy","hypercoagulability","NBTE","cancer-related stroke","oncology","cancer evaluation"],"summary":"Complete the usual arterial and cardiac workup before blaming active cancer: it can coexist with conventional mechanisms or cause thrombosis directly. The 2026 AHA statement grades the certainty of cancer-related causation and highlights how uncertain treatment remains.","consider":["What clinical evidence supports cancer-related thrombosis or another cancer-associated mechanism?","Have recurrent thrombosis, bleeding, cancer treatment and patient goals been reviewed together?"],"caution":"A cancer diagnosis does not establish the mechanism or an automatic anticoagulant indication.","sources":[{"title":"AHA Scientific Statement 2026: Classification and Management of Ischemic Stroke in Patients With Active Cancer","url":"https://pubmed.ncbi.nlm.nih.gov/41623113/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."}],"related":[]},{"id":"preexisting-disability","title":"Stroke with prior disability or dementia","category":"Stroke in specific populations","settings":["on-call","hospital","clinic"],"keywords":["premorbid","prestroke mRS","dementia","disability","reperfusion","baseline function"],"summary":"Prior disability or dementia was usually excluded from reperfusion trials, and observational data suggest many treated patients can return to their own baseline despite a worse overall prognosis; AHA/ASA AIS 2026, ICA or M1 occlusion within 6 h with NIHSS ≥6 and ASPECTS ≥6: EVT is reasonable at prestroke mRS 2 (2a) and might be reasonable at mRS 3–4 (2b). Decide with the actual baseline, supports and the outcomes the patient values.","consider":["What were the patient’s actual baseline function, supports and valued activities?","What additional disability might this stroke cause, and what outcome would the patient consider worthwhile?","Are treatment risks and the limits of the evidence being discussed without relying on a baseline score alone?"],"caution":"Prior disability alone does not decide treatment, and observational benefit does not apply to every patient.","sources":[{"title":"Endovascular Treatment and Thrombolysis for Acute Ischemic Stroke in Patients With Premorbid Disability or Dementia: A Scientific Statement From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35343235/","year":2022,"type":"Scientific statement","checkedAt":"2026-10-22","access":"Primary abstract checked: proposes principles rather than COR/LOE-graded recommendations; the 2a/2b grades on this card are from AHA/ASA AIS 2026 (ais-2026-118/119)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."}],"related":[{"label":"mRS descriptors","href":"#/tools/mrs-descriptors"},{"label":"EVT selection","href":"#/evidence/evt-selection"}]},{"id":"perioperative-stroke","title":"Perioperative stroke","category":"Stroke in specific populations","settings":["on-call","hospital","clinic"],"keywords":["surgery","anesthesia","postoperative","noncardiac surgery","perioperative antithrombotics"],"summary":"After noncardiac, nonneurological surgery, any new deficit should trigger the stroke pathway with prompt imaging, preferring thrombectomy for LVO and weighing surgical-site bleeding before IVT (AHA 2021 statement). Before such surgery, include recent stroke, vascular disease and the procedure in the risk discussion and plan antithrombotic changes as a team.","consider":["Are recent stroke history, vascular disease and the proposed procedure included in the risk discussion?","Are perioperative medication changes and the responsible teams clearly documented?"],"caution":"Surgery timing after a recent stroke and perioperative medication changes need procedure-specific multidisciplinary review.","sources":[{"title":"Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/33827230/","year":2021,"type":"Scientific statement","checkedAt":"2026-10-22","access":"Primary abstract read; the thrombectomy-preference and surgical-site-bleeding points come from the archived transcription (incomplete fragments); full statement not reviewed."},{"title":"2024 AHA/ACC perioperative cardiovascular management for noncardiac surgery: official overview","url":"https://professional.heart.org/en/science-news/2024-guideline-for-perioperative-cardiovascular-management-for-noncardiac-surgery/top-things-to-know","year":2024,"type":"Guideline","checkedAt":"2026-10-01","access":"Official summary read for team-based assessment and individualized perioperative antithrombotic management; full surgery-timing and medication tables not reviewed here."}],"related":[{"label":"Ischemic protocol","href":"#/protocols/ischemic"}]},{"id":"sex-gender-stroke","title":"Sex, gender and equitable stroke care","category":"Stroke in specific populations","settings":["hospital","clinic"],"keywords":["women","menopause","sex differences","gender","equity","thrombectomy"],"summary":"Base reperfusion decisions on the individual's findings and priorities; population-level sex and gender differences in recognition, access and endovascular outcomes do not create separate eligibility rules. Much of the evidence records sex rather than gender, leaving gaps (AHA statement). Acute and secondary-prevention therapies have comparable efficacy in women and men, yet women are less likely to receive timely acute treatment; include hypertensive disorders of pregnancy, menopause and hormone therapy in risk assessment (WSO 2025 statement).","consider":["Could differences in recognition, access, baseline circumstances or support be influencing care?","Does the cited evidence actually address this patient population?"],"caution":"Population-level differences do not establish an individual treatment effect or a separate eligibility rule.","sources":[{"title":"Toward a Better Understanding of Sex- and Gender-Related Differences in Endovascular Stroke Treatment: A Scientific Statement From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35695016/","year":2022,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Addressing sex and gender differences in stroke risk and management: A scientific statement from the World Stroke Organization","url":"https://pubmed.ncbi.nlm.nih.gov/41131690/","year":2025,"type":"Scientific statement","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31 (Int J Stroke, online 2025-10-23); full text not read."},{"title":"Danish Hormonal Contraception Cohort — Stroke and myocardial infarction with contemporary hormonal contraception: real-world, nationwide, prospective cohort study.","url":"https://pubmed.ncbi.nlm.nih.gov/39938934/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Danish Progestogen-Only Contraceptive Cohort — Risk of ischemic and hemorrhagic stroke in users of progestogen-only contraceptives: A Danish registry study.","url":"https://pubmed.ncbi.nlm.nih.gov/42624314/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[]},{"id":"pediatric-stroke","title":"Stroke in neonates and children","category":"Stroke in specific populations","settings":["on-call","hospital","clinic"],"keywords":["pediatric","childhood","neonatal","perinatal","arteriopathy","child stroke"],"summary":"Suspect stroke in any child with a sudden focal deficit, including a first seizure (AHA 2026, COR 1). Image with MRI/MRA, or CT/CTA if MRI is not available within 25 minutes (2a). Alteplase may be considered from 28 days to 18 years within 4.5 h for a disabling deficit (2b). EVT by experienced neurointerventionalists can be effective for LVO at age 6 or older within 6 h, or 6–24 h with salvageable tissue (2a). EVT by neurointerventionalists with pediatric experience may be reasonable from 28 days to 6 years within 24 h with salvageable tissue (2b).","recommendations":[{"text":"In pediatric patients with sudden-onset focal neurological deficits, including first-time seizure, acute stroke is recommended to be suspected to enable timely diagnosis.","cor":"1","loe":"C-EO","source":"AHA/ASA AIS 2026 · ais-2026-25 · p. 18","id":"ais-2026-25"},{"text":"In pediatric patients aged 28 days to 18 years with confirmed AIS presenting within 4.5 hours of symptom onset with disabling deficits, IVT with alteplase may be considered as it appears safe, though efficacy is uncertain.","cor":"2b","loe":"C-LD","source":"AHA/ASA AIS 2026 · ais-2026-97 · p. 38","id":"ais-2026-97"},{"text":"In pediatric patients 6 years or older with acute neurological symptoms from ischemic stroke due to LVO within 6 hours of symptom onset, EVT performed by experienced neurointerventionalists can be effective to improve functional outcomes.","cor":"2a","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-133 · p. 60","id":"ais-2026-133"},{"text":"In pediatric patients 6 years or older with ischemic stroke due to LVO, presenting 6-24 hours from symptom onset with potentially salvageable brain tissue, EVT can be effective to improve functional outcomes.","cor":"2a","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-134 · p. 60","id":"ais-2026-134"},{"text":"In pediatric patients aged 28 days to 6 years with acute neurological symptoms (including first-time seizure) and AIS due to LVO within 24 hours of symptom onset with potentially salvageable brain tissue, EVT by neurointerventionalists with pediatric experience may be reasonable to improve functional outcomes.","cor":"2b","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-135 · p. 60","id":"ais-2026-135"}],"consider":["Call pediatric stroke expertise early and use age-appropriate imaging.","Consider age-specific mechanisms and mimics.","Follow-up should cover development, learning, family support and recurrence prevention."],"caution":"Adult pathways cannot simply be transferred to neonates or children. For intracerebral hemorrhage in children (28 days to 18 years), see the 2025 International Pediatric Stroke Organization consensus (21 acute-phase statements agreed by modified Delphi, not graded; literature to March 2022).","sources":[{"title":"AHA/ASA management of stroke in neonates and children: official overview","url":"https://professional.heart.org/en/science-news/management-of-stroke-in-neonates-and-children/top-things-to-know","year":2019,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official AHA summary page (2019 statement)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Pediatric Intracerebral Hemorrhage Management-Consensus Statement of the International Pediatric Stroke Organization-Part 1: Acute Phase and Workup","url":"https://pubmed.ncbi.nlm.nih.gov/41467366/","year":2025,"type":"Consensus statement","checkedAt":"2026-10-31","access":"Primary abstract and PMC methods read 2026-10-31 (PMC12909056): modified Delphi, statements approved at >80% agreement, ungraded; last literature search March 2022. Individual statements not summarized here."},{"title":"Pediatric Intracerebral Hemorrhage Management-Consensus Statement of the International Pediatric Stroke Organization-Part 2: Outcomes, Rehabilitation, and Transition to Adulthood","url":"https://pubmed.ncbi.nlm.nih.gov/41467378/","year":2025,"type":"Consensus statement","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; PMC full text (PMC12909026) not read."},{"title":"Save ChildS — Feasibility, Safety, and Outcome of Endovascular Recanalization in Childhood Stroke: The Save ChildS Study.","url":"https://pubmed.ncbi.nlm.nih.gov/31609380/","year":2020,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"TIPS design — Thrombolysis in acute childhood stroke: design and challenges of the thrombolysis in pediatric stroke clinical trial.","url":"https://pubmed.ncbi.nlm.nih.gov/19223687/","year":2009,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record and notices checked; outcomes not reviewed here. Trial design report; this citation does not supply completed treatment outcomes."},{"title":"Save ChildS Pro — Endovascular thrombectomy for childhood stroke (Save ChildS Pro): an international, multicentre, prospective registry study.","url":"https://pubmed.ncbi.nlm.nih.gov/39401507/","year":2024,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record and notices checked; outcomes not reviewed here. Prospective observational registry, not a randomized treatment comparison."}],"related":[]},{"id":"sickle-cell-stroke","title":"Sickle cell cerebrovascular disease","category":"Stroke in specific populations","settings":["on-call","hospital","clinic"],"keywords":["SCD","sickle cell","silent cerebral infarct","transfusion","transcranial Doppler","TCD"],"summary":"New neurological symptoms in sickle cell disease need urgent joint stroke and hematology care, including transfusion decisions, and eligible adults can receive IVT without excess sICH or other thrombolytic complications (AHA 2026, 2a). ASH guidance covers overt stroke, silent cerebral injury and prevention; disease-modifying decisions belong with the treating specialists.","consider":["Are the sickle cell genotype, prior cerebral events and preventive treatment history known?","Is the age- and disease-specific screening and follow-up plan clear?"],"caution":"An adult atherosclerotic-stroke pathway does not cover sickle cell disease.","sources":[{"title":"ASH 2020 sickle cell cerebrovascular disease guideline","url":"https://pmc.ncbi.nlm.nih.gov/articles/PMC7189278/","year":2020,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract read via live NLM PubMed record (PMID32298430); official ASH page confirms a 2023 review retained the guideline with evidence monitoring. PMC full text was challenged; detailed treatment tables not reviewed here."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."}],"related":[]},{"id":"poststroke-dysphagia","title":"Dysphagia, nutrition and oral care","category":"Inpatient care and complications","settings":["hospital","clinic"],"keywords":["swallow","aspiration","oral intake","nutrition","hydration","feeding","SLP"],"summary":"Screen swallowing at the bedside before any oral intake (AHA 2026, COR 1); if the screen fails or cannot be done, an instrumental assessment (FEES or videofluoroscopy) is reasonable (2a). Start enteral feeding within 7 days (COR 1): nasogastric tube first, and gastrostomy if unsafe swallowing is expected beyond 2–3 weeks (2a). An oral hygiene protocol may reduce pneumonia (2b).","consider":["Is the current intake plan clear to everyone, including medication routes?","Does a concerning screen or clinical change need specialist assessment?","Are hydration, oral care and reassessment in the plan?"],"caution":"A screening result is not the full swallowing diagnosis; in FOOD, early PEG increased death or poor outcome versus nasogastric feeding (P=0.05), without a difference in death alone.","sources":[{"title":"European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia","url":"https://pubmed.ncbi.nlm.nih.gov/34746431/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial","url":"https://pubmed.ncbi.nlm.nih.gov/15733717/","year":2005,"type":"Randomized trial","checkedAt":"2026-10-22","access":"Primary abstract read: PEG vs nasogastric trial (n=321): death or poor outcome +7.8% (95% CI 0.0–15.5; P=0.05); death +1.0% (P=0.9)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."}],"related":[]},{"id":"stroke-pneumonia","title":"Stroke-associated pneumonia","category":"Inpatient care and complications","settings":["hospital"],"keywords":["SAP","aspiration pneumonia","infection","dysphagia","antibiotics"],"summary":"Diagnose stroke-associated pneumonia with standardized criteria (e.g., PISCES probable or definite), not from a risk score; chest CT or CRP may add value in selected cases (ESO 2026). Prevent it with swallow screening, oral care, positioning and early mobilization within 48 h (ESO 2026), avoiding high-dose, very early mobilization within 24 h of onset (AHA/ASA AIS 2026, COR 3: Harm); do not give prophylactic antibiotics (AHA/ASA AIS 2026, COR 3: No Benefit; ESO 2026). Once SAP is diagnosed, take cultures where feasible and start empirical antibiotics promptly under local protocols for aspiration-associated pathogens (onset >7 days after stroke: hospital-acquired pneumonia protocols); give at least 5 days guided by response and stop early if SAP is refuted (ESO 2026 expert consensus).","consider":["Is pneumonia diagnosed by standardized criteria rather than a risk score or CRP alone?","Have swallowing, positioning, mobility and nutritional needs been reviewed?","Has the regimen been reviewed against cultures and local microbiology for de-escalation or stopping?"],"caution":"Most ESO recommendations rest on expert consensus because direct evidence is limited.","sources":[{"title":"ESO Guideline 2026: Stroke-Associated Pneumonia","url":"https://pubmed.ncbi.nlm.nih.gov/42095755/","year":2026,"type":"Guideline","checkedAt":"2026-10-22","access":"PMC full text read (PMC13151663); recommendation boxes and synoptic table (images) not in the retrieved text."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"PASS — The Preventive Antibiotics in Stroke Study (PASS): a pragmatic randomised open-label masked endpoint clinical trial.","url":"https://pubmed.ncbi.nlm.nih.gov/25612858/","year":2015,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[]},{"id":"stroke-unit-nursing","title":"Stroke-unit nursing and daily care","category":"Inpatient care and complications","settings":["on-call","hospital"],"keywords":["nursing","stroke unit","neurological checks","skin","mobility","discharge education"],"summary":"Care for all ages in an organized stroke unit with a trained interdisciplinary team and standardized orders (AHA 2026, COR 1). Nurse-initiated fever, glucose and swallowing protocols reduced death or dependency (QASC: 42 vs 58%). Make phase-specific monitoring and escalation explicit and carry unresolved issues into discharge planning. After IVT, in patients clinically stable with NIHSS <10 within 2 h of starting thrombolysis, a low-intensity schedule (neurological and vital-sign checks every 15 min for 2 h, every 2 h for 8 h, then every 4 h to 24 h) gave similar 90-day mRS 2–6 to standard monitoring (31.7 vs 30.9%; RR 1.03, 95% CI 0.92–1.15, noninferiority margin 1.15; OPTIMISTmain, 4,922 patients, stepped-wedge cluster RCT); the investigators call this only weak evidence of noninferiority, and it postdates the AHA 2026 evidence review.","consider":["Are phase-specific monitoring and escalation responsibilities clear?","Have functional needs, safety concerns and family teaching been incorporated into daily care?","Are unresolved inpatient issues carried forward into the discharge plan?"],"caution":"These statements do not set a universal monitoring frequency or replace response to deterioration.","sources":[{"title":"Care of the Patient With Acute Ischemic Stroke (Posthyperacute and Prehospital Discharge): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/33691469/","year":2021,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Care of the Patient With Acute Ischemic Stroke (Endovascular/Intensive Care Unit-Postinterventional Therapy): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/33691467/","year":2021,"type":"Scientific statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 42507798 not reconciled."},{"title":"Care of the Patient With Acute Ischemic Stroke (Prehospital and Acute Phase of Care): Update to the 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/33691468/","year":2021,"type":"Scientific statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"QASC — Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/21996470/","year":2011,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"HeadPoST — Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/28636854/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SHINE — Intensive vs Standard Treatment of Hyperglycemia and Functional Outcome in Patients With Acute Ischemic Stroke: The SHINE Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/31334795/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"OPTIMISTmain — Safety and efficacy of low-intensity versus standard monitoring following intravenous thrombolytic treatment in patients with acute ischaemic stroke (OPTIMISTmain): an international, pragmatic, stepped-wedge, cluster-randomised, controlled non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40412428/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked: clinically stable with NIHSS <10 within 2 h of IVT; mRS 2–6 31.7 vs 30.9% (RR 1.03, 95% CI 0.92–1.15; margin 1.15; p=0.057); authors report weak evidence of noninferiority."},{"title":"HeadSOAR — Head positioning after endovascular therapy for acute stroke due to large vessel occlusion (HeadSOAR): multicentre randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42624516/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; summarized on the inpatient-care card; full text not reviewed."}],"related":[]},{"id":"inpatient-medical-complications","title":"Systemic complications during stroke admission","category":"Inpatient care and complications","settings":["hospital"],"keywords":["cardiac complications","infection","glucose","temperature","delirium","aphasia","medical complications"],"summary":"Watch for infection (pneumonia, urinary), fever, hyperglycemia, VTE, acute kidney injury, GI bleeding, urinary retention, cardiac events and delirium, which cluster early after stroke and worsen outcomes. In ischemic stroke (AHA 2026): treat persistent hyperglycemia to 140–180 mg/dL with close monitoring (2a) but not with IV insulin to 80–130 (COR 3: No Benefit; SHINE vs a sliding-scale 80–179 target: no functional benefit, severe hypoglycemia 2.6% vs none); target normothermia in fever (COR 1); avoid routine indwelling bladder catheters (COR 3: Harm). ICH glucose and temperature targets differ (see the ICH card).","consider":["Have new systemic symptoms or laboratory changes been assessed alongside the neurological course?","Could aphasia be limiting the examination, and does fluctuating attention need broader reassessment?","Do medical, nursing and rehabilitation teams share a complication plan?"],"caution":"A bedside impression cannot exclude an acute cause of change; aphasia, delirium and neurological worsening can coexist.","sources":[{"title":"AHA Systemic Complications of Acute Stroke Scientific Statement 2024","url":"https://pubmed.ncbi.nlm.nih.gov/39633600/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"AHA poststroke cognitive impairment: official overview","url":"https://professional.heart.org/en/science-news/cognitive-impairment-after-ischemic-and-hemorrhagic-stroke/top-things-to-know","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official summary read for differential assessment, comorbid delirium, home safety, driving and work considerations; full statement not re-reviewed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"European Stroke Organisation (ESO) guidelines on glycaemia management in acute stroke","url":"https://pubmed.ncbi.nlm.nih.gov/31008333/","year":2018,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"European Stroke Organisation (ESO) guidelines for the management of temperature in patients with acute ischemic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/26148223/","year":2015,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"Hyponatremia & ICH — Severity-Stratified Hyponatremia Is Associated with Increased Mortality and Complications in Nontraumatic Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/42194925/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"INTREPID — Fever Prevention in Patients With Acute Vascular Brain Injury: The INTREPID Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39320879/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SETPOINT2 — Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation: The SETPOINT2 Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35506515/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ELSO LV venting and acute brain injury — Impact of Left Ventricular Venting on Acute Brain Injury in Patients With Cardiogenic Shock: An Extracorporeal Life Support Organization Registry Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/41104911/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"Follow-up imaging","href":"#/evidence/imaging-follow-up"},{"label":"ICH first-hour targets","href":"#/evidence/ich-management"}]},{"id":"vte-prevention","title":"VTE prevention after stroke","category":"Inpatient care and complications","settings":["hospital"],"keywords":["DVT","pulmonary embolism","IPC","immobility","heparin","thromboprophylaxis"],"summary":"Immobile after ischemic stroke: intermittent pneumatic compression unless contraindicated (AHA/ASA AIS 2026, COR 1; CLOTS 3, started within 3 days of admission: proximal DVT 8.5 vs 12.1%), and prophylactic-dose UFH or LMWH is reasonable to reduce VTE (2a), although a survival benefit is not well established (2b). Do not use elastic compression stockings (COR 3: Harm). Nonambulatory after ICH: IPC from the day of diagnosis (AHA 2022, COR 1); low-dose UFH or LMWH can be useful (2a), and starting it 24–48 h after onset may be reasonable (2b), weighing VTE prevention against hematoma expansion.","consider":["What are the current mobility, VTE and bleeding risks?","Is IPC fitted and worn as intended, with skin checks?","Before heparin prophylaxis, review renal function, recent treatment and hemorrhage risk."],"caution":"Graduated compression stockings are not equivalent to intermittent pneumatic compression.","sources":[{"title":"European Stroke Organisation (ESO) guidelines for prophylaxis for venous thromboembolism in immobile patients with acute ischaemic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/31008263/","year":2016,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial","url":"https://pubmed.ncbi.nlm.nih.gov/23727163/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-22","access":"Primary abstract read: immobile patients enrolled day 0–3 of admission; proximal DVT 8.5 vs 12.1%; skin breaks 3 vs 1%. Indexed correction notices not reconciled."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"CLOTS 1 — Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/19477503/","year":2009,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"PREVAIL — The efficacy and safety of enoxaparin versus unfractionated heparin for the prevention of venous thromboembolism after acute ischaemic stroke (PREVAIL Study): an open-label randomised comparison.","url":"https://pubmed.ncbi.nlm.nih.gov/17448820/","year":2007,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[]},{"id":"spasticity","title":"Spasticity and contracture prevention","category":"Recovery and rehabilitation","settings":["hospital","clinic"],"keywords":["tone","muscle overactivity","contracture","botulinum","pain","range of motion"],"summary":"Recognize poststroke spasticity early — pain, hygiene, positioning, mobility or care tasks affected by tone or restricted movement — and refer for rehabilitation assessment before contracture and secondary impairment set in. The AHA 2026 statement defines early treatment as within 3 months of stroke onset (a working definition); for established spasticity, botulinum toxin has the most early-treatment evidence (mainly short-term reduction in muscle overactivity; functional gains less consistent). Higher risk: severe initial sensorimotor impairment, early hyperreflexia or spasticity, hemorrhage, NIHSS ≥10, or lesions >3 cm or in the corticospinal tract, internal capsule, basal ganglia or brainstem.","consider":["What active and passive functional goals matter to the patient and caregiver?","Is timely specialist or rehabilitation assessment needed?"],"caution":"Increased tone is not the only cause of impaired movement; treatment follows a functional assessment.","sources":[{"title":"AHA Scientific Statement 2026: Early Recognition and Intervention for Poststroke Spasticity","url":"https://pubmed.ncbi.nlm.nih.gov/41608795/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-22","access":"PMC body text read (PMC13063836; Table and figures not in the retrieved text); correction 42044236 (Stroke 2026;57(5):e193) not reconciled; the 2026 AHA/ASA rehabilitation guideline was not reviewed for spasticity."}],"related":[]},{"id":"aphasia","title":"Aphasia and communication rehabilitation","category":"Recovery and rehabilitation","settings":["hospital","clinic"],"keywords":["speech","language","communication","SLT","SLP","comprehension","delirium"],"summary":"Offer speech-language therapy of at least 20 h in total (ESO 2025, recommended), ideally ≥3 h a week on ≥4 days (suggested), tailored to the communication activities that matter to the patient and to language-task difficulty, in person with digital augmentation, one-to-one or in groups (all suggested). Use tDCS alongside therapy only within high-quality trials (ESO expert consensus; benefit uncertain).","consider":["Are assessment and shared decisions adapted to language impairment?","Is the therapy plan feasible, sufficiently supported and reassessed as needs change?"],"caution":"Aphasia does not establish impaired decision-making capacity; the ≥20 h recommendation rests on low-quality evidence, and certainty differs across therapy comparisons.","sources":[{"title":"ESO Guideline 2025: Aphasia Rehabilitation","url":"https://pubmed.ncbi.nlm.nih.gov/40401776/","year":2025,"type":"Guideline","checkedAt":"2026-10-21","access":"PMC full text read (PMC12098336)."}],"related":[]},{"id":"visual-recovery","title":"Visual impairment and neglect","category":"Recovery and rehabilitation","settings":["hospital","clinic"],"keywords":["hemianopia","diplopia","visual field","neglect","eye movements","vision","perception"],"summary":"Screen every adult with stroke for visual problems — central vision, eye movements, visual fields, neglect and perception — ideally by eye-team assessment or at least with a validated tool, because many patients cannot report visual symptoms (ESO 2025, suggested). Screen early: by ESO expert consensus this is feasible within 3–4 days and most patients can be assessed within the first week (timing is not an evidence-based recommendation). Refer eye-movement disorders to specialist eye services (meanwhile, partial or total occlusion can relieve diplopia; total occlusion leaves the patient monocular), start compensatory visual scanning training for field loss as early as feasible, and individualize neglect and perceptual treatment with occupational therapy, neuropsychology and eye-care teams (ESO 2025, suggested).","consider":["Has the patient been assessed for the relevant type of visual impairment?","Do reading, mobility or daily activities require adaptations and specialist input?","Are visual findings communicated to the rehabilitation and follow-up teams?"],"caution":"Different visual syndromes need different assessments, and this card does not establish driving fitness.","sources":[{"title":"ESO Guideline 2025: Visual Impairment in Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/40401755/","year":2025,"type":"Guideline","checkedAt":"2026-10-21","access":"PMC full text read (PMC12098360)."}],"related":[{"label":"Acute retinal ischemia and CRAO","href":"#/evidence/retinal-ischemia"}]},{"id":"motor-recovery","title":"Motor recovery, walking and daily activity","category":"Recovery and rehabilitation","settings":["hospital","clinic"],"keywords":["gait","upper limb","arm recovery","balance","sit to stand","exercise","mobility"],"summary":"ESO 2025: add at least 20 h of repetitive upper-limb practice (weak, very low certainty) to improve arm capacity; offer high-intensity gait training to improve walking endurance in chronic stroke with stable cardiovascular status (strong, moderate certainty); add sit-to-stand training for balance (weak, moderate certainty). In subacute inpatient rehabilitation in Canada (12 units; mean 29 days after stroke), a structured, progressive walking protocol (at least 30 min of walking-related activity per session, progressed by heart rate and step count) improved 6-minute walk distance by 43.6 m (95% CI 12.7–76.1) more than usual care at 4 weeks, with no serious adverse events during sessions (Walk 'n Watch, stepped-wedge cluster RCT, 306 patients; postdates ESO 2025, not graded).","consider":["Which movement and participation goals are being measured over time?","Is practice linked to tasks the patient needs in daily life?","Do cardiovascular stability, endurance and access support the proposed training approach?"],"caution":"Results from chronic, stable stroke do not automatically apply during acute illness; dose needs a rehabilitation assessment. The August 2026 AHA/ASA rehabilitation guideline was not reviewed.","sources":[{"title":"ESO Guideline 2025: Motor Rehabilitation After Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/40401760/","year":2025,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract read; PMC returned no body text."},{"title":"2026 Guideline for Adult Stroke Rehabilitation and Recovery: A Guideline From the American Heart Association and American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/42657476/","year":2026,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed record and abstract read: published online 2026-08-27 (Stroke 2026;57(10):e514–e658); replaces the 2016 guideline; literature since 2016 searched June–October 2025, so later evidence is not reflected. No PMC copy; recommendations not reviewed or quoted. A correction was published 2026-10-26 (PMID 42932410; Stroke 2026;57(11):e700–e701); its content was not reviewed. Archive held only an access placeholder."},{"title":"VNS-REHAB — Vagus nerve stimulation paired with rehabilitation for upper limb motor function after ischaemic stroke (VNS-REHAB): a randomised, blinded, pivotal, device trial.","url":"https://pubmed.ncbi.nlm.nih.gov/33894832/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Walk 'n Watch — Safety and effectiveness of the Walk 'n Watch structured, progressive exercise protocol delivered by physical therapists for inpatient stroke rehabilitation in Canada: a phase 3, multisite, pragmatic, stepped-wedge, cluster-randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40683274/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."},{"title":"AVERT dose-response — Prespecified dose-response analysis for A Very Early Rehabilitation Trial (AVERT).","url":"https://pubmed.ncbi.nlm.nih.gov/26888985/","year":2016,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic identity and primary-abstract design checked: observational secondary dose-response analysis of AVERT, irrespective of randomized treatment assignment. This is not a randomized comparison of mobilization doses; Outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."}],"related":[]},{"id":"psychosocial-recovery","title":"Mood, anxiety, fatigue and psychosocial recovery","category":"Recovery and rehabilitation","settings":["hospital","clinic"],"keywords":["depression","anxiety","fatigue","stress","quality of life","psychosocial","caregiver"],"summary":"Screen for depression with a structured inventory (AHA/ASA AIS 2026, COR 1) and treat diagnosed depression (not a positive screen alone) with antidepressants and/or psychotherapy or other nonpharmacological options (COR 1). Ask about anxiety, fatigue and stress, and give patients and families education and access to interdisciplinary support. CSBPR 2025: routine prophylactic antidepressants for all survivors are not recommended (strong recommendation; moderate-quality evidence); supervised exercise, ideally at least 3 times a week, is recommended for mild (strong; high quality) or moderate (strong; moderate quality) depressive symptoms; antidepressants are not recommended for poststroke fatigue without depression or anxiety (strong; moderate quality).","consider":["Which emotional symptoms or fatigue are limiting recovery or daily life?","Is a concerning screen followed by clinical assessment and a practical care pathway?","Post-stroke fatigue (CSBPR 2025): screen for treatable contributors such as mood disorders, sleep disorders, other medical conditions and sedating medications (strong recommendation; low-quality evidence). Modafinil may be considered (conditional recommendation; low-quality evidence); CSBPR notes that no medication is approved specifically for post-stroke fatigue. Cognitive behavioral therapy or mindfulness-based stress reduction may be considered as adjuncts (strong recommendation; low-quality evidence)."],"caution":"A screening score is not a diagnosis, and fatigue or distress should not be assigned a single cause without assessment.","sources":[{"title":"Nursing's Role in Psychosocial Health Management After a Stroke Event: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/39155870/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"2026 Guideline for Adult Stroke Rehabilitation and Recovery: A Guideline From the American Heart Association and American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/42657476/","year":2026,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed record and abstract read: published online 2026-08-27 (Stroke 2026;57(10):e514–e658); replaces the 2016 guideline; literature since 2016 searched June–October 2025, so later evidence is not reflected. No PMC copy; recommendations not reviewed or quoted. A correction was published 2026-10-26 (PMID 42932410; Stroke 2026;57(11):e700–e701); its content was not reviewed. Archive held only an access placeholder."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Canadian Stroke Best Practice Recommendations Rehabilitation, Recovery, and Community Participation Following Stroke, Part Three: Optimizing Activity and Community Participation Following Stroke, 7th Edition Update, 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41258868/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PMC full text (PMC12928792) read 2026-10-31, including section 2 (sleep health and post-stroke fatigue: screening and management); only the prophylactic-antidepressant, supervised-exercise and fatigue recommendations are used, with strength and evidence quality as published."},{"title":"Suicide after stroke — Increased risk of suicide after stroke: A population-based matched cohort study.","url":"https://pubmed.ncbi.nlm.nih.gov/40913243/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"PHQ-2 worksheet","href":"#/tools/phq2"}]},{"id":"driving-work","title":"Driving, seizures and return to participation","category":"Recovery and rehabilitation","settings":["clinic"],"keywords":["driving","work","licensure","seizure","reporting","transportation","return to work"],"summary":"Discuss driving and return to work explicitly at follow-up, before the patient resumes either; seizures, cognitive impairment and medication effects can make driving unsafe. After seizures, the AAN 2025 position is that licensing should ordinarily require at least 3 seizure-free months, extended individually; seizures exclusively provoked by a factor unlikely to recur (e.g., major systemic infection with high fever) may need no interval, but a structural lesion such as stroke is an unfavorable factor that can extend it, and driving should pause during and after an antiseizure-medication taper unless another is started.","consider":["Are seizures, cognition, vision, motor function or medication effects relevant to the intended activity?","Have the applicable licensing rules and any specialist assessment requirements been checked?","What transport, workplace or rehabilitation support is needed?"],"caution":"A position statement is not state law or individual clearance; state seizure-free intervals vary (3 to 18 months) and should be followed. The August 2026 AHA/ASA rehabilitation guideline, which revises return-to-work and driving recommendations, was not reviewed.","sources":[{"title":"Seizures, Driver Licensure, and Medical Reporting Update: An AAN Position Statement","url":"https://pubmed.ncbi.nlm.nih.gov/40073306/","year":2025,"type":"Position statement","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (11 consensus positions); no PMC copy. The provoked-seizure example, stroke as an unfavorable factor and the 3–18-month state range are from the archived full-text transcription."},{"title":"AHA poststroke cognitive impairment: official overview","url":"https://professional.heart.org/en/science-news/cognitive-impairment-after-ischemic-and-hemorrhagic-stroke/top-things-to-know","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official summary read for differential assessment, comorbid delirium, home safety, driving and work considerations; full statement not re-reviewed."},{"title":"2026 Guideline for Adult Stroke Rehabilitation and Recovery: A Guideline From the American Heart Association and American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/42657476/","year":2026,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed record and abstract read: published online 2026-08-27 (Stroke 2026;57(10):e514–e658); replaces the 2016 guideline; literature since 2016 searched June–October 2025, so later evidence is not reflected. No PMC copy; recommendations not reviewed or quoted. A correction was published 2026-10-26 (PMID 42932410; Stroke 2026;57(11):e700–e701); its content was not reviewed. Archive held only an access placeholder."}],"related":[]},{"id":"poststroke-primary-care","title":"Long-term follow-up and primary care","category":"Recovery and rehabilitation","settings":["clinic"],"keywords":["falls","chronic care","caregiver","unmet needs","medication review","primary care"],"summary":"At every follow-up, reconcile risk-factor treatment and medications across clinicians, and rescreen cognition, mood, falls and unmet needs — they remain relevant beyond early recovery (AHA primary-care statement). For community-dwelling survivors over 50, within 5 years of stroke, who had left formal rehabilitation and could walk 10 m, a 6-month home-based physiotherapy/occupational therapy program (functional exercise, home-hazard reduction, community mobility coaching) cut the fall rate by a third over 12 months (FAST RCT, Australia, 370 patients; IRR 0.67, 95% CI 0.48–0.94), although the proportion who fell did not differ; it postdates the 2026 AHA/ASA rehabilitation guideline's literature search.","consider":["Have changes in function, falls, cognition or mood prompted reassessment?","Are patient and caregiver priorities linked to referrals and a named follow-up plan?"],"caution":"Prevention and rehabilitation plans need reassessment as health, function and support change.","sources":[{"title":"AHA/ASA Scientific Statement 2021: Primary Care of Adult Patients After Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/34261351/","year":2021,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"2026 Guideline for Adult Stroke Rehabilitation and Recovery: A Guideline From the American Heart Association and American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/42657476/","year":2026,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed record and abstract read: published online 2026-08-27 (Stroke 2026;57(10):e514–e658); replaces the 2016 guideline; literature since 2016 searched June–October 2025, so later evidence is not reflected. No PMC copy; recommendations not reviewed or quoted. A correction was published 2026-10-26 (PMID 42932410; Stroke 2026;57(11):e700–e701); its content was not reviewed. Archive held only an access placeholder."},{"title":"FAST — Home based, tailored intervention to reduce rate of falls after stroke (FAST): randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41876122/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; PMC full text (PMC13010266) not read."}],"related":[]},{"id":"poststroke-cognition","title":"Cognition after stroke and vascular brain injury","category":"Brain health and cognition","settings":["hospital","clinic"],"keywords":["cognitive impairment","dementia","vascular cognitive impairment","memory","executive function","delirium"],"summary":"Screen cognition after stroke against the person's baseline; vascular injury and preexisting neurodegeneration can interact, so look for associated conditions and plan safety, supports and follow-up across disciplines (AHA 2023). Impairment affects independence, employment and relationships. The VasCog-2-WSO criteria (2025 international Delphi consensus, WSO-endorsed) offer an international standard for diagnosing vascular cognitive impairment and dementia.","consider":["What has changed from the person’s cognitive and functional baseline?","Are language, mood, sensory limitations or acute illness affecting assessment?","Does the care plan address everyday safety, supports and follow-up evaluation?"],"caution":"A single screen does not identify the cause or establish permanent impairment.","sources":[{"title":"AHA Scientific Statement 2023: Cognitive Impairment After Ischemic and Hemorrhagic Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/37125534/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Vascular Contributions to Cognitive Impairment and Brain Health: Clinical Update and Mechanistic Considerations: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/42186798/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment","url":"https://pubmed.ncbi.nlm.nih.gov/34746430/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 35300261 not reconciled."},{"title":"Revised Diagnostic Criteria for Vascular Cognitive Impairment and Dementia-The VasCog-2-WSO Criteria","url":"https://pubmed.ncbi.nlm.nih.gov/40955506/","year":2025,"type":"Consensus statement","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31 (three Delphi survey rounds, 49–54 participants; WSO-endorsed); PMC full text (PMC12441927) not read."}],"related":[]},{"id":"sleep-brain-health","title":"Sleep disorders and brain health","category":"Brain health and cognition","settings":["hospital","clinic"],"keywords":["sleep apnea","OSA","insomnia","sleep fragmentation","circadian","STOP-Bang"],"summary":"Ask about sleep and insomnia, and consider evaluating ischemic stroke or TIA patients for sleep apnea (AHA 2021, 2b) with diagnostic testing rather than a questionnaire alone. Disturbed sleep is linked with worse cerebrovascular and cognitive outcomes, but treatment effects on those outcomes are not established (AHA 2024).","consider":["Are sleep-disordered breathing, insomnia or other sleep symptoms affecting recovery?","Does screening warrant diagnostic evaluation rather than an assumed diagnosis?","Are sleep symptoms and treatment feasibility included in follow-up?","Post-stroke PAP (postdating AHA 2024): a meta-analysis of 21 RCTs (1,457 patients in total) found fewer recurrent vascular events (OR 0.45) and less neurological deficit, but no gain in functional independence. The Sleep SMART trial of CPAP after ischemic stroke (registry enrollment 3,062) had not reported as of October 2026 (registry: active, not recruiting)."],"caution":"A screening questionnaire does not diagnose sleep apnea, and association does not prove that treatment prevents stroke or dementia.","sources":[{"title":"Impact of Sleep Disorders and Disturbed Sleep on Brain Health: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/38235581/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"SAVE — CPAP for Prevention of Cardiovascular Events in Obstructive Sleep Apnea.","url":"https://pubmed.ncbi.nlm.nih.gov/27571048/","year":2016,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Post-stroke PAP meta-analysis — Post-stroke sleep disordered breathing and the effect of positive airway pressure treatment: An updated systematic review and meta-analysis of randomized control trials.","url":"https://pubmed.ncbi.nlm.nih.gov/41297370/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31 (21 RCTs, 1,457 patients; recurrent vascular events OR 0.45; functional independence not improved); bibliographic record checked."}],"related":[{"label":"STOP-Bang worksheet","href":"#/tools/stop-bang"}]},{"id":"lifelong-brain-health","title":"Brain health across the life span","category":"Brain health and cognition","settings":["clinic"],"keywords":["brain health","cognitive resilience","cardiac brain health","cannabis","marijuana","environment","prevention"],"summary":"Address the vascular, sleep, mental-health and social factors relevant to the person's goals without overinterpreting observational findings; the 2026 AHA framework separates established knowledge from research questions.","consider":["Which vascular, sleep, mental-health or social factors are relevant to this person’s goals?","Does the proposed intervention have evidence for the outcome being claimed?"],"caution":"This framework is not a validated brain-health score or proof that any supplement, biomarker or lifestyle change prevents dementia.","sources":[{"title":"Brain Health Across the Life Span: A Framework for Future Studies: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/42047038/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"A Primary Care Agenda for Brain Health: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/33719523/","year":2021,"type":"Scientific statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"Use of Marijuana: Effect on Brain Health: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/35142225/","year":2022,"type":"Scientific statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"Cardiac Contributions to Brain Health: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/39387123/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 39705397 not reconciled."}],"related":[]},{"id":"antiamyloid-vascular-risk","title":"Antiamyloid therapy and cerebrovascular risk","category":"Brain health and cognition","settings":["on-call","hospital","clinic"],"keywords":["ARIA","amyloid","lecanemab","donanemab","Alzheimer","microbleeds","thrombolysis"],"summary":"Ask every suspected stroke patient about antiamyloid antibodies (lecanemab, donanemab): appropriate-use recommendations advise against thrombolysis in treated patients (donanemab: unless MRI unequivocally excludes ARIA), and the donanemab AUR says thrombectomy without thrombolysis should be considered for LVO. ARIA edema can mimic stroke and may be missed on CT/CTA, and fatal hemorrhages after IV thrombolysis have been reported.","consider":["Is current or recent antiamyloid treatment known, and when was the last infusion?","Could the presentation and imaging reflect ARIA, ischemia or another process?","Have the current drug label, imaging history and relevant specialists been consulted?"],"caution":"These are consensus recommendations, not trial evidence. If anticoagulation becomes necessary, the lecanemab AUR advises stopping infusions; standard-dose antiplatelet monotherapy is allowed, but the donanemab AUR makes no recommendation on dual antiplatelet therapy (insufficient safety data). The Encounter IVT checklist lists antiamyloid therapy as generally contraindicated. The AHA ARIA Summit proceedings (JAHA, August 2026; consensus-based, ungraded) advise three things for patients on antiamyloid therapy. With an LVO, skip bridging thrombolysis and go directly to thrombectomy. Thrombolysis should generally not be given when MRI is unavailable to exclude ARIA or shows ARIA. Thrombolytic order sets should list antiamyloid therapy as a relative contraindication. In select cases (MRI unavailable, high NIHSS, clear brainstem syndrome, more than 6–12 months of treatment), thrombolysis without MRI may be considered in consultation with neurology and radiology, although its safety is not established. For acute and subacute antithrombotics, aspirin monotherapy is reasonable; more data are needed, and caution is advised with DAPT or non-aspirin antiplatelets such as ticagrelor.","sources":[{"title":"Vascular Neurology Considerations for Antiamyloid Immunotherapy: A Science Advisory From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/39660440/","year":2024,"type":"Science advisory","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Lecanemab: Appropriate Use Recommendations","url":"https://pubmed.ncbi.nlm.nih.gov/37357276/","year":2023,"type":"Consensus statement","checkedAt":"2026-10-22","access":"PMC full text read (PMC10313141); concomitant-medication section re-read 2026-10-22 (thrombolytics, anticoagulants, standard-dose antiplatelets)."},{"title":"Donanemab: Appropriate Use Recommendations","url":"https://pubmed.ncbi.nlm.nih.gov/40155270/","year":2025,"type":"Consensus statement","checkedAt":"2026-10-22","access":"PMC full text read (PMC12180672); sections 5.2 (antiplatelet monotherapy allowed, no recommendation on dual therapy) and 5.3 (thrombolysis) re-read 2026-10-22."},{"title":"AHA ARIA Summit proceedings: antiamyloid therapy and stroke","url":"https://pubmed.ncbi.nlm.nih.gov/42622140/","year":2026,"type":"Consensus statement","checkedAt":"2026-10-31","access":"PMC full text (PMC13695822) read 2026-10-31: emergency imaging and treatment workflow, and acute and subacute antithrombotics; consensus-based, ungraded."}],"related":[]},{"id":"in-hospital-stroke","title":"In-hospital stroke recognition and response","category":"Systems and transitions of care","settings":["on-call","hospital"],"keywords":["code stroke","inpatient stroke","rapid response","hospital systems","stroke alert"],"summary":"Train all staff to activate the in-hospital stroke alert and give responders immediate neurological expertise (AHA 2022 statement); use an organized protocol for emergent evaluation of acute deficits at any age (AHA 2026, COR 1). Hand over time last known well, the examination, imaging and recent procedures, and track delays for quality review.","consider":["Can staff immediately activate the stroke response from this location?","Are timing, examination, imaging and relevant recent procedures communicated to the response team?","Are transfer barriers and delays captured for review?"],"caution":"Being in a monitored setting does not ensure timely recognition. In US GWTG-Stroke registry data for 2016–2023, in-hospital strokes (3.8% of ischemic stroke admissions) waited longer from recognition to CT (median 51 vs 18 min), were more severe, and had higher in-hospital mortality (adjusted OR 2.27) than community-onset strokes.","sources":[{"title":"Identifying Best Practices to Improve Evaluation and Management of In-Hospital Stroke: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/35137601/","year":2022,"type":"Scientific statement","checkedAt":"2026-10-21","access":"Primary abstract re-read: five core elements of an ungraded statement."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"GWTG-Stroke in-hospital stroke 2016–2023 — In-Hospital Stroke Quality and Outcomes in the Mechanical Thrombectomy Era: Get With The Guidelines-Stroke, 2016 to 2023.","url":"https://pubmed.ncbi.nlm.nih.gov/42145105/","year":2026,"type":"Observational study","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. US registry; the abstract lists no stroke-severity adjustment for mortality."}],"related":[{"label":"Encounter","href":"#/encounter"}]},{"id":"rural-telestroke","title":"Rural care, telestroke and transfer networks","category":"Systems and transitions of care","settings":["on-call","hospital"],"keywords":["rural","telestroke","telehealth","transfer","mobile stroke unit","destination","virtual network"],"summary":"Without in-house stroke expertise, use telestroke for IVT decisions (AHA 2026, COR 1) and teleradiology for rapid image review (COR 1); EMS should go to the closest appropriate stroke-capable hospital (COR 1), although for suspected LVO direct transport to a locally accessible thrombectomy center is reasonable (2a). Where there is neither a well-coordinated stroke system nor a local hospital proficient in thrombolysis and secondary transfer, direct transport to the closest thrombectomy-capable center may be reasonable if it does not disqualify the patient from IVT (2b). In a well-coordinated stroke system with a local stroke center proficient in thrombolysis and secondary transfer, bypassing it for a distant thrombectomy-capable center (e.g., 45–60 min away) does not improve 3-month outcome (COR 3: No Benefit). Agree transfer protocols that minimize door-in-door-out time (COR 1).","consider":["What imaging, specialist and treatment capabilities are available at the referring and receiving sites?","Are clinical information, images and the transfer plan shared through a reliable process?","Is responsibility clear if connection, transport or destination capacity changes?","Bringing the team to the patient: at 13 nonurban stroke centers in Bavaria, a flying neurointerventional team cut median decision-to-puncture time by 89 min versus interhospital transfer and was associated with better 12-month mRS (adjusted common OR 2.03, 1.09–3.84) in a 12-month secondary analysis of a study that alternated the two systems by week (pseudo-randomized; n=146)."],"caution":"Technology and center labels do not establish current local capability.","sources":[{"title":"Identifying Best Practices for Improving the Evaluation and Management of Stroke in Rural Lower-Resourced Settings: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/39665145/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Creating Virtual Stroke Networks: Current and Future Role of Artificial Intelligence, Mobile Imaging Applications, and Telehealth in Triage and Treatment of Acute Ischemic Stroke: A Scientific Statement From the American Heart Association: The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists","url":"https://pubmed.ncbi.nlm.nih.gov/41342129/","year":2025,"type":"Scientific statement","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed. Correction 41871197 (2026) not read."},{"title":"Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities From the Prehospital Stroke System of Care Consensus Conference: A Consensus Statement From the American Academy of Neurology, American Heart Association/American Stroke Association, American Society of Neuroradiology, National Association of EMS Physicians, National Association of State EMS Officials, Society of NeuroInterventional Surgery, and Society of Vascular and Interventional Neurology: Endorsed by the Neurocritical Care Society","url":"https://pubmed.ncbi.nlm.nih.gov/33691507/","year":2021,"type":"Consensus statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 34181455 not reconciled."},{"title":"Targeted Nursing Interventions for Improving Stroke Care and Outcomes in the Rural Setting: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/41164866/","year":2025,"type":"Scientific statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management","url":"https://pubmed.ncbi.nlm.nih.gov/35300251/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"Telestroke care in resource-limited settings: A World Stroke Organization scientific statement","url":"https://pubmed.ncbi.nlm.nih.gov/42630091/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31: systematic literature review combined with a structured survey and consensus process (WSO Telestroke Committee); recommendations not reviewed."},{"title":"INTERACT4 — Intensive Ambulance-Delivered Blood-Pressure Reduction in Hyperacute Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/38752650/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"BEST-MSU — Prospective, Multicenter, Controlled Trial of Mobile Stroke Units.","url":"https://pubmed.ncbi.nlm.nih.gov/34496173/","year":2021,"type":"Observational study","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. PubMed lists 1 correction or notice; check it before applying results."},{"title":"RACECAT — Effect of Direct Transportation to Thrombectomy-Capable Center vs Local Stroke Center on Neurological Outcomes in Patients With Suspected Large-Vessel Occlusion Stroke in Nonurban Areas: The RACECAT Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35510397/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. PubMed lists 1 correction or notice; check it before applying results."},{"title":"GWTG-Stroke door-in-door-out — Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/37581671/","year":2023,"type":"Observational study","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: US registry-based retrospective study; bibliographic record checked."},{"title":"Target Stroke Phase III — Association of Component Strategies of the Target Stroke Phase 3 Nationwide Quality Improvement Program With Accelerated Door-to-Puncture and Door-In-Door-Out Times for Ischemic Stroke Endovascular Thrombectomy in the United States.","url":"https://pubmed.ncbi.nlm.nih.gov/41111412/","year":2025,"type":"Observational study","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: retrospective observational cohort from the GWTG-Stroke registry; bibliographic record checked."},{"title":"AI LVO-detection accuracy meta-analysis — Diagnostic Test Accuracy of Artificial Intelligence in Large Vessel Occlusion: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42028301/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: systematic review and diagnostic-accuracy meta-analysis of 11 studies; bibliographic record checked."},{"title":"Flying Intervention Team, 12-month outcome — One-year functional outcome of the Flying Intervention Team versus patient interhospital transfer in acute ischaemic stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/41947562/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (PMC13058261 not read); bibliographic record checked. Secondary analysis of a pseudo-randomized study that alternated the two systems by week."}],"related":[]},{"id":"transitions-care","title":"Transitions, discharge communication and continuity","category":"Systems and transitions of care","settings":["hospital","clinic"],"keywords":["discharge","handoff","pending results","care transitions","care partner","person-centered"],"summary":"Before discharge, confirm that the patient's priorities, medication plan, open questions and the named follow-up owner reach the next setting, and that patient and care partner have usable information and a way to get help (AHA transitions statement). Match information to the person's health literacy, language and cognition, for example with teach-back; supporting studies are heterogeneous and often underpowered (AHA 2026 health literacy statement).","consider":["Are the patient’s priorities and support needs reflected in the next setting of care?","Are medication plans, outstanding questions and responsibility for follow-up clearly communicated?","Have the patient and care partner received usable information and a way to seek help?"],"caution":"A completed discharge document does not establish a successful transition.","sources":[{"title":"Exploring the Inclusion of Person-Centered Care Domains in Stroke Transitions of Care Interventions: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/38557155/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Health Literacy and Communication in Stroke Prevention, Management, and Recovery: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/42877955/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31 (ungraded scientific statement); full text not read."}],"related":[]},{"id":"rehab-access","title":"Rehabilitation access and recovery barriers","category":"Systems and transitions of care","settings":["hospital","clinic"],"keywords":["insurance","authorization","transport","social determinants","health equity","care access"],"summary":"Match the rehabilitation plan to documented functional needs and check coverage, travel and caregiving barriers early; name who will resolve barriers and reassess if access is delayed (AHA statements).","consider":["Do coverage, travel, caregiving or other circumstances limit the proposed rehabilitation plan?","Are the recommended setting and services linked to documented functional needs?"],"caution":"Placement availability is not the same as clinical suitability.","sources":[{"title":"Improving Access to Stroke Rehabilitation and Recovery: A Policy Statement From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/40740119/","year":2025,"type":"Policy statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Social and Environmental Determinants of Stroke Functional Outcome and Strategies to Reduce Inequities: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/42109096/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."}],"related":[]},{"id":"stroke-program-quality","title":"Stroke programs, standards and quality improvement","category":"Systems and transitions of care","settings":["hospital","clinic"],"keywords":["certification","performance measures","quality improvement","staffing","program development","rehabilitation standards"],"summary":"Match staffing and expertise to the services the program promises, and measure processes and outcomes with named responsibility; certification alone does not establish capability (AHA program guidance). In a cluster RCT at 77 hospitals in China (21,603 patients with acute ischemic stroke), an AI-assisted clinical decision support system improved adherence to performance measures and lowered 3-month new vascular events (2.9 vs 3.9%; adjusted HR 0.74, 95% CI 0.58–0.93), without a difference in disability or mortality (GOLDEN BRIDGE II).","consider":["Do staffing, expertise and operating arrangements match the services the program promises?","Are processes and outcomes measured with clear responsibility for improvement?","Are acute and postacute teams using shared expectations for coordinated care?"],"caution":"Certification does not establish identical capability across sites.","sources":[{"title":"Ideal Foundational Requirements for Stroke Program Development and Growth: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/36748462/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"American Heart Association Standards for Postacute Stroke Rehabilitation Care","url":"https://pubmed.ncbi.nlm.nih.gov/40408522/","year":2025,"type":"Clinical policy","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Clinical Performance Measures for Stroke Rehabilitation: Performance Measures From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34348470/","year":2021,"type":"Performance measures","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2024 AHA/ASA Performance and Quality Measures for Spontaneous Intracerebral Hemorrhage: A Report From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/38695183/","year":2024,"type":"Performance measures","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"Society of Vascular and Interventional Neurology (SVIN) Stroke Interventional Laboratory Consensus (SILC) Criteria for Training Standards and Maintenance of Certification in Neurointervention","url":"https://pubmed.ncbi.nlm.nih.gov/41573319/","year":2025,"type":"Consensus statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. This is a neurointerventional training and certification white paper, not a procedural treatment protocol."},{"title":"GWTG-Stroke door-in-door-out — Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/37581671/","year":2023,"type":"Observational study","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: US registry-based retrospective study; bibliographic record checked."},{"title":"Target Stroke Phase III — Association of Component Strategies of the Target Stroke Phase 3 Nationwide Quality Improvement Program With Accelerated Door-to-Puncture and Door-In-Door-Out Times for Ischemic Stroke Endovascular Thrombectomy in the United States.","url":"https://pubmed.ncbi.nlm.nih.gov/41111412/","year":2025,"type":"Observational study","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: retrospective observational cohort from the GWTG-Stroke registry; bibliographic record checked."},{"title":"AI LVO-detection accuracy meta-analysis — Diagnostic Test Accuracy of Artificial Intelligence in Large Vessel Occlusion: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42028301/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: systematic review and diagnostic-accuracy meta-analysis of 11 studies; bibliographic record checked."},{"title":"GOLDEN BRIDGE II — Effect of a clinical decision support system on stroke care quality and outcomes in patients with acute ischaemic stroke (GOLDEN BRIDGE II): cluster randomised clinical trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41862204/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; PMC full text (PMC13003563) not read."}],"related":[]},{"id":"extended-window-ivt","title":"Wake-up and extended-window thrombolysis","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["wake up","unknown onset","DWI FLAIR","perfusion mismatch","EXTEND","WAKE-UP","late window","TRACE-III","TIMELESS","OPTION","TNK-PLUS","HOPE","EXPECTS","tenecteplase","alteplase","ETERNAL-LVO"],"summary":"Unknown onset within 4.5 h of symptom recognition with DWI–FLAIR mismatch and a DWI lesion <1/3 of the MCA territory: IVT can be beneficial (AHA 2026, 2a; WAKE-UP: mRS 0–1 53.3 vs 41.8%). Perfusion mismatch at 4.5–9 h, or within 9 h of the sleep midpoint, in patients ineligible for EVT: IVT can be beneficial (2a; EXTEND: 35.4 vs 29.5%, sICH 6.2 vs 0.9%). LVO at 4.5–24 h with salvageable tissue and no EVT access: IVT may be beneficial (2b; TRACE-III tenecteplase 33.0 vs 24.2%, sICH 3.0 vs 0.8%). With EVT planned, late tenecteplase added nothing (TIMELESS; TNK-PLUS; basilar: ATTENTION LATE).","recommendations":[{"text":"In AIS patients with unknown onset time who are within 4.5 hours of symptom recognition and have a DWI lesion smaller than one-third of MCA territory with no marked FLAIR signal change, IVT within 4.5 hours of symptom recognition can be beneficial to improve functional outcomes.","cor":"2a","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-100 · p. 44","id":"ais-2026-100"},{"text":"For AIS patients ineligible for EVT who have salvageable penumbra on automated perfusion imaging, IVT can be beneficial within 4.5–9 hours of last known well or within 9 hours of the midpoint of sleep for wake-up stroke.","cor":"2a","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-101 · p. 44","id":"ais-2026-101"},{"text":"In AIS patients with LVO and salvageable ischemic penumbra, presenting 4.5-24 hours from symptom onset or last known well, who cannot receive EVT, IVT directed by clinicians with expertise in thrombolytic stroke care may be beneficial to improve functional outcomes.","cor":"2b","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-102 · p. 44","id":"ais-2026-102"}],"consider":["Perfusion mismatch at 4.5–24 h without planned EVT (China): OPTION (non-LVO, tenecteplase; mRS 0–1 43.6 vs 34.2%, sICH 2.8 vs 0%) and HOPE (with or without LVO, alteplase; 40 vs 26%, sICH 3.8 vs 0.5%) were positive; both postdate the AHA 2026 evidence review (to March 2025) and are not graded there. Posterior circulation at 4.5–24 h, mostly mild, no EVT: EXPECTS (alteplase) functional independence 89.6 vs 72.6%.","ESO Annual Stroke Evidence Update (February 2026; the authors' interpretation, not a guideline recommendation): late-window (4.5–24 h) tenecteplase 'may be considered in carefully selected patients' with perfusion or MRI mismatch and limited established infarction; it notes that these trials enrolled highly selected patients, mostly with advanced imaging and often confirmed LVO.","Pin down last known well, symptom discovery and the imaging route (MRI mismatch vs automated perfusion). Wake-up stroke selected by non-contrast CT alone: tenecteplase did not improve mRS (TWIST, aOR 1.18; 95% CI 0.88–1.58); ESO 2023 recommends against it (strong recommendation, low-quality evidence).","ETERNAL-LVO (Australia; EVT-eligible hemispheric LVO with CT-perfusion mismatch within 24 h of onset, so the early window was included; controls had standard care, which could include IV alteplase; 79% had EVT; stopped early, n=242; postdates the AHA 2026 literature cutoff): tenecteplase did not improve mRS 0–1 or return to baseline (37 vs 43%; aRR 0.90, 0.66–1.21); sICH 4 vs 1%."],"caution":"Benefit beyond 9 h comes from imaging-selected trials in China (TRACE-III, OPTION, HOPE, EXPECTS); the 2a grades rest on WAKE-UP and EXTEND. Late IVT costs more sICH: in a 2026 meta-analysis of 18 RCTs beyond 4.5 h (11 perfusion- or MRI-selected, 7 allowing NCCT/CTA selection), sICH 3.2 vs 1.4% without higher 90-day mortality (13.7 vs 13.0%); in trial-level meta-regression, benefit was smaller where more patients had EVT.","sources":[{"title":"European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/33817340/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"WAKE-UP: MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset","url":"https://pubmed.ncbi.nlm.nih.gov/29766770/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary publication record checked."},{"title":"TRACE-III: Tenecteplase for Ischemic Stroke at 4.5 to 24 Hours without Thrombectomy","url":"https://pubmed.ncbi.nlm.nih.gov/38884324/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"TIMELESS: Tenecteplase for Stroke at 4.5 to 24 Hours with Perfusion-Imaging Selection","url":"https://pubmed.ncbi.nlm.nih.gov/38329148/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"OPTION: Tenecteplase for Acute Non-Large Vessel Occlusion 4.5 to 24 Hours After Ischemic Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/41642827/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"TNK-PLUS: Intravenous Tenecteplase Prior to Endovascular Treatment for Ischemic Stroke at 4.5 to 24 Hours","url":"https://pubmed.ncbi.nlm.nih.gov/42099212/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"HOPE: alteplase at 4.5–24 h with perfusion selection","url":"https://pubmed.ncbi.nlm.nih.gov/40773205/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"EXPECTS: alteplase for posterior circulation stroke at 4.5–24 h","url":"https://pubmed.ncbi.nlm.nih.gov/40174223/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"TWIST: tenecteplase in CT-selected wake-up stroke","url":"https://pubmed.ncbi.nlm.nih.gov/36549308/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"ESO expedited recommendation on tenecteplase (2023)","url":"https://pubmed.ncbi.nlm.nih.gov/37021186/","year":2023,"type":"Guideline","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed; full recommendation tables not reviewed."},{"title":"TRACE-5: tenecteplase for basilar occlusion within 24 h","url":"https://pubmed.ncbi.nlm.nih.gov/41655588/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"ATTENTION LATE: tenecteplase before EVT for late basilar occlusion","url":"https://pubmed.ncbi.nlm.nih.gov/42776543/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"ESO annual stroke evidence update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41706824/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PMC full text (PMC12915583) read 2026-10-31. ESO Guideline Board evidence review; its practice implications are the authors' interpretation, not guideline recommendations."},{"title":"EXTEND — Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/31067369/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"EPITHET — Effects of alteplase beyond 3 h after stroke in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET): a placebo-controlled randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/18296121/","year":2008,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ECASS4-EXTEND — Extending the time window for intravenous thrombolysis in acute ischemic stroke using magnetic resonance imaging-based patient selection.","url":"https://pubmed.ncbi.nlm.nih.gov/30947642/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CHABLIS-T II — Tenecteplase Thrombolysis for Stroke up to 24 Hours After Onset With Perfusion Imaging Selection: The CHABLIS-T II Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39744861/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"OPTION rationale and design — A multicenter, prospective, randomized, open-label, blinded endpoint trial of intravenous thrombolysis with tenecteplase for acute non-large vessel occlusion in extended time window (OPTION): Rationale and design.","url":"https://pubmed.ncbi.nlm.nih.gov/41169527/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record and notices checked; outcomes not reviewed here. Trial design report; this citation does not supply completed treatment outcomes."},{"title":"ETERNAL-LVO — Efficacy of Tenecteplase in Large Vessel Occlusion Stroke Within 24 Hours of Symptom Onset: The ETERNAL-LVO Randomized Controlled Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40927857/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Control arm (no IVT or alteplase), EVT eligibility and basilar exclusion from the ClinicalTrials.gov registry record NCT04454788."},{"title":"Extended-window IVT meta-analysis (18 RCTs) — Exploring Between-Study Heterogeneity in Extended-Window IV Thrombolysis for Acute Ischemic Stroke: A Meta-Analysis of 18 Randomized Controlled Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42475651/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."},{"title":"Late-window IVT meta-analysis (14 RCTs) — Intravenous Thrombolysis Beyond the Conventional Time Window for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42560675/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (PMC13448797 not read); bibliographic record checked."}],"related":[{"label":"Reperfusion overview","href":"#/evidence/acute-reperfusion"},{"label":"CT perfusion","href":"#/evidence/ct-perfusion"},{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"}]},{"id":"minor-stroke-antiplatelets","title":"Minor stroke, TIA and short-course antiplatelets","category":"Acute ischemic stroke","settings":["on-call","hospital","clinic"],"keywords":["minor stroke","nondisabling","DAPT","aspirin","clopidogrel","ticagrelor","CHANCE","POINT","THALES","INSPIRES","ARAMIS","TEMPO-2","TAPIS"],"summary":"Noncardioembolic minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4) within 24 h without IVT: aspirin plus clopidogrel with a loading dose for 21 days, then one agent (AHA 2026, COR 1). CHANCE: stroke 8.2 vs 11.7%; POINT: major ischemic events 5.0 vs 6.5% with major hemorrhage 0.9 vs 0.4%. Lower-grade options: ticagrelor plus aspirin for 30 days (NIHSS ≤5, or TIA with ABCD2 ≥6 or symptomatic stenosis ≥50%; COR 2b; THALES 5.5 vs 6.6%, severe bleeding 0.5 vs 0.1%); presumed atherosclerotic cause at 24–72 h (or NIHSS 4–5 within 24 h): clopidogrel plus aspirin for 21 days (COR 2a; INSPIRES 7.3 vs 9.2%); known CYP2C19 loss-of-function carriers: ticagrelor plus aspirin for 21 days, then ticagrelor, rather than clopidogrel-aspirin (COR 2b; CHANCE-2 6.0 vs 7.6%).","recommendations":[{"text":"In patients with minor noncardioembolic AIS (NIHSS 3 or less) or high-risk TIA (ABCD2 4 or greater) who did not receive IVT, DAPT (aspirin plus clopidogrel with loading dose) is recommended to be initiated within 24 hours of symptom onset and continued for 21 days, followed by single antiplatelet therapy, to reduce the 90-day risk of recurrent ischemic stroke.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-147 · p. 62","id":"ais-2026-147"},{"text":"In patients with recent (under 24 hours) minor noncardioembolic AIS (NIHSS 5 or less) or high-risk TIA (ABCD2 6 or greater, or symptomatic intracranial/extracranial stenosis 50% or greater) who did not receive IVT, DAPT with ticagrelor (including loading dose) plus aspirin for 30 days may be considered to reduce 30-day recurrent stroke risk.","cor":"2b","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-148 · p. 62","id":"ais-2026-148"},{"text":"In patients with minor noncardioembolic AIS (NIHSS 5 or less) or high-risk TIA (ABCD2 4 or greater) within 24-72 hours of onset (or NIHSS 4-5 within 24 hours) who did not receive IVT and have presumed atherosclerotic cause (50% or greater intracranial or extracranial stenosis or acute infarctions of presumed large artery origin), DAPT (clopidogrel plus aspirin) for 21 days followed by SAPT is reasonable to reduce 90-day recurrent stroke risk.","cor":"2a","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-149 · p. 62","id":"ais-2026-149"}],"consider":["Disabling deficit? Assess for IVT/EVT first. Non-disabling: DAPT was noninferior to alteplase (ARAMIS), and alteplase showed no benefit in PRISMS (stopped early).","Write the stop date (day 21 or 30) and the single agent to continue.","After IVT, two Chinese RCTs postdating AHA 2026 disagree: TAPIS (NIHSS 4–10; aspirin plus ticagrelor within 6 h of onset) improved mRS 0–1 (68.7 vs 62.0%; sICH 0.9 vs 0.7%, wide CI); EAST (NIHSS 0–5; clopidogrel plus aspirin within 6 h after IVT) did not (89.7 vs 89.6%). AHA 2026 rates the risk of antiplatelets in the first 24 h after IVT as uncertain (COR 2b, B-NR)."],"caution":"Do not extend DAPT beyond 21–30 days without a separate indication; bleeding rose with DAPT in POINT, THALES and INSPIRES.","sources":[{"title":"European Stroke Organisation expedited recommendation for the use of short-term dual antiplatelet therapy early after minor stroke and high-risk TIA","url":"https://pubmed.ncbi.nlm.nih.gov/34414300/","year":2021,"type":"Guideline","checkedAt":"2026-10-17","access":"PMC full text (PMC8370083) read: recommendations 1–2 with GRADE strength and quality."},{"title":"EAST: clopidogrel plus aspirin after IVT for minor stroke","url":"https://pubmed.ncbi.nlm.nih.gov/40973702/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"CHANCE — Clopidogrel with aspirin in acute minor stroke or transient ischemic attack.","url":"https://pubmed.ncbi.nlm.nih.gov/23803136/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"POINT — Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA.","url":"https://pubmed.ncbi.nlm.nih.gov/29766750/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"THALES — Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA.","url":"https://pubmed.ncbi.nlm.nih.gov/32668111/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"INSPIRES — Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/38157499/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CHANCE-2 — Ticagrelor versus Clopidogrel in CYP2C19 Loss-of-Function Carriers with Stroke or TIA.","url":"https://pubmed.ncbi.nlm.nih.gov/34708996/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"TAPIS — Ticagrelor with aspirin dual antiplatelet therapy combined with intravenous thrombolysis in patients with ischaemic stroke in China (TAPIS): a multicentre, double-blind, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42114550/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"TEMPO-2 — Tenecteplase versus standard of care for minor ischaemic stroke with proven occlusion (TEMPO-2): a randomised, open label, phase 3 superiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38768626/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ARAMIS — Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke: The ARAMIS Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37367978/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"PRISMS — Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits.","url":"https://pubmed.ncbi.nlm.nih.gov/29998337/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."}],"related":[{"label":"DAPT calculator","href":"#/encounter/dapt"},{"label":"TIA evaluation","href":"#/evidence/tia-evaluation"},{"label":"Reperfusion overview","href":"#/evidence/acute-reperfusion"}]},{"id":"thrombolytic-choice","title":"Thrombolytic agent and evidence selection","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["tenecteplase","TNK","TNKase","alteplase","tPA","reteplase","prourokinase","AcT","ATTEST-2","TRACE-2","ORIGINAL","EXTEND-IA TNK","bolus"],"summary":"Within 4.5 h use tenecteplase 0.25 mg/kg (max 25 mg) as a single bolus or alteplase 0.9 mg/kg (max 90 mg) (AHA 2026, COR 1); for LVO within 4.5 h, ESO 2023 recommends tenecteplase 0.25 mg/kg over alteplase (strong, moderate-quality evidence). Tenecteplase was noninferior in AcT, ATTEST-2 (OR 1.07), TRACE-2 and ORIGINAL, and doubled early reperfusion before EVT in EXTEND-IA TNK (22 vs 10%). Do not use tenecteplase 0.4 mg/kg (COR 3: No Benefit, LOE A). Reteplase or mutant prourokinase may be considered when EVT is not planned (2b).","recommendations":[{"text":"In adult AIS patients presenting within 4.5 hours of symptom onset or last known well who are eligible for IVT, tenecteplase 0.25 mg/kg (max 25 mg) or alteplase 0.9 mg/kg (max 90 mg) is recommended to improve functional outcomes.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-98 · p. 42","id":"ais-2026-98"},{"text":"In adult AIS patients presenting within 4.5 hours of symptom onset or last known well who are eligible for IVT, tenecteplase at a dose of 0.4 mg/kg is not recommended.","cor":"3: No Benefit","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-99 · p. 42","id":"ais-2026-99"}],"consider":["Use the agent and dose source your protocol specifies; dose by weight with the calculator.","Angioedema occurred in 1% with either agent (ATTEST-2): be ready to manage the airway and bleeding.","Not recommended: desmoteplase, urokinase, mutant prourokinase plus low-dose alteplase and adjunctive sonothrombolysis (COR 3: No Benefit); streptokinase is COR 3: Harm (higher early mortality)."],"caution":"US labels cover alteplase and (since February 2025) tenecteplase within 3 h of onset, while AHA 2026 (COR 1) supports either agent to 4.5 h; the tenecteplase label uses five weight bands (15–25 mg), above 0.25 mg/kg below 100 kg (0.33 mg/kg at 45 kg), reaching 0.4 mg/kg (rated COR 3: No Benefit) at 37.5 kg or less. A positive trial does not establish local approval or availability of a newer thrombolytic.","sources":[{"title":"European Stroke Organisation (ESO) expedited recommendation on tenecteplase for acute ischaemic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/37021186/","year":2023,"type":"Guideline","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed; full recommendation tables not reviewed."},{"title":"RAISE: Reteplase versus Alteplase for Acute Ischemic Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/38884332/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked; no approval or availability inferred."},{"title":"Food and Drug Administration Approval of Tenecteplase: What This Means for the Field of Acute Stroke Treatment (editorial reproducing the US label dosing table)","url":"https://pubmed.ncbi.nlm.nih.gov/41573708/","year":2025,"type":"Report","checkedAt":"2026-10-21","access":"PMC full text (PMC12697625): label approval date, 3-h window and weight-band table; the FDA label was not reachable."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"AcT — Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35779553/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"TRACE-2 — Tenecteplase versus alteplase in acute ischaemic cerebrovascular events (TRACE-2): a phase 3, multicentre, open-label, randomised controlled, non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/36774935/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ORIGINAL — Tenecteplase vs Alteplase for Patients With Acute Ischemic Stroke: The ORIGINAL Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39264623/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"TNK vs alteplase · RWE — Real-world efficacy and safety of Tenecteplase versus Alteplase in acute ischemic stroke: a propensity score-matched analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42206304/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. Outcome interpretation unresolved, so no summary is shown."},{"title":"TASTE — Tenecteplase versus alteplase for thrombolysis in patients selected by use of perfusion imaging within 4·5 h of onset of ischaemic stroke (TASTE): a multicentre, randomised, controlled, phase 3 non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38880118/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"T-FLAVOR — Standard-Dose Tenecteplase vs Low-Dose Alteplase for Acute Ischemic Stroke From Large-Vessel Occlusion: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42223935/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ATTEST-2 — Tenecteplase versus alteplase for acute stroke within 4·5 h of onset: a randomised, parallel group, open-label trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39424558/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"EXTEND-IA TNK — Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/29694815/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed; bibliographic record checked."}],"related":[{"label":"Tenecteplase dose","href":"#/encounter/tnk"},{"label":"Alteplase dose","href":"#/encounter/alteplase"},{"label":"Post-IVT complications","href":"#/evidence/post-ivt-complications"}]},{"id":"evt-selection","title":"Thrombectomy selection and bridging thrombolysis","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["thrombectomy","EVT","LVO","early window","late window","DAWN","DEFUSE3","HERMES","bridging","SWIFT DIRECT","MR CLEAN-NO IV","DIRECT-MT","BRIDGE-TNK","drip and ship","MILD-MT","LATE-MT","mild stroke","beyond 24 hours"],"summary":"Anterior LVO (ICA or M1), NIHSS ≥6, prestroke mRS 0–1: EVT within 6 h if ASPECTS 3–10, and at 6–24 h if ASPECTS ≥6, or ASPECTS 3–5 with age <80 and no significant mass effect (AHA 2026, COR 1). HERMES (5 RCTs, ≤12 h): mRS shift cOR 2.49; DAWN (6–24 h, clinical–core mismatch): mRS 0–2 49 vs 13%; DEFUSE 3 (6–16 h, perfusion mismatch): 45 vs 17%. Give IVT first when eligible and do not delay EVT; BRIDGE-TNK (China, ≤4.5 h) favored tenecteplase first (mRS 0–2 52.9 vs 44.1%). Outside these criteria, two open-label, perfusion-selected Chinese RCTs postdating AHA 2026 (not graded) found benefit with harms: MILD-MT (NIHSS <6, ≤24 h; mRS 0–1 69.4 vs 50.0%; serious procedural complications 13.2%) and LATE-MT (24–72 h; mRS shift cOR 1.74; sICH 4.8 vs 0%; 90-day mortality 6.0 vs 1.8%).","recommendations":[{"text":"In AIS patients with anterior circulation proximal LVO (ICA or M1), presenting within 6 hours of symptom onset, with NIHSS 6 or greater, prestroke mRS 0-1, and ASPECTS 3-10, EVT (endovascular thrombectomy) is recommended to improve functional outcomes and reduce mortality.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-114 · p. 53","id":"ais-2026-114"},{"text":"In AIS patients with anterior circulation proximal LVO (ICA or M1) presenting 6-24 hours from symptom onset, with NIHSS 6 or greater, prestroke mRS 0-1, and ASPECTS 6 or greater, EVT is recommended to improve functional outcomes and reduce mortality.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-115 · p. 53","id":"ais-2026-115"},{"text":"In AIS patients with anterior circulation proximal LVO (ICA or M1) presenting within 6 hours, NIHSS 6 or greater, ASPECTS 6 or greater, and prestroke mRS of 2, EVT is reasonable to improve functional outcomes and reduce accumulated disability.","cor":"2a","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-118 · p. 53","id":"ais-2026-118"},{"text":"In AIS patients with anterior circulation proximal LVO (ICA or M1) presenting within 6 hours, NIHSS 6 or greater, ASPECTS 6 or greater, and prestroke mRS of 3-4, EVT might be reasonable to improve functional outcomes and reduce accumulated disability.","cor":"2b","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-119 · p. 53","id":"ais-2026-119"}],"consider":["Prestroke mRS 2 (2a) or 3–4 (2b): graded only for ICA/M1 within 6 h with NIHSS ≥6 and ASPECTS ≥6.","Direct to angiography may be considered (2b each): transfers without repeat imaging unless the exam changed or transfer was delayed; EMS arrivals with a positive LVO scale, imaged by flat-panel CT. DIRECT ANGIO (France, 2026; postdates AHA 2026; direct arrivals ≤85 y within 5 h selected by neurologist exam, not a prehospital scale) stopped early for safety: more sICH (15 vs 0%), no evidence of functional benefit (small and imprecise).","ASPECTS ≥6 at 6–24 h keeps COR 1: in July 2026 the writing group declined a request from DAWN/DEFUSE investigators to downgrade it to 2b, while noting an unresolved observational mortality signal favoring perfusion selection (NO-SELECT trial ongoing).","MILD-MT and LATE-MT (NEJM 2026; postdate AHA 2026; no grade) selection: MILD-MT ICA/M1/M2, NIHSS <6 at randomization, core ≤50 mL and mismatch ≥50 mL, ≤24 h (registry also: age 18–80, prestroke mRS 0, ASPECTS ≥6); sICH 3 patients per arm. LATE-MT (registry) ICA–M2, NIHSS ≥6, prestroke mRS ≥2 excluded, CTP core <50 mL with mismatch ratio ≥1.8 and volume ≥15 mL, 24–72 h (median 38.5 h). Single-country and open-label; decide case by case with the neurointerventional team."],"caution":"Only DIRECT-MT and DEVT (both China) found EVT alone noninferior; SWIFT DIRECT, MR CLEAN-NO IV, SKIP, DIRECT-SAFE and the IRIS meta-analysis did not. Give IVT whenever eligible.","sources":[{"title":"European Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischaemic StrokeEndorsed by Stroke Alliance for Europe (SAFE)","url":"https://pubmed.ncbi.nlm.nih.gov/31165090/","year":2019,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"European Stroke Organisation - European Society for Minimally Invasive Neurological Therapy expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischaemic stroke and anterior circulation large vessel occlusion","url":"https://pubmed.ncbi.nlm.nih.gov/35300256/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed. Indexed correction(s) 37021163 not reconciled."},{"title":"AHA/ASA writing group response: EVT imaging selection in the 6–24 h window","url":"https://pubmed.ncbi.nlm.nih.gov/42535264/","year":2026,"type":"Report","checkedAt":"2026-10-21","access":"PMC full text (PMC13491549) read: request to downgrade recommendation 4.7.2 #2 declined; July 2026 print edition adds supporting text."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Canadian Stroke Best Practice Recommendations: Endovascular Thrombectomy for Acute Ischemic Stroke, Interim Update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41340372/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed abstract only. The update addresses posterior circulation stroke, large core and MeVO, and supersedes the EVT recommendations in the 2022 CSBPR acute stroke management module; recommendation wording and evidence levels were not read (publisher and strokebestpractices.ca not reached), so nothing is quoted on the cards."},{"title":"DAWN — Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct.","url":"https://pubmed.ncbi.nlm.nih.gov/29129157/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"DEFUSE-3 — Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging.","url":"https://pubmed.ncbi.nlm.nih.gov/29364767/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"DIRECT ANGIO — Safety and efficacy of direct versus conventional transfer to angiography suite in patients with severe acute stroke treated with thrombectomy (DIRECT ANGIO) in France: a multicentre, open-label, blinded-endpoint, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41864232/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"MILD-MT — Trial of Endovascular Therapy for Mild Stroke with Large-Vessel Occlusion.","url":"https://pubmed.ncbi.nlm.nih.gov/42929671/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card; NEJM full text not reviewed."},{"title":"LATE-MT — Mechanical Thrombectomy 24 to 72 Hours after Large-Vessel Ischemic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/42929656/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card; NEJM full text not reviewed."},{"title":"BRIDGE-TNK — Intravenous Tenecteplase before Thrombectomy in Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/40396577/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"MR CLEAN-LATE — Endovascular treatment versus no endovascular treatment after 6-24 h in patients with ischaemic stroke and collateral flow on CT angiography (MR CLEAN-LATE) in the Netherlands: a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37003289/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"MR CLEAN — A randomized trial of intraarterial treatment for acute ischemic stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25517348/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ESCAPE — Randomized assessment of rapid endovascular treatment of ischemic stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25671798/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"EXTEND-IA — Endovascular therapy for ischemic stroke with perfusion-imaging selection.","url":"https://pubmed.ncbi.nlm.nih.gov/25671797/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SWIFT PRIME — Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25882376/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"REVASCAT — Thrombectomy within 8 hours after symptom onset in ischemic stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25882510/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"HERMES — Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.","url":"https://pubmed.ncbi.nlm.nih.gov/26898852/","year":2016,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"IRIS IPD meta-analysis — Value of intravenous thrombolysis in endovascular treatment for large-vessel anterior circulation stroke: individual participant data meta-analysis of six randomised trials.","url":"https://pubmed.ncbi.nlm.nih.gov/37640037/","year":2023,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"IRIS time-dependency analysis — Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke: A Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/38324409/","year":2024,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"DIRECT-MT — Endovascular Thrombectomy with or without Intravenous Alteplase in Acute Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/32374959/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"SKIP — Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/33464334/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. PubMed lists 1 correction or notice; check it before applying results."},{"title":"DEVT — Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke: The DEVT Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/33464335/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"MR CLEAN-NO IV — A Randomized Trial of Intravenous Alteplase before Endovascular Treatment for Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/34758251/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"SWIFT DIRECT — Thrombectomy alone versus intravenous alteplase plus thrombectomy in patients with stroke: an open-label, blinded-outcome, randomised non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35810756/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"DIRECT-SAFE — Endovascular thrombectomy versus standard bridging thrombolytic with endovascular thrombectomy within 4·5 h of stroke onset: an open-label, blinded-endpoint, randomised non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35810757/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"TNK-PLUS — Intravenous Tenecteplase Prior to Endovascular Treatment for Ischemic Stroke at 4.5 to 24 Hours: The TNK-PLUS Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42099212/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"ATTENTION LATE — Tenecteplase Before Thrombectomy at 4.5 to 24 Hours for Basilar Artery Occlusion: The ATTENTION LATE Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42776543/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."}],"related":[{"label":"DAWN screen","href":"#/encounter/dawn"},{"label":"DEFUSE 3 screen","href":"#/encounter/defuse3"},{"label":"CT perfusion","href":"#/evidence/ct-perfusion"},{"label":"Large core","href":"#/evidence/large-core-evt"},{"label":"Basilar occlusion","href":"#/evidence/basilar-occlusion"},{"label":"MeVO","href":"#/evidence/medium-distal-evt"}]},{"id":"large-core-evt","title":"Large-core infarction and thrombectomy","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["large core","ASPECTS","SELECT2","ANGEL-ASPECT","RESCUE-Japan LIMIT","TENSION","LASTE","TESLA"],"summary":"Large cores still benefit (AHA 2026): in anterior LVO (ICA or M1) with NIHSS ≥6 and prestroke mRS 0–1, EVT is COR 1 for ASPECTS 3–5 within 6 h (no age criterion) and at 6–24 h (age <80, no significant mass effect), and reasonable (2a) for ASPECTS 0–2 within 6 h (age <80, no significant mass effect). SELECT2: generalized OR 1.51 (mRS 0–2 20 vs 7%); ANGEL-ASPECT: GOR 1.37; RESCUE-Japan LIMIT: mRS 0–3 31.0 vs 12.7%; TENSION: cOR 2.58 with lower mortality; LASTE (ASPECTS ≤5 within 6.5 h): mortality 36.1 vs 55.5%; TESLA (NCCT ASPECTS 2–5, ≤24 h) missed its 90-day primary endpoint (posterior probability 0.96; 0.975 required), though at 1 year the utility-weighted mRS favored EVT (difference 1.18; 95% CI 0.42–1.93; reported by SVIN 2025). Expect more hemorrhage (ANGEL-ASPECT sICH 6.1 vs 2.7%).","recommendations":[{"text":"In AIS patients with anterior circulation proximal LVO (ICA or M1), presenting within 6 hours of symptom onset, with NIHSS 6 or greater, prestroke mRS 0-1, and ASPECTS 3-10, EVT (endovascular thrombectomy) is recommended to improve functional outcomes and reduce mortality.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-114 · p. 53","id":"ais-2026-114"},{"text":"In selected patients with AIS from anterior circulation proximal LVO (ICA or M1), presenting 6-24 hours from symptom onset, age under 80, NIHSS 6 or greater, prestroke mRS 0-1, ASPECTS 3-5, and without significant mass effect on imaging, EVT is recommended to improve functional outcomes and reduce mortality.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-116 · p. 53","id":"ais-2026-116"},{"text":"In selected AIS patients with anterior circulation proximal LVO (ICA or M1) presenting within 6 hours, age under 80, NIHSS 6 or greater, prestroke mRS 0-1, ASPECTS 0-2, and without significant mass effect, EVT is reasonable to improve functional outcomes and reduce mortality.","cor":"2a","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-117 · p. 53","id":"ais-2026-117"}],"consider":["Measure the core consistently (NCCT/MRI ASPECTS or CTP core) and confirm age, baseline mRS and mass effect.","Set expectations: the benefit is mostly less disability, not independence (LASTE median mRS 4 vs 6).","SVIN 2025: ASPECTS 0–5 within 6 h (age 18–80, mRS 0–1) is Class I (LASTE); ASPECTS 0–2 at 6–24 h — benefit uncertain (2b).","ATLAS (Lancet 2026; postdates AHA 2026 and SVIN 2025), IPD of 6 RCTs (n=1886): better mRS (aGenOR 1.63) and lower mortality (31.1 vs 37.3%) up to 24 h, consistent across ASPECTS and core strata; evidence is limited for core ≥150 mL beyond 6 h."],"caution":"Trial age limits: ANGEL-ASPECT ≤80; SELECT2 and TESLA ≤85; none in RESCUE-Japan LIMIT or TENSION; LASTE had no upper limit but required ASPECTS 4–5 at age ≥80 (registry: 3–5), so it gives no evidence for ASPECTS 0–2 at that age. All but TENSION (mRS ≤2) required prestroke mRS 0–1.","sources":[{"title":"Endovascular Therapy in Patients With Acute Ischemic Stroke With Large Infarct: A Guideline From the Society of Vascular and Interventional Neurology","url":"https://pubmed.ncbi.nlm.nih.gov/41573174/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PMC full text (PMC12671639) re-read: 0–6 h Class I table and trial age/mRS limits; on 2026-10-31 also the TESLA 1-year utility-weighted mRS result and the Table 2 SELECT2 1-year mortality (45.3 vs 52.2%). The 6–24 h table did not render, so its 2b wording is from the archived transcription."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Canadian Stroke Best Practice Recommendations: Endovascular Thrombectomy for Acute Ischemic Stroke, Interim Update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41340372/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed abstract only. The update addresses posterior circulation stroke, large core and MeVO, and supersedes the EVT recommendations in the 2022 CSBPR acute stroke management module; recommendation wording and evidence levels were not read (publisher and strokebestpractices.ca not reached), so nothing is quoted on the cards."},{"title":"SELECT2 — Trial of Endovascular Thrombectomy for Large Ischemic Strokes.","url":"https://pubmed.ncbi.nlm.nih.gov/36762865/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card. PubMed lists 1 correction or notice; check it before applying results."},{"title":"SELECT2 1-year — Endovascular thrombectomy plus medical care versus medical care alone for large ischaemic stroke: 1-year outcomes of the SELECT2 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38346442/","year":2024,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; 1-year follow-up of the original randomized population."},{"title":"ANGEL-ASPECT — Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct.","url":"https://pubmed.ncbi.nlm.nih.gov/36762852/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ANGEL-ASPECT 1-year — Endovascular Therapy Versus Medical Management for Large Ischemic Infarct: 1-Year Outcomes of the ANGEL-ASPECT Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40854041/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; prespecified 1-year analysis of the original randomized population (complete-case, 425 of 455)."},{"title":"RESCUE-Japan LIMIT — Endovascular Therapy for Acute Stroke with a Large Ischemic Region.","url":"https://pubmed.ncbi.nlm.nih.gov/35138767/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"TENSION — Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37837989/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"LASTE — Trial of Thrombectomy for Stroke with a Large Infarct of Unrestricted Size.","url":"https://pubmed.ncbi.nlm.nih.gov/38718358/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ATLAS — Endovascular thrombectomy for patients with large-core ischaemic stroke presenting up to 24 h after onset (ATLAS): a systematic review and individual patient data meta-analysis with central imaging adjudication.","url":"https://pubmed.ncbi.nlm.nih.gov/42107392/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"TESLA — Thrombectomy for Stroke With Large Infarct on Noncontrast CT: The TESLA Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39374319/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"TESLA 1-year — One-Year Outcomes After Endovascular Treatment for Large Acute Ischemic Stroke: The TESLA Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42545711/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed bibliographic record checked (JAMA research letter; no abstract; PMC13434966 body empty; publisher site unreachable); results not reviewed here. Long-term follow-up of the original randomized population; the 1-year benefit on the card is sourced to the SVIN 2025 large-core guideline."},{"title":"TENSION antithrombotic analysis — Large Core Stroke Thrombectomy Is Safe and Effective Regardless of Prior Antithrombotic or Thrombolytic Treatment: A Secondary Analysis of the Randomized TENSION Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42261979/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. Secondary analysis; prior antithrombotic treatment was not the randomized intervention."},{"title":"LASTE ASPECTS 0-2 — Endovascular Thrombectomy in Patients With Largest Baseline Infarcts (ASPECTS 0-2): An Ancillary Analysis of the LASTE Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41979451/","year":2026,"type":"Report","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. Ancillary analysis of the randomized trial population."},{"title":"ANGEL-ASPECT HMCAS analysis — Effects of Computed Tomography Hyperdense Middle Cerebral Artery Sign on the Efficacy of Endovascular Therapy in Acute Ischemic Stroke With Large Infarcts: A Subgroup Analysis of the ANGEL-ASPECT Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41914357/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. Subgroup analysis; the imaging sign was not a randomized exposure."}],"related":[{"label":"ASPECTS","href":"#/encounter/aspects"},{"label":"CT perfusion","href":"#/evidence/ct-perfusion"},{"label":"Malignant infarction","href":"#/evidence/malignant-edema"}]},{"id":"basilar-occlusion","title":"Basilar artery occlusion","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["basilar","posterior circulation","BAO","LVO","ATTENTION","BAOCHE","BASICS","TRACE-5","ATTENTION LATE","pc-ASPECTS"],"summary":"Basilar occlusion with NIHSS ≥10, PC-ASPECTS ≥6 and baseline mRS 0–1: EVT within 24 h (AHA 2026, COR 1). ATTENTION (≤12 h): mRS 0–3 46 vs 23%, mortality 37 vs 55%; BAOCHE (6–24 h): 46 vs 24%. NIHSS 6–9: benefit not established (2b; ESO suggests best medical treatment for NIHSS <10). Give IVT if eligible (ESO suggests IVT plus EVT over direct EVT); TRACE-5 tenecteplase within 24 h improved mRS 0–1 or return to baseline (38 vs 29%), but ATTENTION LATE found no gain from tenecteplase before EVT at 4.5–24 h (30 vs 30%).","recommendations":[{"text":"In AIS patients with basilar artery occlusion, baseline mRS 0-1, NIHSS 10 or greater, and PC-ASPECTS 6 or greater (mild ischemic damage), EVT within 24 hours of symptom onset is recommended to achieve better functional outcome and reduce mortality.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-122 · p. 56","id":"ais-2026-122"},{"text":"In AIS patients with basilar artery occlusion, baseline mRS 0-1, NIHSS 6-9, and PC-ASPECTS 6 or greater, the effectiveness of EVT within 24 hours for improving functional outcomes and reducing mortality is not well established.","cor":"2b","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-123 · p. 57","id":"ais-2026-123"}],"consider":["A low NIHSS can understate posterior-circulation disability; recheck for fluctuation.","Very extensive bilateral or brainstem infarction: ESO consensus suggests no reperfusion; with PC-ASPECTS 0–6, weigh age, frailty and prestroke disability.","First pass: aspiration is suggested over a stent retriever (ESO, weak). With suspected intracranial atherosclerosis and severe basilar stenosis, ESO consensus (written before ANGEL-REBOOT) suggests rescue angioplasty or stenting after failed EVT; AHA 2026 rates rescue angioplasty or stenting after failed EVT as uncertain (2b)."],"caution":"Most trial patients were Chinese with severe deficits; evidence for mild BAO is weak.","sources":[{"title":"European Stroke Organisation and European Society for Minimally Invasive Neurological Therapy guideline on acute management of basilar artery occlusion","url":"https://pubmed.ncbi.nlm.nih.gov/38752743/","year":2024,"type":"Guideline","checkedAt":"2026-10-21","access":"PMC full text (PMC11569583) synoptic table read; certainty symbols did not render."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Canadian Stroke Best Practice Recommendations: Endovascular Thrombectomy for Acute Ischemic Stroke, Interim Update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41340372/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed abstract only. The update addresses posterior circulation stroke, large core and MeVO, and supersedes the EVT recommendations in the 2022 CSBPR acute stroke management module; recommendation wording and evidence levels were not read (publisher and strokebestpractices.ca not reached), so nothing is quoted on the cards."},{"title":"ATTENTION — Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion.","url":"https://pubmed.ncbi.nlm.nih.gov/36239644/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"BAOCHE — Trial of Thrombectomy 6 to 24 Hours after Stroke Due to Basilar-Artery Occlusion.","url":"https://pubmed.ncbi.nlm.nih.gov/36239645/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"BASICS — Endovascular Therapy for Stroke Due to Basilar-Artery Occlusion.","url":"https://pubmed.ncbi.nlm.nih.gov/34010530/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"VERITAS — Endovascular therapy for acute vertebrobasilar occlusion (VERITAS): a systematic review and individual patient data meta-analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/39674187/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"TRACE-5 — Tenecteplase versus standard medical treatment for basilar artery occlusion within 24 h (TRACE-5): a multicentre, prospective, randomised, open-label, blinded-endpoint, superiority, phase 3 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41655588/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ATTENTION LATE — Tenecteplase Before Thrombectomy at 4.5 to 24 Hours for Basilar Artery Occlusion: The ATTENTION LATE Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42776543/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ATTENTION 1-year secondary analysis — Endovascular vs Medical Management of Acute Basilar Artery Occlusion: A Secondary Analysis of a Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39186280/","year":2024,"type":"Report","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. Secondary follow-up analysis, not a new randomized trial. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ATTENTION 3-year follow-up — Endovascular vs Medical Treatment of Basilar Artery Occlusion: 3-Year Outcomes of the ATTENTION Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41460644/","year":2026,"type":"Report","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. Long-term follow-up of the original randomized population."}],"related":[{"label":"PC-ASPECTS","href":"#/encounter/pc-aspects"},{"label":"Acute dizziness","href":"#/evidence/dizziness"},{"label":"EVT technique and rescue","href":"#/evidence/neurointerventional-care"}]},{"id":"medium-distal-evt","title":"Medium and distal vessel occlusion","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["MeVO","DMVO","distal","M2","M3","dominant M2","ACA","PCA","DISTAL","ESCAPE-MeVO","DISCOUNT","ORIENTAL-MeVO"],"summary":"Routine EVT for medium or distal occlusion is not supported — AHA 2026 rates nondominant or codominant M2, distal MCA, ACA and PCA occlusion COR 3: No Benefit — but EVT is reasonable for a disabling dominant proximal M2 occlusion within 6 h with NIHSS ≥6, ASPECTS ≥6 and prestroke mRS 0–1 (AHA 2026, 2a). DISTAL (n=543) and ESCAPE-MeVO (n=530; mortality 13.3 vs 8.4%) showed no functional benefit, and DISCOUNT (n=244) stopped for futility and excess sICH (11 vs 3% among those treated). ORIENTAL-MeVO (China, NIHSS ≥6, ≤24 h) is the only positive trial (mRS 0–2 58.6 vs 46.6%; sICH 4.7 vs 2.2%). SVIN 2026 says EVT may be considered (2b) for distal, codominant or nondominant M2 with a disabling deficit and NIHSS ≥6, and rates disabling proximal and/or dominant M2 2a.","recommendations":[{"text":"In AIS patients with occlusion of the dominant proximal M2 division of the MCA presenting within 6 hours, prestroke mRS 0-1, NIHSS 6 or greater, and ASPECTS 6 or greater, EVT is reasonable to improve functional outcomes, though benefits are uncertain.","cor":"2a","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-120 · p. 53","id":"ais-2026-120"},{"text":"In AIS patients with occlusion of the proximal nondominant or codominant M2 segment, distal MCA, anterior cerebral artery, or posterior cerebral artery, EVT is not recommended as it does not improve functional outcomes.","cor":"3: No Benefit","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-121 · p. 54","id":"ais-2026-121"},{"text":"EVT is reasonable for patients with disabling stroke due to proximal and/or dominant M2 occlusions, particularly when associated with moderate-to-severe deficits and imaging evidence of salvageable brain tissue.","cor":"2a","loe":"B-NR","source":"SVIN MeVO 2026 · svin-mevo-dvo-evt-2026-r1","id":"svin-mevo-dvo-evt-2026-r1"},{"text":"EVT may be considered in distal, codominant, or nondominant M2 occlusions who present with disabling deficits and an NIHSS score ≥6.","cor":"2b","loe":"B-R","source":"SVIN MeVO 2026 · svin-mevo-dvo-evt-2026-r2","id":"svin-mevo-dvo-evt-2026-r2"}],"consider":["Confirm the segment (dominant vs codominant/nondominant M2, M3, ACA, PCA), a disabling deficit and IVT eligibility; give IVT if eligible.","SVIN 2026: routine EVT is not recommended for distal ACA (A2/A3) or isolated PCA occlusion (COR 3: No Benefit, B-NR) and is not standard for M3/M4 (COR 3: No Benefit, B-R); it may be considered case by case for ACA occlusion with disabling deficits, large territory at risk, favorable imaging and good baseline function (2b, B-NR), and in selected patients with P1–P3 occlusion who present early, have severe deficits or cannot receive IVT (2b, B-R).","Review ORIENTAL-MeVO's population limits with the intervention team.","Secondary analyses (2026; hypothesis-generating): in DISTAL, EVT was associated with a worse 90-day mRS when admission NIHSS was ≤4 (cOR 0.47; 95% CI 0.25–0.89) but not above 4 (cOR 1.05; 95% CI 0.75–1.47); in ESCAPE-MeVO (309 of 530 with baseline perfusion imaging), perfusion mismatch volume or ratio did not modify the EVT effect."],"caution":"The AHA 2026 grading predates ORIENTAL-MeVO and DISCOUNT; one positive Chinese trial does not establish benefit for every M2 or distal lesion.","sources":[{"title":"Endovascular Thrombectomy in Medium and Distal Vessel Occlusions: A Focused Guideline From the Society of Vascular and Interventional Neurology Guidelines and Practice Standards Committee","url":"https://pubmed.ncbi.nlm.nih.gov/42404835/","year":2026,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary full text (PMC13331429) checked for the quoted recommendations."},{"title":"DISTAL: Endovascular Treatment for Stroke Due to Occlusion of Medium or Distal Vessels","url":"https://pubmed.ncbi.nlm.nih.gov/39908430/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"ESCAPE-MeVO: Endovascular Treatment of Stroke Due to Medium-Vessel Occlusion","url":"https://pubmed.ncbi.nlm.nih.gov/39908448/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"ORIENTAL-MeVO: Endovascular Treatment of Medium-Vessel-Occlusion Strokes","url":"https://pubmed.ncbi.nlm.nih.gov/42127389/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Canadian Stroke Best Practice Recommendations: Endovascular Thrombectomy for Acute Ischemic Stroke, Interim Update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41340372/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed abstract only. The update addresses posterior circulation stroke, large core and MeVO, and supersedes the EVT recommendations in the 2022 CSBPR acute stroke management module; recommendation wording and evidence levels were not read (publisher and strokebestpractices.ca not reached), so nothing is quoted on the cards."},{"title":"DISCOUNT — Mechanical Thrombectomy in Ischemic Stroke With a Medium or Distal Arterial Occlusion: The DISCOUNT Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42485024/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ORIENTAL-MeVO ACAo Registry — Endovascular Thrombectomy Versus Standard Medical Management in Acute Anterior Cerebral Artery Occlusion Stroke: The ORIENTAL-MeVO Registry Study.","url":"https://pubmed.ncbi.nlm.nih.gov/42017224/","year":2026,"type":"Observational study","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22; bibliographic record checked. Retrospective propensity-weighted registry analysis, not the randomized ORIENTAL-MeVO trial."},{"title":"DISTAL 12-month follow-up — Endovascular treatment for medium or distal vessel occlusion stroke (DISTAL): 12-month outcomes of a multicentre, open-label, randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42105785/","year":2026,"type":"Report","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. Long-term follow-up of the original randomized population."},{"title":"DISTAL secondary analysis — Differential Effect of Endovascular Treatment in Medium or Distal Vessel Occlusion: A Distal Secondary Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42961033/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; secondary analysis of the randomized population, not a new trial."},{"title":"ESCAPE-MeVO perfusion post hoc — Thrombectomy for Acute Stroke Due to Medium Vessel Occlusion Across Perfusion Mismatch Profiles: A Post Hoc Analysis of the ESCAPE-MeVO Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42867860/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; exploratory post hoc analysis limited to 309 of 530 patients with baseline perfusion imaging."}],"related":[{"label":"DISCOUNT","href":"#/evidence/discount"},{"label":"ESCAPE-MeVO","href":"#/evidence/escape-mevo"}]},{"id":"retinal-ischemia","title":"Acute retinal ischemia and CRAO","category":"Acute ischemic stroke","settings":["on-call","hospital","clinic"],"keywords":["CRAO","retinal artery","monocular vision","amaurosis","retinal stroke","ophthalmology","THEIA","TenCRAOS","nonarteritic","alteplase","tenecteplase"],"summary":"Treat acute central retinal artery occlusion as an ischemic stroke emergency — immediate ED stroke evaluation, urgent ophthalmology, arteritis screening and vascular risk-factor treatment (AHA 2021 statement) — although IVT within 4.5 h for non-arteritic CRAO is of uncertain usefulness (AHA 2026, COR 2b). The grade applies to non-arteritic CRAO with disabling visual loss in an otherwise IVT-eligible adult within 4.5 h of last known well (AHA 2026, COR 2b, LOE C-LD): THEIA (alteplase vs aspirin) and TenCRAOS (tenecteplase vs aspirin) showed no significant visual benefit, and TenCRAOS had one fatal intracranial hemorrhage.","consider":["Confirm the ophthalmic diagnosis and onset; coordinate stroke and ophthalmology assessment.","Both trials studied nonarteritic CRAO; suspected arteritis needs its own pathway.","THEIA measured visual acuity and TenCRAOS a vision-recovery threshold; weigh safety alongside benefit.","ESO 2025 suggests IVT within 4.5 h for CRAO (weak wording; very low-quality nonrandomized evidence through 2023, before THEIA and TenCRAOS). The ESO Annual Stroke Evidence Update (February 2026; the authors' interpretation, not a guideline recommendation) states that THEIA and TenCRAOS do not support routine IVT for acute CRAO and encourages trial enrolment."],"caution":"Small neutral trials do not prove equivalence, and the 2021 AHA statement predates them. A 2025 individual-participant meta-analysis of nonrandomized studies (searched to June 2023; nonarteritic CRAO with severe vision loss; published after the AHA 2026 literature cutoff) associated IVT within 4.5 h with more recovery from severe vision loss than conservative care (28.8 vs 11.1%); its authors call for powered RCTs, and THEIA and TenCRAOS did not show benefit.","sources":[{"title":"Management of Central Retinal Artery Occlusion: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/33677974/","year":2021,"type":"Scientific statement","checkedAt":"2026-10-22","access":"Primary abstract read; ED-triage and arteritis-screening details from the archived transcription; full statement not reviewed. Indexed correction(s) 34029154 not reconciled."},{"title":"THEIA: Intravenous alteplase versus oral aspirin for acute central retinal artery occlusion within 4.5 hours of severe vision loss","url":"https://pubmed.ncbi.nlm.nih.gov/41109232/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"TenCRAOS: A Randomized Trial of Tenecteplase in Acute Central Retinal Artery Occlusion","url":"https://pubmed.ncbi.nlm.nih.gov/41604638/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"ESO guideline on visual impairment in stroke (2025)","url":"https://pubmed.ncbi.nlm.nih.gov/40401755/","year":2025,"type":"Guideline","checkedAt":"2026-10-17","access":"PMC full text (PMC12098360) read for PICO 9 and its evidence table."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"ESO annual stroke evidence update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41706824/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PMC full text (PMC12915583) read 2026-10-31. ESO Guideline Board evidence review; its practice implications are the authors' interpretation, not guideline recommendations."},{"title":"CRAO thrombolysis IPD meta-analysis — Early Thrombolysis and Outcomes in Central Retinal Artery Occlusion: An Individual Participant Data Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/40832714/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Nonrandomized studies searched to June 2023."}],"related":[]},{"id":"neurointerventional-care","title":"EVT technique, anesthesia and rescue questions","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["anesthesia","aspiration","stent retriever","tandem lesion","rescue stenting","angioplasty","intra arterial thrombolysis","adjuncts","EDESTROKE"],"summary":"Aim for eTICI 2b–3 as early as possible with a stent retriever, aspiration or both (AHA 2026, COR 1); general anesthesia or procedural sedation are both acceptable (COR 1). Tandem lesions: treating both may be reasonable (2b). Intra-arterial thrombolytic after mTICI ≥2b may be reasonable (2b); preprocedural tirofiban is not useful (COR 3: No Benefit). Rescue angioplasty or stenting after failed EVT remains uncertain (2b); in ANGEL-REBOOT (China; eTICI 0–2a or >70% residual stenosis after EVT, tirofiban in 96%) it did not improve 90-day mRS (cOR 0.86) and raised sICH (5 vs 1%); a later 1-year report (2025, after the AHA 2026 literature window) found a better mRS distribution (generalized OR 1.34), less same-artery recurrence (4 vs 13%) and similar mortality (15 vs 17%).","consider":["Document final eTICI, complications, access site and the BP plan for the receiving team. Tandem stenting or rescue stenting commits the patient to antiplatelets — weigh hemorrhage risk.","Avoid SBP drops during the procedure (prior ESO advice; the ESO 2025 BP update notes no study defines a safe drop).","Extubation timing after successful EVT under general anesthesia (EDESTROKE, JAMA Neurol 2026; single center in Spain; n=174, anterior-circulation LVO): early (<6 h) vs delayed (6–12 h) extubation did not improve 90-day mRS 0–2 (47.7 vs 45.9%; RR 1.04, 95% CI 0.76–1.43); pneumonia 21.8 vs 29.9% (RR 0.73, 95% CI 0.44–1.22) and reintubation 4.6 vs 2.3% were imprecise.","IA lytic after successful EVT: ANGEL-TNK, PEARL and CHOICE-2 improved mRS 0–1 (CHOICE-2 57.5 vs 42.5%), but 90-day mortality was higher with IA alteplase in CHOICE-2 (12.1 vs 6.4%, P=.03) and PEARL (17.1 vs 11.3%, not significant); POST-UK, POST-TNK and, in the posterior circulation, ATTENTION-IA and IAT-TOP were neutral. ANGEL-TNK and PEARL (2025) appeared after the AHA 2026 literature window (through March 2025), CHOICE-2 and IAT-TOP after the guideline itself."],"caution":"Technique choices depend on operator expertise and devices; this card is not a procedural protocol.","sources":[{"title":"European Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischaemic StrokeEndorsed by Stroke Alliance for Europe (SAFE)","url":"https://pubmed.ncbi.nlm.nih.gov/31165090/","year":2019,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"ANGEL-REBOOT 1-year outcomes: bailout intracranial angioplasty or stenting after thrombectomy","url":"https://pubmed.ncbi.nlm.nih.gov/41122847/","year":2025,"type":"Report","checkedAt":"2026-10-22","access":"Primary abstract read via PubMed on 2026-10-22. Long-term follow-up of the original randomized population (326 of 348 completed 1 year)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"2025 update to European Stroke Organisation (ESO) guideline on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/42095756/","year":2026,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (against intensive SBP lowering <140 in the first 24 h after successful thrombectomy, high certainty); other recommendations from the archived full-text transcription (reviewed 2026-09-30). Published in 2026 under a 2025-update title."},{"title":"CHOICE — Effect of Intra-arterial Alteplase vs Placebo Following Successful Thrombectomy on Functional Outcomes in Patients With Large Vessel Occlusion Acute Ischemic Stroke: The CHOICE Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35143603/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"CHOICE-2 — Adjunctive Intra-Arterial Alteplase After Successful Thrombectomy for Acute Ischemic Stroke: The CHOICE-2 Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42096239/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"ANGEL-REBOOT — Bailout intracranial angioplasty or stenting following thrombectomy for acute large vessel occlusion in China (ANGEL-REBOOT): a multicentre, open-label, blinded-endpoint, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38914085/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"PROTECT-MT — Balloon guide catheters for endovascular thrombectomy in patients with acute ischaemic stroke due to large-vessel occlusion in China (PROTECT-MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39579782/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"PEARL — Intra-Arterial Alteplase After Successful Endovascular Reperfusion in Acute Stroke: The PEARL Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42262770/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"ANGEL-TNK — Intra-arterial Tenecteplase for Acute Stroke After Successful Endovascular Therapy: The ANGEL-TNK Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40616323/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"IAT-TOP — Intra-arterial Alteplase Thrombolysis After Successful Thrombectomy for AIS in the Posterior Circulation: The IAT-TOP Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42026933/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"DATE (IA tenecteplase dose-escalation) — Intra-Arterial Tenecteplase After Successful Reperfusion in Large Vessel Occlusion Stroke: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40616333/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"IA Thrombolysis Dose Network Meta-analysis — Dose-Specific Intra-Arterial Thrombolysis After Endovascular Thrombectomy for Large-Vessel Occlusion Stroke: A Network Meta-Analysis of Randomized Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42088338/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: network meta-analysis of 7 randomized trials (2126 patients), hypothesis-generating per its authors; bibliographic record checked."},{"title":"ASTER — Effect of Endovascular Contact Aspiration vs Stent Retriever on Revascularization in Patients With Acute Ischemic Stroke and Large Vessel Occlusion: The ASTER Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/28763550/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"COMPASS (thrombectomy) — Aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion (COMPASS): a multicentre, randomised, open label, blinded outcome, non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/30860055/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"ASTER2 — Effect of Thrombectomy With Combined Contact Aspiration and Stent Retriever vs Stent Retriever Alone on Revascularization in Patients With Acute Ischemic Stroke and Large Vessel Occlusion: The ASTER2 Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/34581737/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"VECTOR — Safety and efficacy of stent retrievers plus contact aspiration in patients with acute ischaemic anterior circulation stroke and positive susceptibility vessel sign in France (VECTOR): a randomised, single-blind trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38876748/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"SIESTA — Effect of Conscious Sedation vs General Anesthesia on Early Neurological Improvement Among Patients With Ischemic Stroke Undergoing Endovascular Thrombectomy: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/27785516/","year":2016,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"GOLIATH — Effect of General Anesthesia and Conscious Sedation During Endovascular Therapy on Infarct Growth and Clinical Outcomes in Acute Ischemic Stroke: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/29340574/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"AnStroke — General Anesthesia Versus Conscious Sedation for Endovascular Treatment of Acute Ischemic Stroke: The AnStroke Trial (Anesthesia During Stroke).","url":"https://pubmed.ncbi.nlm.nih.gov/28522637/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CANVAS II — General Anesthesia vs Conscious Sedation for Endovascular Treatment in Patients With Posterior Circulation Acute Ischemic Stroke: An Exploratory Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/36156704/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"GA vs non-GA Bayesian meta-analysis — General Anesthesia Versus Non-GA in Endovascular Therapy for Acute Ischemic Stroke: A Systematic Review and Bayesian Meta-Analysis of RCTs.","url":"https://pubmed.ncbi.nlm.nih.gov/42462185/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"EDESTROKE — Early vs Delayed Extubation After Thrombectomy for Acute Ischemic Stroke: The EDESTROKE Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41910960/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; single-center trial; full text (PMC13036632) not reviewed."},{"title":"CERES-TANDEM — Emergent Carotid Stenting for Acute Anterior Circulation Ischemic Stroke With Tandem Lesions: The Multicenter CERES-TANDEM Study.","url":"https://pubmed.ncbi.nlm.nih.gov/41453121/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"IRIS tandem-lesion carotid-stenting analysis — Acute Carotid Stenting for Tandem Lesions in Patients Randomized to Endovascular Treatment With or Without Thrombolysis: Results From the IRIS Individual Participant Data Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/41104449/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"POST-TNK — Intra-Arterial Tenecteplase Following Endovascular Reperfusion for Large Vessel Occlusion Acute Ischemic Stroke: The POST-TNK Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39804681/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"POST-UK — Intra-Arterial Urokinase After Endovascular Reperfusion for Acute Ischemic Stroke: The POST-UK Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39804674/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"ATTENTION-IA — Intra-arterial tenecteplase after successful endovascular recanalisation in patients with acute posterior circulation arterial occlusion (ATTENTION-IA): multicentre randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39809509/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."}],"related":[{"label":"Post-EVT reference","href":"#/protocols/ischemic/post-evt"}]},{"id":"malignant-edema","title":"Malignant infarction: hemicraniectomy and cerebellar decompression","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["malignant infarction","edema","hemicraniectomy","decompressive craniectomy","DESTINY","DECIMAL","HAMLET","cerebellar infarct","suboccipital","hydrocephalus","osmotherapy"],"summary":"Age ≤60 with unilateral MCA infarction deteriorating within 48 h despite medical therapy: decompressive craniectomy (AHA 2026, COR 1) — pooled DECIMAL/DESTINY/HAMLET: survival 78 vs 29% and mRS ≤3 43 vs 21% (NNT 2 and 4). Over 60: may be considered to reduce mortality (2b); DESTINY II (61–82 y) doubled survival with mRS 0–4 (38 vs 18%), but no one reached mRS 0–2. Cerebellar infarction: ventriculostomy for obstructive hydrocephalus; suboccipital decompression for brainstem compression or volume ≥35 mL (COR 1).","recommendations":[{"text":"In patients 60 years of age or younger with unilateral MCA infarctions who deteriorate neurologically within 48 hours from brain swelling despite medical therapy, decompressive craniectomy with dural expansion is recommended to reduce mortality and improve functional outcome.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-189 · p. 82","id":"ais-2026-189"},{"text":"In patients over 60 years of age with unilateral MCA infarctions who deteriorate neurologically within 48 hours from brain swelling despite medical therapy, decompressive craniectomy with dural expansion may be considered to reduce mortality.","cor":"2b","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-190 · p. 82","id":"ais-2026-190"},{"text":"In patients with cerebellar infarction and obstructive hydrocephalus, ventriculostomy is recommended to improve neurological function and decrease mortality. Concomitant or subsequent decompressive craniectomy may or may not be necessary based on infarction size, neurological condition, degree of brainstem compression, and effectiveness of medical management.","cor":"1","loe":"C-LD","source":"AHA/ASA AIS 2026 · ais-2026-192 · p. 84","id":"ais-2026-192"},{"text":"In patients with cerebellar infarction causing neurological deterioration from brainstem compression or infarct volumes 35 mL or greater, decompressive suboccipital craniectomy with dural expansion is recommended to improve outcomes and decrease mortality.","cor":"1","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-193 · p. 84","id":"ais-2026-193"}],"consider":["Discuss goals early and transfer large MCA or cerebellar infarcts to a neurosurgical center before they swell.","Falling consciousness from swelling is a reasonable trigger for surgery (2a); use osmotherapy only as a bridge.","Avoid hypothermia, barbiturates and corticosteroids for swelling (COR 3: Harm); IV glibenclamide did not help at ages 18–70 (COR 3: No Benefit)."],"caution":"Surgery saves lives, but most older survivors need help with daily care; decide with the outcomes the patient would accept.","sources":[{"title":"European Stroke Organisation (ESO) guidelines on the management of space-occupying brain infarction","url":"https://pubmed.ncbi.nlm.nih.gov/34414308/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"NCS acute treatment of cerebral edema guideline","url":"https://pubmed.ncbi.nlm.nih.gov/32227294/","year":2020,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract and source scope checked; full recommendation text not reviewed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"CHARM — Intravenous glibenclamide for cerebral oedema after large hemispheric stroke (CHARM): a phase 3, double-blind, placebo-controlled, randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39577921/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"DECIMAL — Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial).","url":"https://pubmed.ncbi.nlm.nih.gov/17690311/","year":2007,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"DESTINY — Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/17690310/","year":2007,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"HAMLET — Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/19269254/","year":2009,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"DESTINY II — Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/24645942/","year":2014,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"DECIMAL/DESTINY/HAMLET — Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials.","url":"https://pubmed.ncbi.nlm.nih.gov/17303527/","year":2007,"type":"Meta-analysis","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed; bibliographic record checked."}],"related":[{"label":"Prognosis","href":"#/evidence/neuroprognostication"},{"label":"Goals of care","href":"#/evidence/goals-of-care"}]},{"id":"acute-bp","title":"Acute blood pressure targets by pathway","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["blood pressure","post EVT","post IVT","hypertension","permissive hypertension","ENCHANTED","OPTIMAL-BP","HOPE","INTERACT4","prehospital"],"summary":"Before IVT <185/110 (AHA 2026, COR 1); EVT without IVT: ≤185/110 before the procedure (AHA 2026, 2a); after IVT <180/105 for at least 24 h (COR 1); during and for 24 h after EVT ≤180/105 (AHA 2026, 2a; ESO 2025 update: <180/105), but do not target SBP <140 for 72 h after successful (mTICI 2b–3) anterior-LVO EVT (COR 3: Harm). The ESO 2025 update also advises against SBP <140 in the first 24 h after successful EVT (high certainty): ENCHANTED2/MT (<120) worsened mRS (OR 1.37), OPTIMAL-BP (<140) lowered mRS 0–2 from 54.4 to 39.4%, and Cochrane 2026 (9 RCTs after IVT or EVT; intensive targets <160, mostly <140, vs mostly <180) found probably higher mortality (RR 1.19, 95% CI 1.08–1.32). HOPE (2026, post-guideline; open-label, stopped early, hypothesis-generating) favored reperfusion-guided targets but does not override COR 3: Harm. No reperfusion and <220/120: starting treatment in the first 48–72 h does not help; ≥220/120: benefit uncertain (AHA 2026, 2b; ESO 2025 expert consensus: if lowered, reduce SBP by <15% over 24 h). No routine prehospital lowering (AHA 2026, COR 3: No Benefit; ESO 2025, moderate certainty; INTERACT4 ischemic stroke cOR 1.30).","recommendations":[{"text":"AIS patients with elevated BP who are otherwise eligible for IVT are recommended to have SBP lowered below 185 mmHg and DBP below 110 mmHg before initiating IVT therapy to reduce hemorrhagic complications.","cor":"1","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-72 · p. 35","id":"ais-2026-72"},{"text":"After IVT treatment, BP is recommended to be maintained below 180/105 mmHg for at least the first 24 hours.","cor":"1","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-74 · p. 35","id":"ais-2026-74"},{"text":"In patients who undergo EVT, it is reasonable to maintain BP at or below 180/105 mmHg during and for 24 hours after the procedure.","cor":"2a","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-76 · p. 35","id":"ais-2026-76"},{"text":"In AIS patients with anterior circulation LVO who have been successfully recanalized by EVT (mTICI 2b, 2c, or 3) without other indications for specific BP targets, intensive SBP reduction to below 140 mmHg for the first 72 hours is harmful and not recommended.","cor":"3: Harm","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-77 · p. 35","id":"ais-2026-77"},{"text":"In patients with mild to moderate severity AIS treated with IVT, intensive SBP reduction (target below 140 mmHg compared with below 180 mmHg) is not recommended as it does not improve functional outcome.","cor":"3: No Benefit","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-75 · p. 35","id":"ais-2026-75"}],"consider":["After alteplase, SBP 130–140 did not improve 90-day function versus <180, though any ICH was less frequent (14.8 vs 18.7%) (ENCHANTED; AHA 2026 COR 3: No Benefit, graded for mild-to-moderate stroke); in its prespecified severe-stroke subgroup (LVO, EVT, large-artery disease or NIHSS >10), intensive lowering raised mortality (OR 1.52; hypothesis-generating).","Treat hypertension early when a comorbid condition requires it (e.g., ACS, heart failure, aortic dissection, post-IVT sICH, preeclampsia; AHA 2026 COR 1); correct hypotension and hypovolemia. For neurological deterioration without IVT or EVT, ESO 2025 discourages routine vasopressors to raise BP (low certainty).","Hold home oral antihypertensives while swallowing is unsafe; ESO advises against routinely continuing them in the acute phase."],"caution":"One number does not fit every pathway; ICH and long-term targets are on their own cards.","sources":[{"title":"2025 update to European Stroke Organisation (ESO) guideline on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/42095756/","year":2026,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; recommendation boxes and the >220/120 expert consensus not read at primary scope."},{"title":"The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/38804130/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"ENCHANTED (BP arm): intensive vs guideline BP lowering with alteplase","url":"https://pubmed.ncbi.nlm.nih.gov/30739745/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"Comparative effects of intensive-blood pressure versus standard-blood pressure-lowering treatment in patients with severe ischemic stroke in the ENCHANTED trial","url":"https://pubmed.ncbi.nlm.nih.gov/33031175/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-22","access":"Primary abstract read: prespecified subgroup of the ENCHANTED BP arm (1,311 severe ischemic strokes: LVO, EVT, large-artery disease or NIHSS >10); mortality OR 1.52 (1.09–2.13), clinician-reported ICH OR 0.63."},{"title":"Cochrane review: BP management in reperfused ischemic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/42445947/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed (9 RCTs; search to March 2025)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"HOPE (reperfusion-guided BP) — Personalized Blood Pressure Targeting After Endovascular Therapy for Acute Ischemic Stroke: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42258192/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"INTERACT3 — The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37245517/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ENCHANTED2/MT — Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/36341753/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"INTERACT2 — Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/23713578/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ATACH-2 — Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/27276234/","year":2016,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"OPTIMAL-BP — Intensive vs Conventional Blood Pressure Lowering After Endovascular Thrombectomy in Acute Ischemic Stroke: The OPTIMAL-BP Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37668619/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"INTERACT4 — Intensive Ambulance-Delivered Blood-Pressure Reduction in Hyperacute Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/38752650/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"CATIS — Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial.","url":"https://pubmed.ncbi.nlm.nih.gov/24240777/","year":2014,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CATIS-2 — Early versus delayed antihypertensive treatment in patients with acute ischaemic stroke: multicentre, open label, randomised, controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37813418/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ENOS — Efficacy of nitric oxide, with or without continuing antihypertensive treatment, for management of high blood pressure in acute stroke (ENOS): a partial-factorial randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/25465108/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"COSSACS — Effects of antihypertensive treatment after acute stroke in the Continue or Stop Post-Stroke Antihypertensives Collaborative Study (COSSACS): a prospective, randomised, open, blinded-endpoint trial.","url":"https://pubmed.ncbi.nlm.nih.gov/20621562/","year":2010,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SCAST — The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial.","url":"https://pubmed.ncbi.nlm.nih.gov/21316752/","year":2011,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CHASE — Controlling Hypertension After Severe Cerebrovascular Event (CHASE): A randomized, multicenter, controlled study.","url":"https://pubmed.ncbi.nlm.nih.gov/32525464/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Early AHT in AIS meta-analysis — Early antihypertensive therapy in acute ischemic stroke: A Meta-analysis of randomized controlled trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42546365/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"BP-TARGET — Safety and efficacy of intensive blood pressure lowering after successful endovascular therapy in acute ischaemic stroke (BP-TARGET): a multicentre, open-label, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/33647246/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"BEST-II — Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke: The BEST-II Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37668620/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"IDENTIFY — Early intensive blood pressure management after endovascular treatment in ischaemic stroke (IDENTIFY): a multicentre, open-label, blinded-endpoint, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40538518/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"OPTIMAL-BP 1-year — Intensive Versus Conventional Blood Pressure Lowering After Successful Endovascular Thrombectomy: OPTIMAL-BP 1-Year Outcomes.","url":"https://pubmed.ncbi.nlm.nih.gov/42212393/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; 1-year follow-up extension of the original randomized population (294 of 306 completed); summarized on the OPTIMAL-BP card."},{"title":"INTERACT1-4 pooled — Effects of blood pressure lowering in relation to time in acute intracerebral haemorrhage: a pooled analysis of the four INTERACT trials.","url":"https://pubmed.ncbi.nlm.nih.gov/40541207/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; individual-patient pooled analysis of four randomized trials, not a new trial. INTERACT3 (7,036 of 11,312 patients) tested a care bundle, and the time-from-onset effect comes from the CT substudy (2,921 patients)."},{"title":"Deep vs lobar ICH BP meta-analysis — Functional Outcomes After Intensive Blood Pressure Reduction in Deep and Lobar Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/41962119/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked. Study-level stepwise meta-analysis (ATACH-2 individual data; INTERACT2 and INTERACT3 published pooled results); poor outcome was mRS 4–6 in ATACH-2 and INTERACT3 and 3–6 in INTERACT2, and INTERACT3 tested a care bundle."},{"title":"BP lowering by hematoma location (INTERACT1–4 and ATACH-2 IPD) — Effects of Blood Pressure Lowering by Hematoma Location in Acute Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/42848972/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; individual-patient pooled analysis of five randomized trials, not a new trial; full text not reviewed."}],"related":[{"label":"Ischemic BP protocol","href":"#/protocols/ischemic/bp"},{"label":"ICH protocol","href":"#/protocols/ich"},{"label":"ICH first-hour targets","href":"#/evidence/ich-management"}]},{"id":"antithrombotic-reversal","title":"Antithrombotic-associated ICH: reversal","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital"],"keywords":["reversal","PCC","4F-PCC","andexanet","Andexxa","idarucizumab","vitamin K","protamine","platelets","DDAVP","desmopressin","apixaban","rivaroxaban","warfarin","dabigatran"],"summary":"Anticoagulant-associated ICH: stop the anticoagulant and reverse it as soon as ICH is diagnosed (AHA 2022, COR 1); antiplatelet-associated ICH: no platelet transfusion unless neurosurgery is planned (NCS/SCCM 2026, conditional; AHA 2022 COR 3: Harm for aspirin). Factor Xa inhibitor: 4F-PCC rather than andexanet (NCS/SCCM 2026, conditional); andexanet (Andexxa) was withdrawn from the US market effective 22 December 2025. Warfarin with INR ≥2.0: 4F-PCC over FFP, then IV vitamin K (COR 1). Dabigatran: idarucizumab (2a). Unfractionated heparin: protamine (2a); LMWH: protamine may partially reverse (2b). On aspirin and going to neurosurgery: platelet transfusion (conditional). No recommendation on desmopressin or on reversal in small ICH.","recommendations":[{"text":"Immediate discontinuation of anticoagulation and rapid reversal are recommended as soon as possible after diagnosis of anticoagulant-associated spontaneous ICH to improve survival.","cor":"1","loe":"C-LD","source":"AHA/ASA ICH 2022 · ich-2022-26 · p. 19","id":"ich-2022-26"},{"text":"We suggest using 4-factor prothrombin complex concentrate rather than andexanet alfa in patients with factor Xa inhibitor-associated spontaneous ICH.","cor":"Conditional","loe":"Moderate","source":"NCS/SCCM 2026 · Rec 1-1","id":"ncs-reversal-2026-1-1"},{"text":"We suggest against administering platelet transfusions to patients with spontaneous intraparenchymal hemorrhage taking antiplatelet agents who do not require neurosurgical intervention.","cor":"Conditional","loe":"Low","source":"NCS/SCCM 2026 · Rec 2-1","id":"ncs-reversal-2026-2-1"},{"text":"We suggest administering platelet transfusions to patients with spontaneous intraparenchymal hemorrhage who were on aspirin therapy who require neurosurgical intervention.","cor":"Conditional","loe":"Very low","source":"NCS/SCCM 2026 · Rec 2-2","id":"ncs-reversal-2026-2-2"},{"text":"4-factor PCC is recommended over FFP for patients with VKA-associated spontaneous ICH and INR ≥ 2.0 to achieve rapid INR correction and limit hemorrhage expansion.","cor":"1","loe":"B-R","source":"AHA/ASA ICH 2022 · ich-2022-27 · p. 19","id":"ich-2022-27"},{"text":"Idarucizumab is reasonable for patients with dabigatran-associated spontaneous ICH to reverse the anticoagulant effect.","cor":"2a","loe":"B-NR","source":"AHA/ASA ICH 2022 · ich-2022-31 · p. 19","id":"ich-2022-31"}],"consider":["Record drug, dose, last intake and renal function; activated charcoal may help if a DOAC was taken within the previous few hours (2b).","Dabigatran without idarucizumab: PCC/aPCC or renal replacement therapy may be considered (2b).","Traumatic ICH: viscoelastic-assay-guided treatment if available (NCS/SCCM 2026)."],"caution":"ANNEXA-I's better hemostasis came with more thrombotic events and no functional gain; take doses from the ICH protocol.","sources":[{"title":"Treatment of Antithrombotic-Associated Intracranial Hemorrhage in Adults: A Focused Guideline Update from the Neurocritical Care Society and the Society of Critical Care Medicine","url":"https://pubmed.ncbi.nlm.nih.gov/42786382/","year":2026,"type":"Guideline","checkedAt":"2026-10-17","access":"Abstract rechecked 2026-10-17: direction and population of the recommendations it summarizes. GRADE strength and certainty were transcribed from the full text on 2026-09-30 and not re-verified (no PMC copy)."},{"title":"AABB news: AstraZeneca withdraws factor Xa reversal agent (Andexxa) from the U.S. market","url":"https://www.aabb.org/news-resources/news/article/2025/12/23/astrazeneca-withdraws-factor-xa-reversal-agent-from-u.s.-market","year":2025,"type":"Report","checkedAt":"2026-10-03","access":"News report dated 2025-12-23; withdrawal effective 2025-12-22, consistent with the archived 2026-09-26 safety review."},{"title":"European Stroke Organisation Guideline on Reversal of Oral Anticoagulants in Acute Intracerebral Haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/31903428/","year":2019,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine","url":"https://pubmed.ncbi.nlm.nih.gov/26714677/","year":2016,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"ANNEXA-I — Andexanet for Factor Xa Inhibitor-Associated Acute Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/38749032/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ANNEXA-4 — Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors.","url":"https://pubmed.ncbi.nlm.nih.gov/30730782/","year":2019,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Andexanet vs 4F-PCC meta-analysis — Efficacy and Safety of Andexanet Alfa Versus Four Factor Prothrombin Complex Concentrate for Emergent Reversal of Factor Xa Inhibitor Associated Intracranial Hemorrhage: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/39379749/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"ICH reversal protocol","href":"#/protocols/ich/reversal"},{"label":"Anticoagulant labels","href":"#/evidence/anticoagulant-labels"},{"label":"ANNEXA-I","href":"#/evidence/annexa-i"}]},{"id":"caa-ich-recurrence","title":"CAA, lobar hemorrhage and recurrence risk","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital","clinic"],"keywords":["CAA","amyloid angiopathy","lobar ICH","cortical superficial siderosis","convexity SAH","TFNE","CAA-ri","anticoagulation after ICH"],"summary":"In patients aged 50 or older, suspect CAA with lobar ICH, convexity SAH or transient focal episodes; MRI with blood-sensitive sequences looks for lobar microbleeds and cortical superficial siderosis (ICAA/WSO 2025). Recurrence risk rises with lobar location, older age, more lobar microbleeds, disseminated superficial siderosis, poor BP control, Asian or Black race and APOE ε2/ε4 (AHA 2022, 2a). Restarting antiplatelets may be reasonable (2b; RESTART: recurrent ICH 4 vs 9%, not significant). In AF after ICH, PRESTIGE-AF found fewer ischemic strokes but more recurrent ICH with DOACs; a 2025 meta-analysis of six RCTs (798 patients, including PRESTIGE-AF; postdates AHA 2022) found the same trade-off (ischemic stroke RR 0.20; recurrent ICH RR 3.14; all-cause mortality not different) — individualize; if anticoagulation is restarted, starting 7–8 weeks after ICH may be considered after weighing individual factors (AHA 2022, 2b); left atrial appendage closure may be considered if anticoagulation is not possible (2b).","consider":["Transient focal episodes may be CAA rather than TIA — avoid reflex antithrombotics.","Long-term BP <130/80 is reasonable after ICH (AHA 2022, 2a). RECAP-ICH (individual-participant meta-analysis of 4 trials; 2,944 ICH survivors, 75% Asian; postdates AHA 2022): BP-lowering treatment vs placebo or standard care (mean SBP difference 11.2 mm Hg) reduced recurrent stroke (6.5 vs 10.4%; HR 0.62), driven by fewer recurrent ICH (2.2 vs 5.6%; HR 0.39), without excess serious adverse events.","Ask about antiamyloid therapy; CAA changes those decisions.","ENRICH-AF (edoxaban vs no anticoagulation, antiplatelet monotherapy allowed, in AF after intracranial hemorrhage; 948 enrolled; completed July 2026; no peer-reviewed report as of October 2026): after a safety review of the first 699 patients, its DSMB advised halting enrollment of patients with lobar ICH (174) or isolated convexity SAH (34), subtypes typically caused by CAA and now excluded in the registry criteria, and stopping study drug in that subgroup (WSO 2025). A 2025 meta-analysis attributes this to excess recurrent intracranial bleeding; WSO 2025 notes that the data behind the recommendation were unpublished, and that an earlier individual-patient meta-analysis of four trials (412 patients) found no treatment interaction with lobar ICH or convexity SAH."],"caution":"Recurrence estimates are population averages, not an individual prognosis.","sources":[{"title":"Diagnosis and management of cerebral amyloid angiopathy: a scientific statement from the International CAA Association and the World Stroke Organization","url":"https://pubmed.ncbi.nlm.nih.gov/40721902/","year":2025,"type":"Scientific statement","checkedAt":"2026-10-22","access":"Primary abstract read; recommendations 1 (suspect CAA at age ≥50) and 4 (blood-sensitive MRI) from the archived transcription; full statement not reviewed."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"Ischemic stroke prevention in patients with atrial fibrillation and a recent ischemic stroke, TIA, or intracranial hemorrhage: A World Stroke Organization (WSO) scientific statement","url":"https://pubmed.ncbi.nlm.nih.gov/39719823/","year":2025,"type":"Scientific statement","checkedAt":"2026-10-31","access":"PMC full text (PMC11951358) read 2026-10-31. It grades the strength of evidence for each statement (for example B2, C1) instead of making clinical recommendations; the AF prevention card uses its device-detected AF (statement 11) and breakthrough-stroke (statements 16–19) evidence statements. The CAA and ICH recurrence card uses its ENRICH-AF DSMB paragraph, the 412-patient meta-analysis paragraph and statements 23–25."},{"title":"ENRICH-AF — Anticoagulation in patients with cerebral amyloid angiopathy.","url":"https://pubmed.ncbi.nlm.nih.gov/37839419/","year":2023,"type":"Report","checkedAt":"2026-10-31","access":"PubMed bibliographic record re-checked 2026-10-31 (Lancet 2023;402:1418-1419, letter, no abstract); letter not read and not summarized (outcome interpretation unresolved, so no summary is shown). Main trial: ClinicalTrials.gov registry record NCT03950076 read 2026-10-31: randomized open-label (PROBE) design; edoxaban vs non-anticoagulant therapy, meaning no antithrombotic or antiplatelet monotherapy, after intracranial hemorrhage with AF and CHA₂DS₂-VASc ≥2; status completed, 948 enrolled, primary completion 2026-07-22, no posted results. Lobar ICH and isolated convexity SAH were enrolled until the DSMB stopped their enrollment and are now excluded; the DSMB also advised stopping study drug in that subgroup (WSO 2025 statement, PMC11951358, read 2026-10-31). News coverage reports an ESC Congress 2026 presentation, but no peer-reviewed report was found in PubMed as of 2026-10-31: presented only; do not summarize or apply its outcomes until published."},{"title":"Anticoagulation after ICH in AF meta-analysis — Safety and efficacy of oral anticoagulation in patients with intracranial hemorrhage and atrial fibrillation: a systematic review and meta-analysis of randomized controlled clinical trials.","url":"https://pubmed.ncbi.nlm.nih.gov/41446322/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract and PMC full text (PMC12722659) read 2026-10-31; bibliographic record checked. Six RCTs including PRESTIGE-AF; the recurrent-ICH result lost significance without PRESTIGE-AF; STATICH data came from a conference presentation. Source of the ENRICH-AF lobar ICH/convexity SAH safety withdrawal. The ENRICH-AF withdrawal statement is in its discussion (a secondary source)."},{"title":"Edinburgh CT criteria — The Edinburgh CT and genetic diagnostic criteria for lobar intracerebral haemorrhage associated with cerebral amyloid angiopathy: model development and diagnostic test accuracy study.","url":"https://pubmed.ncbi.nlm.nih.gov/29331631/","year":2018,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Edinburgh criteria & ICH recurrence (IPD) — Association between the Edinburgh CT and genetic diagnostic criteria for cerebral amyloid angiopathy-associated lobar intracerebral haemorrhage and recurrent intracerebral haemorrhage: an individual patient data meta-analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/40975099/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"RECAP-ICH — Intensive blood pressure lowering after spontaneous intracerebral haemorrhage for secondary stroke prevention (RECAP-ICH): a systematic review and individual participant data meta-analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42586098/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (2,944 participants; recurrent stroke HR 0.62, recurrent ICH HR 0.39); bibliographic record checked; full text not read. Individual-participant meta-analysis of 4 trials of BP-lowering treatment vs placebo or standard care, not a test of the <130/80 target. Included trials are not named in the abstract; overlap with TRIDENT not confirmed."}],"related":[{"label":"PRESTIGE-AF","href":"#/evidence/prestige-af"},{"label":"RESTART","href":"#/evidence/restart"}]},{"id":"unruptured-aneurysms","title":"Unruptured intracranial aneurysm review","category":"Hemorrhage and neurocritical care","settings":["hospital","clinic"],"keywords":["aneurysm","UIA","PHASES","ELAPSS","UIATS","rupture risk","coiling","clipping","flow diversion"],"summary":"Weigh rupture risk (size, location, growth, morphology, prior SAH; PHASES, ELAPSS and UIATS support the discussion) against treatment risk and patient preference in a multidisciplinary team; for symptomatic aneurysms (cranial nerve deficit, mass effect or thromboembolism), ESO consensus suggests repair. Stop smoking and treat hypertension. All ESO recommendations rest on very low-certainty evidence.","consider":["Review aneurysm size, location, morphology, growth and prior hemorrhage alongside patient factors.","Clarify the purpose and interval of surveillance with the treating team.","Discuss treatment alternatives, smoking/BP review and preferences in a multidisciplinary setting.","ADPKD (KDIGO 2025, per an ERA Working Group commentary): screening for unruptured aneurysms is selective, centered on a family history of aneurysm, SAH or unexplained sudden death; contrast-free time-of-flight MR angiography is the preferred test, and high-risk people with a negative first screen may be rescreened every 5–10 years (practice points)."],"caution":"Scores support discussion; they do not choose a procedure or capture every relevant feature.","sources":[{"title":"European Stroke Organisation (ESO) guidelines on management of unruptured intracranial aneurysms","url":"https://pubmed.ncbi.nlm.nih.gov/36082246/","year":2022,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract read; the symptomatic-aneurysm expert consensus is from the archived transcription; full recommendation tables not reviewed."},{"title":"KDIGO 2025 Clinical Practice Guideline for ADPKD: a commentary on intracranial aneurysms and other vascular manifestations from the ERA Working Group Genes & Kidney","url":"https://pubmed.ncbi.nlm.nih.gov/42065712/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract and PMC full text (PMC13719708) read 2026-10-31; its recommendation boxes are images absent from the text, and the KDIGO 2025 guideline itself (PMID 39848759) was not read, so the card avoids the graded wording of recommendation 6.1.2 and labels the imaging and rescreening items as practice points."},{"title":"PHASES — Development of the PHASES score for prediction of risk of rupture of intracranial aneurysms: a pooled analysis of six prospective cohort studies.","url":"https://pubmed.ncbi.nlm.nih.gov/24290159/","year":2014,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"PHASES","href":"#/tools/phases"}]},{"id":"poststroke-seizures","title":"Seizures after stroke: treatment versus prophylaxis","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital","clinic"],"keywords":["seizure","EEG","levetiracetam","phenytoin","prophylaxis","epilepsy","ASM withdrawal"],"summary":"Treat clinical or EEG-confirmed seizures. Do not give prophylactic antiseizure drugs after ischemic stroke or ICH without seizures (AHA 2026; AHA 2022: no benefit). After aSAH, AHA 2023 allows prophylaxis only with high-risk features (2b) and lists phenytoin as harmful (3: Harm); NCS 2026 suggests ASM or no ASM (conditional, low certainty) and allows either agent and duration; its expert guidance prefers levetiracetam, stopped by 3 days unless seizures or EEG features suggest ongoing risk. Continuous EEG (at least 24 h) is reasonable for unexplained or fluctuating mental status after ICH (AHA 2022, 2a).","recommendations":[{"text":"In adult AIS patients, prophylactic antiseizure medication is not recommended as it does not prevent seizures or improve functional outcome.","cor":"3: No Benefit","loe":"C-LD","source":"AHA/ASA AIS 2026 · ais-2026-195 · p. 84","id":"ais-2026-195"},{"text":"Prophylactic antiseizure medication is not beneficial for patients with spontaneous ICH who have no evidence of seizures with regard to functional outcomes, long-term seizure control, or mortality.","cor":"3: No Benefit","loe":"B-NR","source":"AHA/ASA ICH 2022 · ich-2022-73 · p. 34","id":"ich-2022-73"}],"consider":["After an unprovoked poststroke seizure, choose the antiseizure drug by patient factors (AHA 2026, COR 1).","Document the indication and a review date for any antiseizure drug continued at discharge.","High seizure risk (SeLECT ≥5 after ischemic stroke or CAVE ≥2 after ICH) is not an indication for prophylaxis outside trials: in a phase 2a trial (125 patients, underpowered), eslicarbazepine 800 mg/day for 30 days, started within 96–120 h, did not significantly reduce first unprovoked seizure, death or discontinuation at 6 months (28 vs 37%; OR 0.66, 95% CI 0.31–1.40); all 5 deaths were in the drug arm (judged unrelated).","aSAH with a seizure at onset: treat for no more than 7 days; longer courses do not reduce later seizures."],"caution":"Permissive prophylaxis recommendations do not justify indefinite treatment.","sources":[{"title":"Guidelines for Seizure Prophylaxis in Patients Hospitalized with Nontraumatic Intracerebral Hemorrhage: A Clinical Practice Guideline for Health Care Professionals from the Neurocritical Care Society","url":"https://pubmed.ncbi.nlm.nih.gov/39707127/","year":2024,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Guidelines for Seizure Prophylaxis in Patients with Aneurysmal Subarachnoid Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society","url":"https://pubmed.ncbi.nlm.nih.gov/42552475/","year":2026,"type":"Guideline","checkedAt":"2026-10-17","access":"PMC full text (PMC13642444) read 2026-10-17; supplementary tables not reviewed."},{"title":"Antiseizure Medication Withdrawal in Seizure-Free Patients: Practice Advisory Update Summary: Report of the AAN Guideline Subcommittee","url":"https://pubmed.ncbi.nlm.nih.gov/34873018/","year":2021,"type":"Practice advisory","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"European Stroke Organisation guidelines for the management of post-stroke seizures and epilepsy","url":"https://pubmed.ncbi.nlm.nih.gov/31008306/","year":2017,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/37212182/","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 38011240 (Stroke 2023;54:e516) is indexed; its body was not re-read."},{"title":"PEACH — Safety and efficacy of prophylactic levetiracetam for prevention of epileptic seizures in the acute phase of intracerebral haemorrhage (PEACH): a randomised, double-blind, placebo-controlled, phase 3 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35963261/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"PEACH EEG analysis — Dynamics of early electroencephalographic patterns and epileptic seizures in acute intracerebral hemorrhage: A prospective controlled study.","url":"https://pubmed.ncbi.nlm.nih.gov/41250972/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record and notices checked; outcomes not reviewed here. Secondary EEG-pattern analysis of trial participants."},{"title":"Eslicarbazepine antiepileptogenesis (BIA-2093-213) — Safety and efficacy of eslicarbazepine acetate for seizure prevention in patients with stroke at high risk of developing post-stroke epilepsy: a proof-of-concept, phase 2a, randomised, double-blind, placebo-controlled antiepileptogenesis trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41722592/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Phase 2a; its authors call it underpowered."}],"related":[]},{"id":"functional-seizures","title":"Functional seizures and diagnostic communication","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital","clinic"],"keywords":["functional seizure","PNES","dissociative seizure","video EEG","nonepileptic"],"summary":"Make a positive diagnosis from the event history, witness accounts and, when feasible, video-EEG of a typical event; explain it respectfully, screen for coexisting epilepsy and psychiatric conditions, and arrange continuity (AAN 2025). Do not prescribe ASMs or benzodiazepines for functional seizures without another indication, taper ASMs that lack one, and refer appropriate patients for psychological treatment (AAN 2025).","consider":["Review event history, witness information and typical-event recording or video-EEG when feasible.","Explain the diagnostic rationale and arrange continuity rather than relying on a label alone.","Do not prescribe ASMs or benzodiazepines for functional seizures alone; taper ASMs that lack another indication."],"caution":"Functional seizures and epilepsy can coexist; a normal routine EEG or one bedside sign does not make the diagnosis.","sources":[{"title":"Management of Functional Seizures Practice Guideline Executive Summary: Report of the AAN Guidelines Subcommittee","url":"https://pubmed.ncbi.nlm.nih.gov/41370742/","year":2025,"type":"Guideline","checkedAt":"2026-10-17","access":"Primary abstract (executive summary) checked 2026-10-17; full recommendation tables not reviewed."}],"related":[]},{"id":"neuroprognostication","title":"Stroke prognosis: timing, confounders and uncertainty","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital","clinic"],"keywords":["prognosis","ICH score","NIHSS","withdrawal of life support","swallow","tracheostomy","recovery"],"summary":"Do not settle prognosis early — aside from the most clinically devastated patients, defer ICH neuroprognostication for at least the first 48–72 h of ICU admission (NCS 2023 good-practice statement) — but discuss goals before deterioration in large hemispheric infarction (NCS 2026, strong) and honor documented prior wishes. After ICH, full care with new DNAR or withdrawal deferred until at least the second full hospital day is reasonable unless prior wishes say otherwise (AHA 2022, 2a). Severity scores such as the ICH score frame discussion but must not be the sole basis to limit treatment (COR 3), and a DNAR order alone should not limit other care. Clear confounders such as sedation and medical instability first (NCS).","recommendations":[{"text":"A baseline severity score alone is not recommended as the sole basis for forecasting individual prognosis or deciding to limit life-sustaining treatment in patients with spontaneous ICH.","cor":"3: No Benefit","loe":"B-NR","source":"AHA/ASA ICH 2022 · ich-2022-94 · p. 44","id":"ich-2022-94"}],"consider":["Identify sedation, medical instability and other confounders before discussing prognosis.","Explain the outcome being estimated, the time horizon and the range of uncertainty.","Revisit recovery over time and incorporate what outcomes the patient would value.","After ICH, the original ICH score or the max-ICH score alone is not a reliable predictor of poor function at ≥3 months, nor the original score of 30-day mortality (NCS 2023; weak, low or very low certainty)."],"caution":"Premature withdrawal can distort both individual care and the evidence used to estimate prognosis.","sources":[{"title":"Guidelines for Neuroprognostication in Critically ill Adults with Acute Ischemic Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/41942818/","year":2026,"type":"Guideline","checkedAt":"2026-10-22","access":"PMC full text (PMC13249629) read 2026-10-22, including the premature-prognostication and large-hemispheric-infarction goals-of-care recommendations; evidence tables not reviewed."},{"title":"Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/37923968/","year":2023,"type":"Guideline","checkedAt":"2026-10-17","access":"PMC full text (PMC10959839) read 2026-10-17; evidence tables not reviewed."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."}],"related":[{"label":"ICH severity score","href":"#/encounter/ich-score"},{"label":"Goals of care","href":"#/evidence/goals-of-care"}]},{"id":"goals-of-care","title":"Consent, goals of care and palliative support","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital","clinic"],"keywords":["consent","capacity","surrogate","palliative","goals of care","end of life","shared decision"],"summary":"Offer palliative support alongside restorative stroke care. With large cerebral or cerebellar infarcts at risk of swelling, discuss options and likely outcomes early (AHA 2026, COR 1). Clarify capacity and the appropriate surrogate; after ICH, a surrogate–physician shared decision-making model is reasonable for patients who cannot fully participate (AHA 2022 ICH, 2a).","consider":["Clarify capacity, the appropriate surrogate and known preferences.","Explain the decision, alternatives and uncertainty in language suited to the situation.","Identify symptom burden, psychosocial needs and when specialist support would help."],"caution":"Palliative care is not withdrawal of treatment; emergency consent rules depend on the setting.","sources":[{"title":"Palliative and End-of-Life Care in Stroke: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/39676661/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Consent Issues in the Management of Acute Ischemic Stroke: AAN Position Statement","url":"https://pubmed.ncbi.nlm.nih.gov/35312627/","year":2022,"type":"Position statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"Clinical Guidance in Neuropalliative Care: An AAN Position Statement","url":"https://pubmed.ncbi.nlm.nih.gov/35256519/","year":2022,"type":"Position statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."}],"related":[{"label":"Neuroprognostication","href":"#/evidence/neuroprognostication"}]},{"id":"brain-death","title":"BD/DNC: determination and communication resources","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital"],"keywords":["brain death","BD DNC","apnea test","ancillary testing","cerebral circulatory arrest","DSA"],"summary":"Use the institutional BD/DNC process and the 2023 multisociety guideline for prerequisites, confounders, examination, apnea testing and ancillary-test indications; the 2025 AAN statement covers communication, objections, pregnancy and public trust.","consider":["Use the complete institutional process for prerequisites, confounders and examiner qualifications.","Consult the guideline for neurologic examination, apnea testing and valid ancillary-test indications.","Plan clear communication and address accommodations or objections through the relevant process."],"caution":"This is a source navigator, not a determination checklist.","sources":[{"title":"2023 Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline","url":"https://pubmed.ncbi.nlm.nih.gov/37821233/","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract and source scope checked; full recommendation text not reviewed."},{"title":"Brain Death/Death by Neurologic Criteria Guidance on Communication, Objections, Pregnancy, and Public Trust: An AAN Position Statement","url":"https://pubmed.ncbi.nlm.nih.gov/41187308/","year":2025,"type":"Clinical policy","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Technical Performance and Interpretation of Digital Subtraction Angiography to Determine Cerebral Circulatory Arrest in Patients Being Evaluated for Brain Death/Death by Neurological Criteria: A Brief Practice Update From the Society of Vascular and Interventional Neurology (SVIN)","url":"https://pubmed.ncbi.nlm.nih.gov/41816515/","year":2025,"type":"Practice update","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Concerns DSA for cerebral circulatory arrest in brain-death evaluation, not collateral grading (the archive ID is historical)."}],"related":[]},{"id":"moyamoya","title":"Moyamoya disease and syndrome","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["moyamoya","RNF213","bypass","hemodynamic impairment","collaterals"],"summary":"Moyamoya with ischemic stroke or TIA: direct or indirect extracranial–intracranial bypass can be beneficial to prevent recurrent ischemia (AHA 2021, 2a); refer to an experienced center. Distinguish ischemic from hemorrhagic presentations and moyamoya disease from secondary moyamoya syndrome, and review perfusion studies and the antithrombotic rationale.","consider":["Confirm the vascular pattern and whether a secondary moyamoya syndrome is plausible.","Ischemic presentation with hemodynamic impairment (adults and children): ESO 2023 suggests direct or combined rather than indirect bypass, 6–12 weeks after the last event; it recommends direct bypass for adults with hemorrhagic presentation (low-quality evidence); long-term antiplatelet therapy for non-hemorrhagic moyamoya is expert consensus.","Clarify surveillance imaging and perioperative planning."],"caution":"Do not manage moyamoya as ordinary atherosclerotic stenosis.","sources":[{"title":"European Stroke Organisation (ESO) Guidelines on Moyamoya angiopathy Endorsed by Vascular European Reference Network (VASCERN)","url":"https://pubmed.ncbi.nlm.nih.gov/37021176/","year":2023,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (bypass by presentation, technique and timing; antiplatelet consensus); full recommendation tables not reviewed."},{"title":"Adult Moyamoya Disease and Syndrome: Current Perspectives and Future Directions: A Scientific Statement From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/37609846/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-21","access":"Primary abstract read 2026-10-21; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."}],"related":[]},{"id":"cns-vasculitis","title":"Suspected primary CNS vasculitis","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["PACNS","CNS vasculitis","angiitis","RCVS","CSF","biopsy","vessel wall MRI"],"summary":"Do not diagnose PACNS from imaging alone: no single MRI pattern or routine CSF abnormality establishes it. Exclude RCVS, infection and other mimics, and confirm with expert multidisciplinary review, including tissue diagnosis when needed, before prolonged immunotherapy (ESO 2023).","consider":["Review alternative vascular, infectious, inflammatory and noninflammatory explanations.","Discuss the roles and limitations of vascular imaging, CSF studies and tissue diagnosis.","Clarify what evidence supports the diagnosis before committing to prolonged immunotherapy."],"caution":"Evidence is sparse, and vessel imaging alone cannot separate PACNS from mimics such as RCVS.","sources":[{"title":"European Stroke Organisation (ESO) guidelines on Primary Angiitis of the Central Nervous System (PACNS)","url":"https://pubmed.ncbi.nlm.nih.gov/37903069/","year":2023,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."}],"related":[{"label":"RCVS and PRES","href":"#/evidence/rcvs-pres"}]},{"id":"rcvs-pres","title":"RCVS and PRES","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["RCVS","reversible cerebral vasoconstriction","RCVS2","thunderclap","convexity SAH","PRES","posterior reversible encephalopathy","eclampsia","postpartum"],"summary":"Recurrent thunderclap headaches with segmental cerebral vasoconstriction suggest RCVS; over half of cases are postpartum or follow adrenergic or serotonergic drugs. Vasoconstriction peaks 2–3 weeks after onset and resolves within 3 months, and stroke can follow initially normal imaging. RCVS2 (thunderclap headache, carotid involvement, vasoconstrictive trigger, sex, SAH; range −2 to +10): ≥5 was 99% specific and 90% sensitive for RCVS; ≤2 was 100% specific (85% sensitive) for excluding it; performance was similar against PACNS in a separate validation cohort. PRES (bilateral subcortical vasogenic edema) follows BP fluctuation, renal failure, cytotoxic drugs, autoimmune disease or eclampsia, and usually resolves.","consider":["Exclude aneurysmal SAH first and remove vasoactive triggers; avoid empirical glucocorticoids when RCVS is likely (in 162 patients they independently predicted worsening and poor outcome; observational).","Repeat vessel imaging if early imaging is normal but suspicion persists.","Nimodipine may ease thunderclap headache within 48 h but has no proven effect on stroke or hemorrhage.","PRES: treat the driver (BP, drug, eclampsia) and watch for hemorrhage or posterior-fossa edema with hydrocephalus."],"caution":"Evidence is observational; RCVS2 was derived from 30 RCVS patients at one center.","sources":[{"title":"RCVS2 score and diagnostic approach for RCVS","url":"https://pubmed.ncbi.nlm.nih.gov/30635475/","year":2019,"type":"Observational study","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"Reversible cerebral vasoconstriction syndrome (review)","url":"https://pubmed.ncbi.nlm.nih.gov/22995694/","year":2012,"type":"Report","checkedAt":"2026-10-03","access":"Abstract verified via PubMed."},{"title":"PRES: clinical and radiological manifestations and pathophysiology (review)","url":"https://pubmed.ncbi.nlm.nih.gov/26184985/","year":2015,"type":"Report","checkedAt":"2026-10-03","access":"Abstract verified via PubMed."},{"title":"Glucocorticoid-associated worsening in RCVS","url":"https://pubmed.ncbi.nlm.nih.gov/27940651/","year":2017,"type":"Observational study","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed; retrospective cohort."}],"related":[{"label":"Sudden severe headache","href":"#/evidence/thunderclap-sah-evaluation"},{"label":"CNS vasculitis","href":"#/evidence/cns-vasculitis"},{"label":"Maternal stroke","href":"#/evidence/maternal-stroke"}]},{"id":"spinal-cord-infarction","title":"Spinal cord infarction","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital"],"keywords":["spinal cord infarction","spinal stroke","owl eyes","anterior spinal artery","myelopathy","aortic surgery"],"summary":"Suspect spinal cord infarction with sudden severe myelopathy reaching its nadir within 12 h (77% of 133 Mayo patients; 76% had vascular risk factors). The first spine MRI was normal in 24%, so repeat it with DWI and axial T2: owl-eye (65%) or pencil-like (40%) T2 signal, and DWI restriction in 67% of those imaged. Supportive findings: adjacent arterial dissection or occlusion (20%) and vertebral body infarction (9%); CSF was mildly inflammatory in only 8%.","consider":["Recent aortic surgery or repair, hypotension or vertebral dissection?","Selective pain and temperature loss (39%) and a stuttering course (23%) occur; do not label transverse myelitis too early.","Apply the proposed definite, probable and possible criteria, and exclude cord compression."],"caution":"The criteria come from one center, and acute treatments lack randomized evidence.","sources":[{"title":"Spontaneous spinal cord infarction: characteristics and proposed diagnostic criteria","url":"https://pubmed.ncbi.nlm.nih.gov/30264146/","year":2019,"type":"Observational study","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"related":[{"label":"Cervical artery dissection","href":"#/evidence/dissection"}]},{"id":"inherited-arteriopathy","title":"Inherited small-vessel disease and CADASIL","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["CADASIL","NOTCH3","CARASIL","HTRA1","COL4A1","Fabry","genetic stroke","young stroke"],"summary":"Suspect CADASIL or another inherited small-vessel disease when age, family history, clinical pattern and MRI phenotype fit; confirm molecularly with genetic counseling, and treat vascular risk factors while separating established care from unproven disease-modifying treatment (AHA 2023).","consider":["Review the age, family history, clinical pattern and imaging phenotype together.","Consider genetic counseling and the implications of testing for the patient and relatives.","Address modifiable vascular factors while distinguishing established care from unproven disease-modifying treatment.","A tocotrienol-rich vitamin E complex did not slow CADASIL: in a 51-patient double-blind, placebo-controlled RCT in genetically confirmed CADASIL (T3CAD, 2026), treatment failure (stroke, disability progression or cognitive decline) over 24 months was 68.0 vs 61.5%, meeting predefined futility criteria."],"caution":"A suggestive MRI pattern is not a molecular diagnosis.","sources":[{"title":"Management of Inherited CNS Small Vessel Diseases: The CADASIL Example: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/37602377/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"T3CAD — Tocotrienol-rich vitamin E complex in CADASIL (T3CAD): a randomised, double-blind, placebo-controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42005919/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked."}],"related":[]},{"id":"lacunar-small-vessel","title":"Lacunar stroke and covert small-vessel disease","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["lacunar","small vessel","white matter hyperintensity","covert infarct","leukoaraiosis","SPS3"],"summary":"Symptomatic lacunar stroke: start antiplatelets as soon as possible (ESO 2024 expert consensus; its text adds that short-term DAPT per CHANCE/POINT may be reasonable), then long-term single antiplatelet, BP control and lipid lowering per current guidelines (ESO 2024); covert small-vessel disease found only on imaging is not an indication for antiplatelet drugs (ESO 2021). In SPS3, SBP <130 vs 130–149 did not significantly reduce all stroke but reduced ICH (HR 0.37). Address cognition and gait when relevant.","consider":["Is there a corresponding clinical stroke syndrome or only an incidental imaging finding?","Review BP, lifestyle and competing stroke mechanisms rather than assuming every small lesion is lacunar.","Address cognition, gait and functional consequences when clinically relevant."],"caution":"Do not start an antiplatelet solely for incidental white-matter changes.","sources":[{"title":"European stroke organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/38380638/","year":2024,"type":"Guideline","checkedAt":"2026-10-22","access":"PMC full text (PMC10916806) read 2026-10-22 for acute antiplatelet timing: PICO 2 expert consensus (12 of 12) and the CHANCE/POINT DAPT discussion; long-term prevention from the abstract."},{"title":"ESO Guideline on covert cerebral small vessel disease","url":"https://pubmed.ncbi.nlm.nih.gov/34414301/","year":2021,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"SPS3 — Effects of clopidogrel added to aspirin in patients with recent lacunar stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/22931315/","year":2012,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SSI antiplatelet network meta-analysis — Efficacy and safety of antiplatelet therapy for secondary prevention of small subcortical infarction: A systematic review and network meta-analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/40215388/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"Minor stroke DAPT","href":"#/evidence/minor-stroke-antiplatelets"}]},{"id":"cardiac-sources","title":"LV thrombus, LV dysfunction and other cardiac sources","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["LV thrombus","LV dysfunction","cardiomyopathy","echo","cardiac MRI","prosthetic valve","TAVR","LVAD","ECMO","cardioembolic"],"summary":"LV thrombus with stroke: warfarin for at least 3 months (AHA 2021, COR 1); DOAC safety for a new LV thrombus is uncertain (2b). The 2022 AHA LV-thrombus statement considers a DOAC a reasonable alternative to warfarin (ungraded); an RCT meta-analysis (7 trials) found similar thrombus resolution and bleeding. LV dysfunction without thrombus (sinus rhythm): anticoagulant vs antiplatelet is uncertain (AHA 2021, 2b); a 2026 AHA scientific statement (ungraded; LVEF ≤40% or wall-motion abnormality; meta-analysis of secondary trial analyses) reports anticoagulation may be associated with less recurrent stroke and net benefit vs antiplatelet therapy, so individualize with cardiology. Mechanical valves: warfarin — dabigatran (RE-ALIGN) and apixaban (PROACT Xa) caused more thromboembolism. Mechanical assist device: warfarin plus aspirin can be beneficial (AHA 2021, 2a); ARIES-HM3 (2023; first-time HeartMate 3 recipients, excluding those needing antiplatelets for other conditions) later found VKA plus placebo noninferior to VKA plus aspirin for 12-month survival free of hemocompatibility events, with less nonsurgical bleeding and no more strokes; it did not test stopping aspirin after a stroke.","consider":["Clarify the suspected source and whether the cardiac imaging adequately addresses it.","Review valve/device status, rhythm, ventricular function and the antithrombotic indication with cardiology.","Consider bleeding risk and concurrent antiplatelet exposure when discussing therapy."],"caution":"Prosthetic valves and circulatory support devices need their own specialist pathways.","sources":[{"title":"Management of Patients at Risk for and With Left Ventricular Thrombus: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/36106537/","year":2022,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Management of Patients at Risk of Ischemic Stroke With Left Ventricular Systolic Dysfunction in the Absence of Intracardiac Thrombus: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/42389837/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (LV dysfunction defined as LVEF ≤40% or wall-motion abnormality; narrative summary and meta-analysis of secondary analyses of RCTs); no PMC copy, full statement not reviewed."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"INVICTUS — Rivaroxaban in Rheumatic Heart Disease-Associated Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/36036525/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"RE-ALIGN — Dabigatran versus warfarin in patients with mechanical heart valves.","url":"https://pubmed.ncbi.nlm.nih.gov/23991661/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"PROACT Xa — Apixaban or Warfarin in Patients with an On-X Mechanical Aortic Valve.","url":"https://pubmed.ncbi.nlm.nih.gov/38320162/","year":2023,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"BHF PROTECT-TAVI — Routine Cerebral Embolic Protection during Transcatheter Aortic-Valve Implantation.","url":"https://pubmed.ncbi.nlm.nih.gov/40162661/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"PROTECTED TAVR — Cerebral Embolic Protection during Transcatheter Aortic-Valve Replacement.","url":"https://pubmed.ncbi.nlm.nih.gov/36121045/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Warfarin resumption after ICH with a mechanical valve (meta-analysis) — Resumption of Warfarin After Intracranial Hemorrhage in Patients With Mechanical Heart Valves: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/41823243/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"DOACs vs warfarin for LV thrombus (RCT meta-analysis) — Direct oral anticoagulants or warfarin in left ventricular thrombus: an updated systematic review and meta-analysis of randomized trials.","url":"https://pubmed.ncbi.nlm.nih.gov/41359218/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"RIVAWAR — Rivaroxaban vs Warfarin in Acute Left Ventricular Thrombus Following Myocardial Infarction: RIVAWAR, An Open-Label RCT.","url":"https://pubmed.ncbi.nlm.nih.gov/40706143/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ARIES-HM3 — Aspirin and Hemocompatibility Events With a Left Ventricular Assist Device in Advanced Heart Failure: The ARIES-HM3 Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37950897/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-22","access":"PubMed bibliographic record, abstract and ClinicalTrials.gov record NCT04069156 re-read 2026-10-22: first durable HeartMate 3 implant; investigator-mandated antiplatelet therapy excluded; PMC copy has no body text."},{"title":"ELSO LV venting and acute brain injury — Impact of Left Ventricular Venting on Acute Brain Injury in Patients With Cardiogenic Shock: An Extracorporeal Life Support Organization Registry Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/41104911/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"BHF PROTECT-TAVI cognitive analysis — Impact of Cerebral Embolic Protection on Cognitive Function After Transcatheter Aortic Valve Implantation: Data From the BHF PROTECT-TAVI Randomized Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40884786/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record and notices checked; outcomes not reviewed here. Secondary cognitive-outcome analysis, not a new randomized trial."}],"related":[]},{"id":"endocarditis","title":"Stroke with suspected infective endocarditis","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital"],"keywords":["endocarditis","septic embolus","infective aneurysm","mycotic aneurysm","vegetation","prosthetic valve"],"summary":"Suspected endocarditis with stroke: do not give IV thrombolysis (ESC 2023, class III; thrombectomy may be considered, IIb) and involve cardiology, infectious diseases and cardiac surgery early. Recurrent emboli with persistent vegetations despite antibiotics: early surgery is reasonable if there is no ICH or extensive brain injury (AHA 2021, 2a); with a major ischemic stroke or ICH, delaying valve surgery for at least 4 weeks may be considered if hemodynamically stable (AHA 2021, 2b). ESC 2023 differs after ischemic stroke: do not delay indicated surgery if the patient is not comatose and CT/MRI excludes hemorrhage (class I). After ICH both favor waiting: ESC suggests delaying more than 1 month if feasible, with frequent clinical and imaging reassessment (IIa).","consider":["Assess whether the presentation warrants an endocarditis evaluation and multidisciplinary team involvement.","Clarify the neurologic complication and any hemorrhage or infective aneurysm concern.","Coordinate antimicrobial, valve/device and surgical timing decisions with neurology, cardiology and infectious diseases."],"caution":"Do not apply a routine cardioembolic-stroke pathway without checking the endocarditis-specific guidance.","sources":[{"title":"2023 ESC endocarditis guideline — selected sections","url":"https://academic.oup.com/eurheartj/article/44/39/3948/7243107","year":2023,"type":"Guideline","checkedAt":"2026-10-22","access":"Publisher text not reachable and PubMed (37622656) has no abstract; the thrombolysis (class III), thrombectomy (IIb) and post-stroke surgical-timing (Table 17: class I, IIa) recommendations are from the archived transcription, re-read 2026-10-22. Corrections 37738322, 38086544 and 39824219 not reconciled."},{"title":"Infective Endocarditis: Diagnosis, Antibiotic Therapy, and Management: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/42708190/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-31","access":"Abstract read 2026-10-31 (updates the 2015 AHA statement); full text not read, so its neurologic-complication, thrombolysis/thrombectomy and surgical-timing content and any recommendation grading were not reviewed; correction 42862916 (Oct 2026) not reconciled."},{"title":"2023 ESC Guidelines for the management of endocarditis","url":"https://pubmed.ncbi.nlm.nih.gov/37622656/","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 37738322, 38086544, 39824219 not reconciled."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"IE baseline antithrombotic therapy and ICH — Baseline Antithrombotic Therapy and Intracranial Hemorrhage Risk in Infective Endocarditis: A Multicenter Prospective Cohort Study.","url":"https://pubmed.ncbi.nlm.nih.gov/41643743/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Thrombectomy for IE-related LVO (meta-analysis) — Efficacy and Safety of Mechanical Thrombectomy for Patients with Infective Endocarditis-Related Large Vessel Occlusion: a Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/40830541/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"COOPER — Characteristics and Outcomes of Operated Versus Nonoperated Patients With Infective Endocarditis and Cerebral Complications: the COOPER Study.","url":"https://pubmed.ncbi.nlm.nih.gov/41864422/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"IE-associated vs AF-associated stroke imaging phenotype — Clinical and Imaging Characteristics of Infective Endocarditis-Associated Versus Atrial Fibrillation-Associated Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/41168944/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[]},{"id":"primary-prevention","title":"First-stroke prevention and metabolic health","category":"Prevention and antithrombotics","settings":["clinic","hospital"],"keywords":["primary prevention","diabetes","GLP-1","obesity","smoking","exercise","diet","Life Essential 8","STAREE","VESALIUS-CV"],"summary":"Prevention without prior stroke: control BP, lipids and glucose, stop tobacco, and address activity, diet, weight and sleep (AHA/ASA 2024), including sex-specific risk factors.","consider":["Review BP, lipids, glycemia, tobacco exposure, activity, diet, weight and sleep in context. Clarify sex-specific and other risk factors that affect the prevention discussion.","Assess medication indications, access and adherence using the relevant disease-specific guidance.","Age ≥70 without cardiovascular disease, diabetes or dementia: in STAREE (Australia, 9,971 adults, median 5.9 years), atorvastatin 40 mg vs placebo lowered major cardiovascular events (CV death, nonfatal MI or stroke, or coronary revascularization; 10.9 vs 15.5 per 1,000 person-years; HR 0.70) but did not extend disability-free survival (HR 0.94). Musculoskeletal, hepatobiliary and diabetes-related adverse events were more common. It postdates AHA/ASA 2024.","Atherosclerosis or diabetes without prior MI or stroke and LDL ≥90 mg/dL: evolocumab vs placebo lowered CHD death, MI or ischemic stroke (VESALIUS-CV, 12,257 patients; 5-year estimate 6.2 vs 8.0%; HR 0.75). Patients with prior stroke were excluded. It postdates AHA/ASA 2024."],"caution":"Evidence for a metabolic drug in one population does not establish an indication in every stroke-risk group.","sources":[{"title":"2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/39429201/","year":2024,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed. Indexed correction(s) 39585937, 39869715 not reconciled."},{"title":"VESALIUS-CV — Evolocumab in Patients without a Previous Myocardial Infarction or Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/41211925/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31: adults with atherosclerosis or diabetes, no prior MI or stroke, LDL ≥90 mg/dL; evolocumab vs placebo lowered 3-point MACE (CHD death, MI or ischemic stroke; 5-year estimate 6.2 vs 8.0%; HR 0.75); bibliographic record checked."},{"title":"SOUL — Oral Semaglutide and Cardiovascular Outcomes in High-Risk Type 2 Diabetes.","url":"https://pubmed.ncbi.nlm.nih.gov/40162642/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SURPASS-CVOT — Cardiovascular Outcomes with Tirzepatide versus Dulaglutide in Type 2 Diabetes.","url":"https://pubmed.ncbi.nlm.nih.gov/41406444/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"STAREE — Atorvastatin, Cardiovascular Events, and Disability-free Survival in Older Adults.","url":"https://pubmed.ncbi.nlm.nih.gov/42670961/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked."},{"title":"Danish Hormonal Contraception Cohort — Stroke and myocardial infarction with contemporary hormonal contraception: real-world, nationwide, prospective cohort study.","url":"https://pubmed.ncbi.nlm.nih.gov/39938934/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Danish Progestogen-Only Contraceptive Cohort — Risk of ischemic and hemorrhagic stroke in users of progestogen-only contraceptives: A Danish registry study.","url":"https://pubmed.ncbi.nlm.nih.gov/42624314/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[]},{"id":"af-prevention","title":"AF stroke prevention beyond start timing","category":"Prevention and antithrombotics","settings":["hospital","clinic"],"keywords":["atrial fibrillation","subclinical AF","device detected","AHRE","LAAO","Watchman","rheumatic","mitral stenosis","mechanical valve","ALONE-AF","OCEAN"],"summary":"After ischemic stroke or TIA with AF, anticoagulate regardless of AF pattern (paroxysmal, persistent or permanent); use a DOAC over warfarin unless there is moderate-to-severe mitral stenosis or a mechanical valve (AHA 2021, COR 1). Do not routinely add an antiplatelet without active coronary disease or a recent stent (AHA 2026, harm). Device-detected subclinical AF: apixaban reduced stroke and embolism but increased major bleeding (ARTESiA), while edoxaban did not help (NOAH-AFNET 6). ACC/AHA 2023 (device-detected atrial high-rate episodes without a previous AF diagnosis, within shared decision-making; literature search May–November 2022, before NOAH-AFNET 6 and ARTESiA): anticoagulation is reasonable for episodes ≥24 h with CHA₂DS₂-VASc ≥2 (2a, B-NR), may be reasonable for 5 min–24 h with CHA₂DS₂-VASc ≥3 (2b, B-NR), and should not be given for episodes <5 min without another indication (3: No Benefit, B-NR). History of stroke or TIA (remote events per WSO 2025), in prespecified subgroups postdating the ACC/AHA 2023 and AHA 2021 guidelines: in ARTESiA (346 patients, 8.6%; 2025), stroke or systemic embolism was 1.20 vs 3.14% per year with apixaban vs aspirin (HR 0.40; 95% CI 0.17–0.95) and major bleeding 2.26 vs 1.16% per year (HR 1.94; 95% CI 0.77–4.87); NOAH-AFNET 6's subgroup (253 patients; edoxaban vs placebo) was inconclusive. Data are lacking for device-detected AF lasting <24 h and not confirmed on 12-lead ECG that is found after a recent stroke or TIA (WSO 2025, evidence statement, not a recommendation). Nonreversible contraindication to long-term anticoagulation (CHA₂DS₂-VASc ≥2): percutaneous left atrial appendage closure is reasonable (ACC/AHA 2023, 2a; AHA 2021 stroke guideline 2b if at least 45 days of anticoagulation can be tolerated); with high bleeding risk on anticoagulation it may be an alternative (ACC/AHA 2023, 2b). Postdating these (2026; AF populations not limited to stroke), device closure was not noninferior to physician-directed best medical care, including a DOAC if eligible, at high stroke and bleeding risk, with more primary events (16.8 vs 13.3 per 100 patient-years; CLOSURE-AF). Also in 2026, in anticoagulation candidates without stroke or TIA in the prior 30 days, closure was noninferior to a DOAC for 3-year cardiovascular death, stroke or systemic embolism (5.7 vs 4.8%; margin 4.8 points), with less non-procedural bleeding (10.9 vs 19.0%); reviews report numerically more ischemic strokes with closure (HR 1.61), and its 5-year ischemic stroke or embolism endpoint is pending (CHAMPION-AF). Pooling 6 RCTs of closure vs anticoagulation (7,004 patients with AF, not stroke-specific; 2026), closure had more ischemic strokes (3.2 vs 2.1%; RR 1.41, 95% CI 1.04–1.91) and less nonprocedural major bleeding (6.2 vs 10.7%), with no difference in any stroke, mortality or total major bleeding including procedural events; a second analysis of the same 6 trials rated the ischemic-stroke excess low certainty, sensitive to excluding single trials and short of the required information size. Rheumatic AF: rivaroxaban was worse than a VKA (INVICTUS).","consider":["Confirm how AF was documented, its clinical context and the actual thromboembolic indication. Review valve disease, renal function, interactions, prior bleeding and concurrent antiplatelets. For LAAO or device-detected AF, check the specific trial population and follow-up.","2025 SCAI/HRS LAAO guideline (GRADE; AF populations, not stroke-specific; evidence review searched to January 2024, before CHAMPION-AF and CLOSURE-AF): suggests LAAO over no therapy when anticoagulation is contraindicated (conditional recommendation, very low certainty), and suggests anticoagulation or LAAO as options for patients pursuing stroke prevention (moderate-certainty evidence from 3 RCTs), naming elevated bleeding risk, prior bleeding or a strong wish to avoid long-term anticoagulation as reasons to choose LAAO; it left LAAO for patients without a contraindication to anticoagulation outside its scope pending trials.","Stroke despite anticoagulation: check adherence, dose and interactions and look for a competing mechanism (large- or small-artery disease, cancer) before calling it anticoagulant failure. WSO 2025 (evidence review, not graded recommendations) found no definite evidence that switching anticoagulants changes recurrence, and adding a long-term antiplatelet can raise ICH risk without added protection; LAAO after a breakthrough stroke rests on one retrospective study with substantial bias, and RCTs are ongoing.","Rhythm control after stroke: in STABLED (249 patients in Japan with ECG-documented nonvalvular AF and ischemic stroke within 6 months, all on edoxaban), adding catheter ablation 1–6 months after the stroke did not reduce recurrent ischemic stroke, systemic embolism, death or heart-failure hospitalization (5.6 with ablation vs 4.9 per 100 person-years with standard therapy; HR 1.11, 95% CI 0.62–2.01). Safety signals were imprecise but went against ablation: deaths 2.8 vs 1.0 per 100 person-years (HR 2.79, 0.98–7.92), ISTH major bleeding 1.9 vs 0.6 (HR 2.99, 0.79–11.3) and hemorrhagic stroke in 3 vs 0 patients. 14% crossed over, and the trial was underpowered. Stopping anticoagulation after successful ablation: ALONE-AF (840 patients in Korea, arrhythmia-free ≥1 year after ablation; mean CHA₂DS₂-VASc 2.1) found fewer 2-year stroke, embolism or major bleeding events after stopping a DOAC (0.3 vs 2.2%), driven mainly by less major bleeding (0 vs 1.4%); OCEAN (1,284 patients ≥1 year after successful ablation) found no significant difference between rivaroxaban and aspirin in stroke, embolism or new covert embolic infarcts (0.31 vs 0.66 per 100 patient-years). Neither was restricted to patients with prior stroke, and neither establishes stopping anticoagulation after a stroke."],"caution":"Valve- and device-specific evidence overrides general AF risk scores.","sources":[{"title":"2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines","url":"https://pubmed.ncbi.nlm.nih.gov/38033089/","year":2023,"type":"Guideline","checkedAt":"2026-10-31","access":"Primary NLM identity and abstract checked. PMC full text (PMC11095842) read 2026-10-31 for section 6.4.1 (device-detected atrial high-rate episodes without a previous AF diagnosis: recommendation table, grades as published) and the literature-search dates (May 12 to November 3, 2022, before NOAH-AFNET 6 and ARTESiA); other recommendations not reviewed. Publisher-indexed text of corrections 38153996, 38408149 and 38857333 checked on 2026-10-02: trial names/disclosures, ATRIA hypertension entry and a rate-control figure footnote. None changes this overview. Direct correction PDFs unavailable."},{"title":"2024 ESC/EACTS atrial fibrillation guideline","url":"https://pubmed.ncbi.nlm.nih.gov/39210723/","year":2024,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary publication identity and official ESC overview checked live; complete corrected recommendations not reviewed for this companion source."},{"title":"CLOSURE-AF — Left Atrial Appendage Closure or Medical Therapy in Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/41849741/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (control arm, primary event rates, restricted mean survival time); full report not reviewed."},{"title":"CHAMPION-AF — Left Atrial Appendage Closure or Anticoagulation for Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/41910347/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-22","access":"Primary abstract (noninferiority margin 4.8 percentage points) and ClinicalTrials.gov record NCT04394546 re-read 2026-10-22: excludes stroke or TIA within 30 days and LVEF <30%; the 5-year ischemic stroke or systemic embolism endpoint is pending (active, not recruiting). Full report not reviewed; the ischemic stroke signal is quoted from the 2026 review below, not from the primary abstract."},{"title":"Who can benefit from percutaneous left atrial appendage closure? Recent advances (narrative review of CHAMPION-AF and CLOSURE-AF).","url":"https://pubmed.ncbi.nlm.nih.gov/42747337/","year":2026,"type":"Report","checkedAt":"2026-10-22","access":"Abstract read 2026-10-22: \"Ischemic stroke alone, however, was numerically more frequent with LAAC (HR 1.61)\". A second 2026 review (PMID 42739532, abstract) agrees on direction. Secondary source; the CHAMPION-AF full report was not reachable."},{"title":"Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/36912134/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-02","access":"Primary NLM identity and abstract checked; full statement not reviewed. Publisher-indexed correction 37093973 checked on 2026-10-02: supplemental dabigatran renal/interaction conditions and apixaban dose-reduction criteria. This overview supplies no dosing rule. Direct correction PDF unavailable."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Antithrombotic treatment for secondary prevention of stroke and other thromboembolic events in patients with stroke or transient ischemic attack and non-valvular atrial fibrillation: A European Stroke Organisation guideline","url":"https://pubmed.ncbi.nlm.nih.gov/31984228/","year":2019,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract read 2026-10-21; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2025 SCAI/HRS Clinical Practice Guidelines on Transcatheter Left Atrial Appendage Occlusion","url":"https://pubmed.ncbi.nlm.nih.gov/41040442/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PMC full text (PMC12485513) read 2026-10-31: recommendations 1.1 and 2.1 with their remarks and evidence certainty, and the statement that LAAO without a contraindication to anticoagulation is outside its scope; other recommendations not reviewed. Co-published in Heart Rhythm (PMID 40758072). Evidence search through January 5, 2024, per the companion SCAI/HRS technical review abstract (PMID 40758073)."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"Ischemic stroke prevention in patients with atrial fibrillation and a recent ischemic stroke, TIA, or intracranial hemorrhage: A World Stroke Organization (WSO) scientific statement","url":"https://pubmed.ncbi.nlm.nih.gov/39719823/","year":2025,"type":"Scientific statement","checkedAt":"2026-10-31","access":"PMC full text (PMC11951358) read 2026-10-31. It grades the strength of evidence for each statement (for example B2, C1) instead of making clinical recommendations; the AF prevention card uses its device-detected AF (statement 11) and breakthrough-stroke (statements 16–19) evidence statements. The CAA and ICH recurrence card uses its ENRICH-AF DSMB paragraph, the 412-patient meta-analysis paragraph and statements 23–25."},{"title":"AVERROES — Apixaban in patients with atrial fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/21309657/","year":2011,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ARTESiA — Apixaban for Stroke Prevention in Subclinical Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/37952132/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ARTESiA prior stroke or TIA subgroup — Apixaban versus aspirin for stroke prevention in people with subclinical atrial fibrillation and a history of stroke or transient ischaemic attack: subgroup analysis of the ARTESiA randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39862882/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Prespecified subgroup (346 participants, 8.6%), intention to treat."},{"title":"ARTESiA major bleeding subanalysis — Major Bleeding With Apixaban vs Aspirin: A Subanalysis of the ARTESiA Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41222953/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; PMC full text (PMC12613090) not read. Prespecified on-treatment subanalysis (3,961 patients)."},{"title":"STABLED — Catheter Ablation and Oral Anticoagulation for Secondary Stroke Prevention in Atrial Fibrillation: The STABLED Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41770549/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract and PMC full text (PMC12954600) read 2026-10-31; bibliographic record checked; the major-bleeding and hemorrhagic-stroke figures appear in both the Results text and Table 3. A JAMA Neurol 'Clarification to Table 3' (PMID 41973432, same issue; PMC13077508 has no text) could not be read and is not reconciled."},{"title":"ALONE-AF — Long-Term Anticoagulation Discontinuation After Catheter Ablation for Atrial Fibrillation: The ALONE-AF Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40886309/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract and PMC Key Points read 2026-10-31 (PMC body text not returned); bibliographic record checked. ClinicalTrials.gov NCT04432220 eligibility read: prior stroke neither required nor excluded."},{"title":"OCEAN — Antithrombotic Therapy after Successful Catheter Ablation for Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/41211931/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Patients at least 1 year after successful ablation; not selected for prior stroke."},{"title":"PRESTIGE-AF — Direct oral anticoagulants versus no anticoagulation for the prevention of stroke in survivors of intracerebral haemorrhage with atrial fibrillation (PRESTIGE-AF): a multicentre, open-label, randomised, phase 3 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40023176/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 2 corrections or notices; check them before applying results."},{"title":"ENRICH-AF — Anticoagulation in patients with cerebral amyloid angiopathy.","url":"https://pubmed.ncbi.nlm.nih.gov/37839419/","year":2023,"type":"Report","checkedAt":"2026-10-31","access":"PubMed bibliographic record re-checked 2026-10-31 (Lancet 2023;402:1418-1419, letter, no abstract); letter not read and not summarized (outcome interpretation unresolved, so no summary is shown). Main trial: ClinicalTrials.gov registry record NCT03950076 read 2026-10-31: randomized open-label (PROBE) design; edoxaban vs non-anticoagulant therapy, meaning no antithrombotic or antiplatelet monotherapy, after intracranial hemorrhage with AF and CHA₂DS₂-VASc ≥2; status completed, 948 enrolled, primary completion 2026-07-22, no posted results. Lobar ICH and isolated convexity SAH were enrolled until the DSMB stopped their enrollment and are now excluded; the DSMB also advised stopping study drug in that subgroup (WSO 2025 statement, PMC11951358, read 2026-10-31). News coverage reports an ESC Congress 2026 presentation, but no peer-reviewed report was found in PubMed as of 2026-10-31: presented only; do not summarize or apply its outcomes until published."},{"title":"SoSTART — Effects of oral anticoagulation for atrial fibrillation after spontaneous intracranial haemorrhage in the UK: a randomised, open-label, assessor-masked, pilot-phase, non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/34487722/","year":2021,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"APACHE-AF — Apixaban versus no anticoagulation after anticoagulation-associated intracerebral haemorrhage in patients with atrial fibrillation in the Netherlands (APACHE-AF): a randomised, open-label, phase 2 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/34687635/","year":2021,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"COCROACH — Effects of oral anticoagulation in people with atrial fibrillation after spontaneous intracranial haemorrhage (COCROACH): prospective, individual participant data meta-analysis of randomised trials.","url":"https://pubmed.ncbi.nlm.nih.gov/37839434/","year":2023,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"LAAOS III — Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/33999547/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"NOAH-AFNET 6 — Anticoagulation with Edoxaban in Patients with Atrial High-Rate Episodes.","url":"https://pubmed.ncbi.nlm.nih.gov/37622677/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"NOAH-AFNET 6 prior stroke or TIA analysis — Anticoagulation in Patients With Device-Detected Atrial Fibrillation With and Without a Prior Stroke or Transient Ischemic Attack: The NOAH-AFNET 6 Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39190564/","year":2024,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; PMC full text (PMC11646511) not read. 253 patients with prior stroke or TIA (edoxaban vs placebo); its authors call the analysis hypothesis-generating."},{"title":"INVICTUS — Rivaroxaban in Rheumatic Heart Disease-Associated Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/36036525/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"OPTION — Left Atrial Appendage Closure after Ablation for Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/39555822/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"LAAC vs anticoagulation meta-analysis (Circ Arrhythm Electrophysiol 2026) — Left Atrial Appendage Closure Versus Oral Anticoagulation in Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42626769/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Six RCTs, 7,004 patients with AF (not stroke-specific)."},{"title":"LAAO vs anticoagulation meta-analysis with trial sequential analysis (JACC Adv 2026) — Left Atrial Appendage Occlusion versus Oral Anticoagulation in Atrial Fibrillation: A Meta-Analysis of Randomized Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42954691/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Same 6 trials (N = 7,004); GRADE low certainty for the ischemic-stroke excess; trial sequential analysis reached 41% of the required information size."},{"title":"DOAC network meta-analysis in AF with prior stroke — Comparative Safety and Efficacy of Oral Anticoagulants in Patients With Atrial Fibrillation and Prior Ischemic Stroke: A Systematic Review and Network Meta-Analysis of Randomized-Controlled Clinical Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42953941/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31 (Stroke, published online 2026-10-29; no PMC full text); bibliographic record checked. Star-shaped network of 6 RCTs (18,395 patients); all between-DOAC comparisons indirect."},{"title":"LOOP — Implantable loop recorder detection of atrial fibrillation to prevent stroke (The LOOP Study): a randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/34469766/","year":2021,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."}],"related":[{"label":"AF timing after stroke","href":"#/evidence/af-timing"},{"label":"Anticoagulant label review","href":"#/evidence/anticoagulant-labels"}]},{"id":"lipid-management","title":"Lipids, vascular risk and treatment follow-up","category":"Prevention and antithrombotics","settings":["hospital","clinic"],"keywords":["LDL","statin","ezetimibe","PCSK9","Lp(a)","apolipoprotein B","triglycerides","hemorrhagic stroke"],"summary":"Atherosclerotic stroke or TIA: statin ± ezetimibe to LDL <70 mg/dL (AHA 2021, COR 1; Treat Stroke to Target events 8.5 vs 10.9%), but LDL-C <55 when very high risk (ischemic stroke plus another major ASCVD event or ≥2 high-risk conditions; ACC/AHA 2026, COR 1). No known coronary disease or major cardiac source and LDL >100: atorvastatin 80 mg (COR 1; SPARCL stroke 11.2 vs 13.1%, with more hemorrhagic strokes). ACC/AHA 2026, very high risk: high-intensity statin to LDL-C <55 and non-HDL-C <85 mg/dL, adding ezetimibe and/or a PCSK9 antibody as needed (COR 1); other atherosclerotic stroke: LDL-C <70 (COR 1), and adding a nonstatin toward <55 is reasonable (2a). Recheck lipids 4–12 weeks after starting or changing therapy.","consider":["Clarify the vascular indication, lipid profile, prior treatment and adherence.","Triglycerides 135–499 mg/dL on a statin: icosapent ethyl is reasonable in selected patients (2a).","After ICH, weigh statin benefit against hemorrhage risk individually (AHA 2022, 2b).","Published after the ACC/AHA 2026 guideline (evidence search Oct–Dec 2024): in Ez-PAVE (South Korea, open-label; 3,048 adults aged 19–80 with ASCVD, stroke or TIA eligible), targeting LDL-C <55 rather than <70 mg/dL (achieved median 56 vs 66) lowered the 3-year composite of cardiovascular death, nonfatal MI, nonfatal stroke, any revascularization or unstable-angina admission (6.6 vs 9.7%; HR 0.67). The share with prior stroke and stroke-specific results were not reviewed."],"caution":"The AHA 2021 <70 mg/dL goal predates the 2026 dyslipidemia guideline, which sets <55 mg/dL for very-high-risk ASCVD.","sources":[{"title":"2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines","url":"https://pubmed.ncbi.nlm.nih.gov/41824552/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract checked; section 4.2.6 (secondary prevention LDL-C goals) checked against the archived full-text transcription. Indexed correction(s) 42330109, 42709919 not reconciled."},{"title":"Aggressive LDL-C Lowering and the Brain: Impact on Risk for Dementia and Hemorrhagic Stroke: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/37706297/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 37878679 not reconciled."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"VESALIUS-CV — Evolocumab in Patients without a Previous Myocardial Infarction or Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/41211925/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31: adults with atherosclerosis or diabetes, no prior MI or stroke, LDL ≥90 mg/dL; evolocumab vs placebo lowered 3-point MACE (CHD death, MI or ischemic stroke; 5-year estimate 6.2 vs 8.0%; HR 0.75); bibliographic record checked."},{"title":"Ez-PAVE — Intensive LDL Cholesterol Targeting in Atherosclerotic Cardiovascular Disease.","url":"https://pubmed.ncbi.nlm.nih.gov/41910315/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31 (<55 vs <70 mg/dL; composite 6.6 vs 9.7%, HR 0.67) and registry NCT04626973 (ages 19–80; stroke/TIA eligible); bibliographic record checked."},{"title":"ROCATIS-1 — The impact of concomitant use of rosuvastatin or atorvastatin plus clopidogrel on the platelet inhibition and clinical outcomes in acute large-vessel minor stroke or TIA: A randomized controlled multi-center trial, the ROCATIS-1 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42662137/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[]},{"id":"bp-prevention","title":"Long-term blood pressure prevention","category":"Prevention and antithrombotics","settings":["clinic","hospital"],"keywords":["hypertension","home BP","ambulatory BP","orthostasis","adherence","secondary prevention"],"summary":"For long-term prevention after stroke or TIA (not the acute phase), target office BP <130/80 for most (AHA 2021, COR 1), and treat an average office BP ≥130/80 even without prior hypertension (2a). PROGRESS: perindopril plus indapamide lowered BP by 12/5 mm Hg and stroke by 43%, whereas perindopril alone (5/3 mm Hg) gave no clear reduction. After ICH, long-term SBP <130 and DBP <80 is reasonable (AHA 2022, 2a). Postdating it, the TRIDENT low-dose triple pill reduced recurrent stroke (4.6 vs 7.4%; HR 0.61). The RECAP-ICH individual-participant meta-analysis (4 trials, 2,944 patients, 75% Asian) compared fixed-dose or target-based BP lowering with placebo or standard care (mean SBP difference 11 mm Hg). It found fewer recurrent strokes (6.5 vs 10.4%; HR 0.62), mainly through fewer recurrent ICH (2.2 vs 5.6%; HR 0.39). Lacunar stroke: SPS3 (<130) reduced ICH.","consider":["Confirm measurement technique, home readings and possible orthostatic symptoms.","Review adherence, reversible contributors and access to treatment.","Individualize the follow-up and medication plan using current guidance and comorbidities.","Lower targets: in ESPRIT (China, open-label; 11,255 high-risk hypertensive adults, 3,022 with prior stroke), an SBP target <120 vs <140 mm Hg (achieved 119 vs 135) reduced major vascular events (9.7 vs 11.1%; HR 0.88), with more serious syncope. Stroke, a secondary outcome, was not significantly reduced (4.7 vs 5.4%; HR 0.86). Fewer hemorrhagic strokes (0.4 vs 0.8%) came from a post hoc analysis."],"caution":"Long-term targets do not apply in the acute phase.","sources":[{"title":"2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines","url":"https://pubmed.ncbi.nlm.nih.gov/40811516/","year":2025,"type":"Guideline","checkedAt":"2026-10-02","access":"Primary NLM identity and abstract checked; complete recommendations not reviewed. Publisher-indexed corrections 41259465 and 42160500 checked on 2026-10-02: resistant-hypertension/table text and labetalol repeat interval, not reproduced by this overview. Correction 41984986 and complete tables remain unreviewed; direct correction PDFs unavailable."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"TRIDENT — Three Low-Dose Antihypertensive Agents in a Single Pill after Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/42019018/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ESPRIT (BP) — Lowering systolic blood pressure to less than 120 mm Hg versus less than 140 mm Hg in patients with high cardiovascular risk with and without diabetes or previous stroke: an open-label, blinded-outcome, randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38945140/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31 (China; 11,255 participants, 3,022 with prior stroke; primary composite HR 0.88); bibliographic record checked. Stroke results from the prespecified JACC 2025 secondary analysis (PMID 40864014), abstract read 2026-10-31; subtype results post hoc."},{"title":"BPROAD — Intensive Blood-Pressure Control in Patients with Type 2 Diabetes.","url":"https://pubmed.ncbi.nlm.nih.gov/39555827/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CRHCP 7-year follow-up — Long-Term Effectiveness of Intensive Blood Pressure Management Led by Nonphysician Community Healthcare Providers on Cardiovascular Events: 7-Year Follow-Up of a Cluster Randomized Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42666029/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"RECAP-ICH — Intensive blood pressure lowering after spontaneous intracerebral haemorrhage for secondary stroke prevention (RECAP-ICH): a systematic review and individual participant data meta-analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42586098/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (2,944 participants; recurrent stroke HR 0.62, recurrent ICH HR 0.39); bibliographic record checked; full text not read. Individual-participant meta-analysis of 4 trials of BP-lowering treatment vs placebo or standard care, not a test of the <130/80 target. Included trials are not named in the abstract; overlap with TRIDENT not confirmed."}],"related":[{"label":"Acute BP context","href":"#/evidence/acute-bp"}]},{"id":"brain-avm","title":"Brain arteriovenous malformation","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["AVM","bAVM","arteriovenous malformation","Spetzler Martin","ARUBA","embolization","radiosurgery"],"summary":"Separate ruptured from unruptured AVMs and decide with a multidisciplinary vascular team, weighing natural history against surgical, endovascular and radiosurgical risks (AHA/ASA 2017). In ARUBA (226 adults with unruptured AVMs judged suitable for intervention; non-blinded, mixed interventions), medical management alone had fewer deaths or symptomatic strokes over a mean 50 months (3.39 vs 12.32 per 100 patient-years; HR 0.31). In MARS (9 cohorts, 2 population-based; 3,030 people with unruptured brain AVMs; observational, censored at first treatment), first ICH occurred at 1.40 per 100 person-years, lower than the commonly quoted 2–4% per year; risk was higher with age 60+ at diagnosis (HR 2.01 vs <20 years), associated arterial aneurysms (HR 1.66) and deep or cerebellar location (HR 1.87).","consider":["Clarify rupture status, anatomy, symptoms and associated lesions.","Review expected natural history and treatment risks with a multidisciplinary vascular team.","Discuss the specific treatment goal and follow-up plan with the patient."],"caution":"The 2017 statement is dated, and no grading scale or single trial selects treatment for every AVM.","sources":[{"title":"AHA/ASA brain AVM statement — official key points","url":"https://professional.heart.org/en/science-news/management-of-brain-arteriovenous-malformations/top-things-to-know","year":2017,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official AHA key points page."},{"title":"ARUBA final follow-up (unruptured brain AVMs)","url":"https://pubmed.ncbi.nlm.nih.gov/32562682/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract read via PubMed."},{"title":"MARS — Risk of Future Hemorrhage From Unruptured Brain Arteriovenous Malformations: The Multicenter Arteriovenous Malformation Research Study (MARS).","url":"https://pubmed.ncbi.nlm.nih.gov/41051760/","year":2025,"type":"Observational study","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Pooled cohorts (2 population-based, 7 referral-based), censored at first AVM treatment, death or last visit."}],"related":[]},{"id":"cavernous-malformation","title":"Cerebral and spinal cavernous malformation","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["cavernoma","CCM","cavernous angioma","DVA","familial","hemorrhage","seizure"],"summary":"Establish lesion location, prior symptomatic hemorrhage, seizures and whether lesions are familial or multiple, then plan imaging, genetic counseling and any intervention in a specialist setting; evidence gaps remain substantial (2025 consensus). Brain MRI should include susceptibility-weighted sequences (Class 1). A cavernous malformation should not preclude needed antithrombotics (Class 2a, B-NR); with a known unruptured, untreated one, IV alteplase may be considered if otherwise indicated for AIS; its risk is not well established (Class 2b, C-LD).","consider":["Clarify lesion location, prior symptomatic hemorrhage, seizures and whether lesions are familial or multiple.","Review imaging, genetic counseling and follow-up needs in the appropriate specialty setting.","Compare intervention risks with the clinical history and the outcomes the patient values.","In a Scottish population-based cohort (190 people aged 16+ with symptomatic CCM; median 16-year follow-up; observational), the 37 who had intervention (35 resections) were younger and more often presented with ICH. Intervention was not associated with the primary outcome (OHS ≥2) but was associated with dependence or death (OHS ≥3; aHR 2.66) and with CCM- or intervention-related ICH or new focal deficit (aHR 3.59); the authors call for an RCT."],"caution":"Many recommendations rely on limited evidence, and incidental and symptomatic brainstem or spinal lesions need different discussions.","sources":[{"title":"Alliance to Cure CM 2025 guidelines for cavernous malformations of the brain and spinal cord","url":"https://pubmed.ncbi.nlm.nih.gov/40396744/","year":2025,"type":"Consensus statement","checkedAt":"2026-10-17","access":"PMC full text (PMC12680281) read 2026-10-17: graded recommendations."},{"title":"Scottish CCM intervention cohort — Intervention or Conservative Management for Symptomatic Cerebral Cavernous Malformations: A Prospective, Population-Based Cohort Study.","url":"https://pubmed.ncbi.nlm.nih.gov/42585604/","year":2026,"type":"Observational study","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Nonrandomized comparison; treated patients differed at baseline (younger, more ICH presentations, fewer brainstem lesions)."}],"related":[]},{"id":"sah-critical-care","title":"aSAH critical care and CSF diversion","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital"],"keywords":["subarachnoid hemorrhage","DCI","vasospasm","EVD","hydrocephalus","CSF drainage","transfusion","antifibrinolytic"],"summary":"Keep euvolemia (AHA 2023, 2a); induced hypervolemia and prophylactic hemodynamic augmentation are harmful (COR 3: Harm). Monitor for DCI with frequent neurological exams (COR 1); TCD, and CTA or CT perfusion with suspected vasospasm or an unreliable exam, are reasonable (2a). Symptomatic vasospasm: raising SBP may be reasonable; severe vasospasm: intra-arterial vasodilators or angioplasty may be reasonable (2b). ESO 2026 gives no evidence-based recommendation on these; its guidance reserves induced hypertension for after the aneurysm is secured and fluids have failed, and angioplasty for last-line rescue. Acute symptomatic hydrocephalus: EVD and/or lumbar drainage (COR 1) under a bundled EVD protocol. EARLYDRAIN (lumbar drain after securing) reduced poor outcome, but ESO 2026 makes no recommendation on prophylactic lumbar drainage.","consider":["Do not drain CSF for radiological hydrocephalus alone when consciousness is normal (ESO consensus).","Liberal transfusion (Hb ≤10 g/dL) did not improve 12-month outcome (SAHaRA).","Pharmacological or mechanical VTE prophylaxis is recommended once the aneurysm is secured (AHA 2023, COR 1, C-LD)."],"caution":"Drain management needs the full neurosurgical protocol.","sources":[{"title":"NCS 2023 neurocritical care of aneurysmal SAH","url":"https://pubmed.ncbi.nlm.nih.gov/37202712/","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract and source scope checked; full recommendation text not reviewed."},{"title":"NCS insertion and management of external ventricular drains","url":"https://pubmed.ncbi.nlm.nih.gov/26738503/","year":2016,"type":"Consensus statement","checkedAt":"2026-10-01","access":"Primary abstract and source scope checked; full recommendation text not reviewed."},{"title":"European Stroke Organisation (ESO), European Association of Neurosurgical Societies (EANS) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on aneurysmal subarachnoid haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/42095754/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendations from the archived full-text transcription (reviewed 2026-09-30); cited in topic summaries."},{"title":"2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/37212182/","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 38011240 (Stroke 2023;54:e516) is indexed; its body was not re-read."},{"title":"SAHaRA — Liberal or Restrictive Transfusion Strategy in Aneurysmal Subarachnoid Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/39655786/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ULTRA — Ultra-early tranexamic acid after subarachnoid haemorrhage (ULTRA): a randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/33357465/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"EARLYDRAIN — Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37330974/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."}],"related":[{"label":"aSAH overview","href":"#/evidence/sah"}]},{"id":"research-adjuncts","title":"New and adjunct therapies: match the evidence","category":"Prevention and antithrombotics","settings":["on-call","hospital","clinic"],"keywords":["factor XI","asundexian","OCEANIC-STROKE","OCEANIC-AF","MOST","argatroban","eptifibatide","colchicine","CONVINCE","CHANCE-3","neuroprotection","nerinetide","ESCAPE-NEXT","remote ischemic conditioning","RESIST","SERIC-EVT","tirofiban","cytoprotection","minocycline","EMPHASIS","MIST-A","loberamisal","LAIS","edaravone","ERASE-STROKE","TASTE-2","glenzocimab","ACTISAVE"],"summary":"Asundexian (factor XIa inhibitor; confirm regulatory status), added to antiplatelets within 72 h of noncardioembolic ischemic stroke or high-risk TIA with a nonlacunar infarct or atherosclerosis, reduced ischemic stroke (OCEANIC-STROKE 6.2 vs 8.4%; major bleeding 1.9 vs 1.7%) but was worse than apixaban in AF (OCEANIC-AF). Adjunctive IV argatroban or eptifibatide after IVT did not help and increased mortality (MOST: 24% and 12% vs 8%). Nerinetide (ESCAPE-NEXT; post hoc signals of benefit when given within 3 h, at 90 days in a pooled 3-trial analysis and at 1 year, are hypothesis-generating), prehospital remote ischemic conditioning (RESIST) and colchicine (CONVINCE, CHANCE-3) were neutral; SERIC-EVT (conditioning after EVT) was positive, but EnTRIPS (postconditioning after EVT) was neutral.","consider":["Compare the population, background therapy and primary endpoint with your patient before applying a new result. Separate confirmatory results from subgroup signals, and look for independent replication.","Confirm regulatory approval and local availability before using any new agent.","Cytoprotection RCTs published after the AHA 2026 literature cutoff (March 2025), all double-blind, placebo-controlled and run only in China (replication awaited): minocycline orally within 72 h, NIHSS 4–25 (EMPHASIS: mRS 0–1 52.6 vs 47.4%); IV loberamisal within 48 h, NIHSS 7–20 (LAIS: 69.7 vs 56.3%); oral edaravone (TTYP01) within 24 h for disabling anterior-circulation stroke without reperfusion therapy (ERASE-STROKE: 65.4 vs 47.1%); edaravone dexborneol started before EVT for anterior LVO was borderline (TASTE-2: mRS 0–2 55.0 vs 49.6%; RR 1.11, 1.00–1.23; P=0.05). Minocycline after successful EVT did not reduce infarct growth (MIST-A, open-label phase 2), and the antiplatelet glenzocimab added to IVT did not improve outcome (ACTISAVE, international phase 2/3). AHA 2026 does not grade these trials.","Tirofiban (Chinese RCTs) improved 90-day function as an IV infusion after IVT in noncardioembolic stroke without EVT (ASSET-IT, mRS 0–1 65.9 vs 54.9%; sICH 1.7 vs 0%) or after inadequate response to tenecteplase without LVO, MeVO or cardioembolism (INSTANT, 63.8 vs 52.2%), and as an intra-arterial bolus plus IV infusion after successful EVT (ATTRACTION, mRS 0–2 49 vs 43%; sICH 12 vs 9%, not significant); IV tirofiban before EVT was neutral (RESCUE BT), and AHA 2026 rates preprocedural tirofiban before EVT as not useful (COR 3: No Benefit, B-R). With literature through March 2025, before ASSET-IT, INSTANT and ATTRACTION, AHA 2026 rates IV tirofiban efficacy as not well established (COR 2b, B-R)."],"caution":"AHA 2026 does not recommend neuroprotective agents to improve function (COR 3: No Benefit, LOE A), adjunctive argatroban with IVT (COR 3: No Benefit, LOE A) or adjunctive IV eptifibatide in patients given IVT within 3 h of onset (COR 3: No Benefit, LOE B-R).","sources":[{"title":"OCEANIC-STROKE: Asundexian for Secondary Stroke Prevention","url":"https://pubmed.ncbi.nlm.nih.gov/41985132/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract read via NLM; selected noncardioembolic add-on population and endpoint checked. No regulatory or availability inference."},{"title":"OCEANIC-AF: Asundexian versus Apixaban","url":"https://pubmed.ncbi.nlm.nih.gov/39225267/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked; no approval or availability inferred."},{"title":"ESCAPE-NEXT: Nerinetide with EVT without previous thrombolysis","url":"https://pubmed.ncbi.nlm.nih.gov/39955119/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked; no approval or availability inferred."},{"title":"RESIST: Remote Ischemic Conditioning for Acute Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/37787796/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked; no approval or availability inferred."},{"title":"SERIC-EVT: Remote ischaemic conditioning after thrombectomy","url":"https://pubmed.ncbi.nlm.nih.gov/40796242/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked; no approval or availability inferred."},{"title":"CONVINCE: Long-term colchicine after noncardioembolic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/38857611/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked; no approval or availability inferred."},{"title":"CHANCE-3: Colchicine after acute stroke or TIA","url":"https://pubmed.ncbi.nlm.nih.gov/38925803/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked; no approval or availability inferred."},{"title":"EnTRIPS: remote ischemic postconditioning after EVT","url":"https://pubmed.ncbi.nlm.nih.gov/42267436/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"ASSET-IT: tirofiban infusion after IVT","url":"https://pubmed.ncbi.nlm.nih.gov/40616232/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"INSTANT: IV tirofiban after tenecteplase","url":"https://pubmed.ncbi.nlm.nih.gov/42100960/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"ATTRACTION: tirofiban after successful EVT","url":"https://pubmed.ncbi.nlm.nih.gov/42341797/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"RESCUE BT: IV tirofiban before EVT","url":"https://pubmed.ncbi.nlm.nih.gov/35943471/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"STRATEGY: tirofiban for branch atheromatous disease","url":"https://pubmed.ncbi.nlm.nih.gov/42671865/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"ESO annual stroke evidence update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41706824/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PMC full text (PMC12915583) read 2026-10-31. ESO Guideline Board evidence review; its practice implications are the authors' interpretation, not guideline recommendations."},{"title":"LAIS — Loberamisal for Acute Ischemic Stroke: The LAIS Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42721021/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."},{"title":"ERASE-STROKE — Early and prolonged oral edaravone for neuroprotection in acute ischemic stroke: the ERASE-STROKE randomized controlled phase 3 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42705987/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Country (China) and the no-reperfusion criterion from the ClinicalTrials.gov registry record NCT06648304."},{"title":"CHOICE — Effect of Intra-arterial Alteplase vs Placebo Following Successful Thrombectomy on Functional Outcomes in Patients With Large Vessel Occlusion Acute Ischemic Stroke: The CHOICE Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35143603/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"CHOICE-2 — Adjunctive Intra-Arterial Alteplase After Successful Thrombectomy for Acute Ischemic Stroke: The CHOICE-2 Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42096239/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"RESCUE BT2 — Tirofiban for Stroke without Large or Medium-Sized Vessel Occlusion.","url":"https://pubmed.ncbi.nlm.nih.gov/37256974/","year":2023,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CLEAR SYNERGY (colchicine) — Colchicine in Acute Myocardial Infarction.","url":"https://pubmed.ncbi.nlm.nih.gov/39555823/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"AXIOMATIC-SSP — Safety and efficacy of factor XIa inhibition with milvexian for secondary stroke prevention (AXIOMATIC-SSP): a phase 2, international, randomised, double-blind, placebo-controlled, dose-finding trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38101902/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"PEARL — Intra-Arterial Alteplase After Successful Endovascular Reperfusion in Acute Stroke: The PEARL Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42262770/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"ANGEL-TNK — Intra-arterial Tenecteplase for Acute Stroke After Successful Endovascular Therapy: The ANGEL-TNK Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40616323/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"IAT-TOP — Intra-arterial Alteplase Thrombolysis After Successful Thrombectomy for AIS in the Posterior Circulation: The IAT-TOP Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42026933/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"DATE (IA tenecteplase dose-escalation) — Intra-Arterial Tenecteplase After Successful Reperfusion in Large Vessel Occlusion Stroke: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40616333/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"IA Thrombolysis Dose Network Meta-analysis — Dose-Specific Intra-Arterial Thrombolysis After Endovascular Thrombectomy for Large-Vessel Occlusion Stroke: A Network Meta-Analysis of Randomized Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42088338/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: network meta-analysis of 7 randomized trials (2126 patients), hypothesis-generating per its authors; bibliographic record checked."},{"title":"MOST — Adjunctive Intravenous Argatroban or Eptifibatide for Ischemic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/39231343/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ESCAPE-NA1 — Efficacy and safety of nerinetide for the treatment of acute ischaemic stroke (ESCAPE-NA1): a multicentre, double-blind, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/32087818/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ACTISAVE — Glenzocimab Efficacy and Safety Added to Intravenous Thrombolysis With or Without Mechanical Thrombectomy in Patients With Acute Ischemic Stroke-ACTISAVE: A Prospective, Randomized, Double-Blind Study.","url":"https://pubmed.ncbi.nlm.nih.gov/42044230/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."},{"title":"TASTE (edaravone dexborneol) — Edaravone Dexborneol Versus Edaravone Alone for the Treatment of Acute Ischemic Stroke: A Phase III, Randomized, Double-Blind, Comparative Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/33588596/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"TASTE-2 — Edaravone dexborneol versus placebo on functional outcomes in patients with acute ischaemic stroke undergoing endovascular thrombectomy (TASTE-2): randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41500725/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."},{"title":"EMPHASIS — Efficacy and safety of minocycline in patients with acute ischaemic stroke (EMPHASIS): a multicentre, double-blind, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41628627/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."},{"title":"MIST-A — Efficacy and safety of minocycline on patients with acute anterior circulation ischaemic stroke undergoing mechanical thrombectomy (MIST-A): a multicentre, prospective, randomised, open-label, blinded-endpoint, phase 2 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42305108/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."},{"title":"ESCAPE-NEXT year 1 — Safety and Efficacy of Nerinetide at Year 1 in Participants Enrolled in ESCAPE-NEXT: A Multicenter, Double-Blind, Randomized Controlled Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42333641/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (PMC13477396 not read); bibliographic record checked. Year-1 outcomes in 513 of 850; the early-window interaction was post hoc."},{"title":"RICAMIS — Effect of Remote Ischemic Conditioning vs Usual Care on Neurologic Function in Patients With Acute Moderate Ischemic Stroke: The RICAMIS Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35972485/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Anti-inflammatory CV meta-analysis — Effects of anti-inflammatory agents on cardiovascular outcomes: A systematic review and meta-analysis of randomised controlled trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42291081/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Y-6 phase 2 — Efficacy and safety of sublingual cilostazol and dexborneol for the treatment of acute ischaemic stroke: a randomised phase 2 trial in China.","url":"https://pubmed.ncbi.nlm.nih.gov/42621146/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"OPENS-2 — Normobaric hyperoxia combined with endovascular treatment for acute ischaemic stroke in China (OPENS-2 trial): a multicentre, randomised, single-blind, sham-controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39922675/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"POST-TNK — Intra-Arterial Tenecteplase Following Endovascular Reperfusion for Large Vessel Occlusion Acute Ischemic Stroke: The POST-TNK Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39804681/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"POST-UK — Intra-Arterial Urokinase After Endovascular Reperfusion for Acute Ischemic Stroke: The POST-UK Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39804674/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"ATTENTION-IA — Intra-arterial tenecteplase after successful endovascular recanalisation in patients with acute posterior circulation arterial occlusion (ATTENTION-IA): multicentre randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39809509/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."}],"related":[]},{"id":"evidence-interpretation","title":"Rapid appraisal of a trial or guideline","category":"Systems and transitions of care","settings":["on-call","hospital","clinic"],"keywords":["evidence based medicine","EBM","critical appraisal","relative risk","absolute risk","NNT","confidence interval","noninferiority","subgroup","systematic review"],"summary":"Use a structured appraisal before converting a study headline into a clinical decision: population, comparison, outcome, uncertainty and applicability.","consider":["Is the outcome patient-important, and is the quoted result the prespecified primary analysis?","Compare absolute and relative effects, confidence intervals, missing data and harms.","Check whether subgroup, noninferiority or composite-endpoint claims support the proposed inference."],"caution":"A neutral superiority trial does not prove equivalence.","sources":[{"title":"Oxford CEBM critical appraisal and EBM tools","url":"https://www.cebm.ox.ac.uk/resources/ebm-tools","year":2026,"type":"Educational resource","checkedAt":"2026-10-01","access":"Official resource index verified in live search; direct page returned 403. Year records this resource check, not a new guideline publication."}],"related":[]},{"id":"ich-expansion-ivh","title":"ICH expansion and intraventricular extension","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital"],"keywords":["hematoma expansion","IVH","intraventricular hemorrhage","EVD","CLEAR III","TICH-2","FASTEST","tranexamic acid","factor VIIa","hemostatic"],"summary":"In ICH without anticoagulant use, no hemostatic drug has been shown to improve function (anticoagulant-associated ICH still needs rapid reversal: AHA 2022, COR 1). Recombinant factor VIIa within 2 h (FASTEST) slowed growth by 3.7 mL but did not change 180-day mRS (cOR 1.09) and increased life-threatening thromboembolism (RR 3.41); tranexamic acid (TICH-2) also gave no functional benefit (aOR 0.88). A 2026 individual-patient meta-analysis (5 trials, 2,860 patients treated within 12 h) confirmed no 90-day functional benefit (cOR 0.93) but found small reductions in hematoma expansion (OR 0.81) and 7-day mortality (aOR 0.70). Hydrocephalus contributing to reduced consciousness: ventricular drainage (AHA 2022, COR 1); large IVH with impaired consciousness: EVD rather than medical management alone (COR 1). CLEAR III (stable supratentorial ICH <30 mL or primary IVH; IVH obstructing the third or fourth ventricle; routine EVD): intraventricular alteplase lowered 180-day mortality (18 vs 29%) without improving mRS ≤3 and increased mRS 5 (17 vs 9%). AHA 2022, for GCS >3 with primary IVH or IVH extension from supratentorial ICH <30 mL requiring EVD: reasonable to reduce mortality (2a); functional benefit uncertain (2b).","consider":["Is the problem expansion, ventricular obstruction, hydrocephalus or mass effect?","Repeat CT within 24 h, sooner with any decline, to catch expansion.","Discuss procedural risks and patient-valued outcomes with neurosurgery."],"caution":"Lower mortality without functional gain can mean more survivors with severe disability.","sources":[{"title":"TICH-2: Tranexamic acid for hyperacute primary ICH","url":"https://pubmed.ncbi.nlm.nih.gov/29778325/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-22","access":"PMC full text read (PMC5976950): excluded ICH secondary to anticoagulation, thrombolysis, trauma or a structural abnormality; no approval or availability inferred."},{"title":"CLEAR III: Thrombolytic removal of intraventricular hemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/28081952/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract and registry (NCT00784134) checked 2026-10-17; no approval or availability inferred."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"Tranexamic acid in ICH IPD meta-analysis — Effect of tranexamic acid for acute spontaneous intracerebral haemorrhage: a systematic review and individual patient data meta-analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42276775/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Individual data from 5 placebo-controlled trials (2,860 participants, 90% of those eligible), including TICH-2."},{"title":"FASTEST — Recombinant factor VIIa versus placebo for spontaneous intracerebral haemorrhage within 2 h of symptom onset (FASTEST): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41653933/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card. PubMed lists 1 correction or notice; check it before applying results."},{"title":"STOP-MSU — Tranexamic acid versus placebo in individuals with intracerebral haemorrhage treated within 2 h of symptom onset (STOP-MSU): an international, double-blind, randomised, phase 2 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38648814/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"ICH immediate priorities","href":"#/evidence/ich-management"},{"label":"ICH surgical options","href":"#/evidence/ich-surgery"}]},{"id":"antiphospholipid-syndrome","title":"Antiphospholipid syndrome and stroke","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["APS","antiphospholipid","aPL","lupus anticoagulant","anticardiolipin","beta-2 glycoprotein","thrombophilia","warfarin","DOAC","recurrent thrombosis"],"summary":"APS assessment connects the clinical thrombotic history with persistent antiphospholipid antibodies. An isolated positive test does not establish APS; acute illness and anticoagulants can distort lupus-anticoagulant testing. In a 2026 meta-analysis of mostly hospital-based case-control studies (single-time testing; diagnosed APS excluded; most studies before 2010), about 1 in 5 ischemic stroke patients had at least one positive antiphospholipid antibody (19.1%; highly heterogeneous, possibly overestimated). Seropositivity was associated with first ischemic stroke (OR 2.93; strongest for lupus anticoagulant) but not significantly with recurrence in 9 cohorts (OR 1.20; 95% CI 0.87–1.67; not adjusted for post-stroke treatment), which the authors say is not evidence against its relevance.","consider":["Does the stroke mechanism, age, vascular-risk profile or prior thrombotic/obstetric history justify targeted testing?","Review the antibody profile, assay conditions and repeat testing at least 12 weeks apart with hematology and the laboratory.","For established APS-associated stroke, review its specific antithrombotic evidence; DOAC results from AF should not be transferred to arterial APS."],"caution":"Classification criteria are not a standalone diagnostic test, and this card does not choose a drug, INR target or duration.","sources":[{"title":"BSH 2024 guidelines on the investigation and management of antiphospholipid syndrome","url":"https://onlinelibrary.wiley.com/doi/10.1111/bjh.19635","year":2024,"type":"Guideline","checkedAt":"2026-10-02","access":"BSH guideline, selected sections."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"Antiphospholipid antibodies in ischemic stroke meta-analysis — Prevalence and Clinical Relevance of Antiphospholipid Antibodies in Ischemic Stroke: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42663055/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract and PMC full text (PMC13528693) read 2026-10-31; bibliographic record checked. Mostly hospital-based case-control studies with single-time antibody testing; patients with diagnosed APS excluded."}],"related":[{"label":"Stroke mechanism and workup","href":"#/evidence/stroke-workup"},{"label":"Anticoagulant label review","href":"#/evidence/anticoagulant-labels"},{"label":"Cerebral venous thrombosis","href":"#/evidence/cvt"}]},{"id":"thunderclap-sah-evaluation","title":"Sudden severe headache and suspected SAH","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital"],"keywords":["thunderclap","worst headache","subarachnoid","SAH diagnosis","negative CT","lumbar puncture","LP","CTA","Ottawa SAH","acute headache"],"summary":"Sudden severe headache warrants prompt evaluation for SAH and other serious causes. Interpret a negative CT with the onset interval, neurologic findings, scanner quality and reader expertise.","consider":["Establish time to peak pain, onset time, examination findings and whether the presentation fits the source population.","AHA/ASA 2023 recommends LP after a negative CT when presentation is more than 6 hours after onset or there is a new neurologic deficit; early CT-only assessment has specific quality and examination requirements.","ACEP 2019 allows LP or CTA when SAH risk remains after negative CT, with shared discussion of limitations. Review these differing recommendations with the local diagnostic pathway.","In ED patients with non-traumatic acute headache, the Ottawa and Emerald SAH rules had pooled sensitivity of 99% but specificity of only 23–27%, and the Ottawa rule did not significantly reduce CT use (2025 meta-analysis). In a UK and Ireland neurosurgical-referral audit (10,187 spontaneous SAH), 55 aneurysmal SAHs had a CT reported negative within 6 h of onset and a positive LP; these were real-world reports, often not by neuroradiologists."],"caution":"A negative CT is not universal clearance, and CTA can find an incidental aneurysm.","sources":[{"title":"AHA/ASA 2023 aneurysmal SAH guideline: Section 4, clinical manifestations and diagnosis","url":"https://www.ahajournals.org/doi/10.1161/STR.0000000000000436","year":2023,"type":"Guideline","checkedAt":"2026-10-02","access":"Publisher-indexed Section 4 recommendation table read, including CT timing, examination/reader requirements and LP. Complete guideline and supplements not reviewed. Previously indexed correction PMID 38011240 remains unreconciled; no correction-access retry or full corrected-guideline claim."},{"title":"ACEP 2019 clinical policy: acute headache, diagnostic questions 3 and 4","url":"https://www.acep.org/siteassets/sites/acep/media/clinical-policies/cp-headache.pdf","year":2019,"type":"Guideline","checkedAt":"2026-10-02","access":"Official published policy PDF, questions 3 and 4 (pp. e50–e51), recommendations and diagnostic limitations read. Complete policy/evidence tables not reviewed. A 2026 update was listed as a draft for comment; draft recommendations were not used."},{"title":"SAH decision rules meta-analysis — Diagnostic Accuracy and Application of Subarachnoid Hemorrhage Decision Rules Among Patients With Non-Traumatic Acute Headache: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/40605232/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Emergency-department patients with non-traumatic acute headache."},{"title":"UK and Ireland SAH lumbar puncture audit — Multicentre study of the role of lumbar puncture in the diagnosis of spontaneous subarachnoid haemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/40676358/","year":2025,"type":"Observational study","checkedAt":"2026-10-31","access":"PMC full text (PMC12270960) read 2026-10-31; bibliographic record checked. Retrospective multicentre audit of neurosurgical referrals; CT reports came mostly from referring hospitals, often not by an expert neuroradiologist, so it did not test the AHA 2023 early CT-only criteria."}],"related":[{"label":"Aneurysmal SAH","href":"#/evidence/sah"},{"label":"RCVS and PRES","href":"#/evidence/rcvs-pres"},{"label":"CVT","href":"#/evidence/cvt"},{"label":"Dissection","href":"#/evidence/dissection"}]},{"id":"fibromuscular-dysplasia","title":"Fibromuscular dysplasia: vascular assessment and follow-up","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["FMD","fibromuscular dysplasia","beading","nonatherosclerotic","renal artery","multivessel","aneurysm screening","cervical dissection"],"summary":"FMD is a nonatherosclerotic arterial disorder that can involve several vascular beds. The ESH/SVM consensus requires a focal or multifocal arterial lesion; dissection, aneurysm or tortuosity alone does not establish FMD.","consider":["Review the vascular imaging diagnosis and any associated dissection, aneurysm or hypertension with an experienced team.","For established FMD, the 2019 consensus supports at least one brain-to-pelvis CTA or contrast-enhanced MRA assessment for additional disease, aneurysms and dissections.","Arrange longitudinal clinical review; customize subsequent imaging to the affected vessels, symptoms, prior procedures and aneurysm/dissection findings."],"caution":"Consensus guidance with limited treatment evidence; there is no universal follow-up imaging interval.","sources":[{"title":"ESH/SVM 2019 first international consensus on the diagnosis and management of fibromuscular dysplasia","url":"https://journals.sagepub.com/doi/pdf/10.1177/1358863X18821816","year":2019,"type":"Consensus statement","checkedAt":"2026-10-02","access":"Selected primary PDF passages read: diagnostic consensus points (p. 167), cerebrovascular assessment (p. 175), brain-to-pelvis imaging and antiplatelet evidence limits (p. 177), longitudinal follow-up (pp. 182–183). Full document and supplements not comprehensively reviewed."},{"title":"FMD consensus corrigendum: carotid stenosis wording","url":"https://journals.sagepub.com/doi/10.1177/1358863X19865703","year":2019,"type":"Correction","checkedAt":"2026-10-02","access":"Complete publisher-indexed notice text read; it replaces an erroneous reference to severe carotid stenting with severe carotid stenosis in a cervical-dissection procedural sentence. That sentence is not reproduced here. Direct notice-page fetch timed out."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."}],"related":[{"label":"Cervical artery dissection","href":"#/evidence/dissection"},{"label":"Unruptured aneurysm review","href":"#/evidence/unruptured-aneurysms"},{"label":"Long-term blood pressure prevention","href":"#/evidence/bp-prevention"}]}],"studies":[{"id":"elan","title":"ELAN — timing of anticoagulation after AF-associated stroke","headline":"Early DOAC: composite 2.9 vs 4.1% (difference not significant)","year":2023,"settings":["hospital","clinic"],"keywords":["DOAC","atrial fibrillation","early anticoagulation"],"question":"How did earlier DOAC initiation compare with a later schedule?","population":"2,013 people with acute ischemic stroke and atrial fibrillation.","comparison":"Earlier: within 48 hours for minor/moderate stroke or days 6–7 for major stroke. Later: days 3–4, 6–7 or 12–14, respectively.","result":"The 30-day composite of recurrent ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage or vascular death was 2.9% versus 4.1% (risk difference −1.18 percentage points; 95% CI −2.84 to 0.47). Symptomatic intracranial hemorrhage was 0.2% in both groups.","limits":"The confidence interval includes no difference. Trial severity categories and exclusions require review; this is not an automatic start-date rule.","sources":[{"title":"ELAN primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37222476/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"af-timing"},{"id":"optimas","title":"OPTIMAS — early versus delayed DOAC initiation","headline":"DOAC ≤4 days noninferior to days 7–14 (3.3% each)","year":2024,"settings":["hospital","clinic"],"keywords":["DOAC","atrial fibrillation","early anticoagulation"],"question":"Was initiation within four days noninferior to starting at 7–14 days?","population":"3,621 analyzed adults with AF-associated ischemic stroke at 100 UK hospitals; clinicians were uncertain about timing.","comparison":"DOAC initiation within four days versus days 7–14.","result":"At 90 days, recurrent ischemic stroke, symptomatic intracranial hemorrhage, unclassifiable stroke or systemic embolism occurred in 3.3% of each group. Noninferiority met the two-percentage-point margin; superiority was not demonstrated. Symptomatic intracranial hemorrhage was 0.6% versus 0.7%.","limits":"Open-label treatment with masked adjudication. Apply the trial selection criteria; identical observed rates do not prove identical individual risk.","sources":[{"title":"OPTIMAS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/39491870/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract read via PubMed/NLM. January 2025 publisher correction checked: wording and figure-at-risk count corrected; no endpoint change stated."}],"relatedTopic":"af-timing"},{"id":"catalyst","title":"CATALYST — pooled randomized evidence on DOAC timing","headline":"DOAC ≤4 days: 2.1 vs 3.0% (OR 0.70); sICH 0.4% each","year":2025,"settings":["hospital","clinic"],"keywords":["IPD","meta-analysis","ELAN","OPTIMAS","TIMING","START","atrial fibrillation"],"question":"What does pooled participant-level evidence show about earlier initiation?","population":"5,441 participants from TIMING, ELAN, OPTIMAS and START; median NIHSS 5. Primary outcome data were available for 5,429.","comparison":"DOAC initiation within four days versus day five or later; individual participant data meta-analysis.","result":"At 30 days, recurrent ischemic stroke, symptomatic intracerebral hemorrhage or unclassified stroke occurred in 2.1% versus 3.0% (OR 0.70; 95% CI 0.50–0.98). Symptomatic intracerebral hemorrhage was 0.4% in each group.","limits":"This synthesis includes ELAN and OPTIMAS participants; it is not an independent additional randomized trial. Results retain the component trials’ selection limits.","sources":[{"title":"CATALYST primary report","url":"https://pubmed.ncbi.nlm.nih.gov/40570866/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"af-timing"},{"id":"point","title":"POINT — acute dual antiplatelet benefit and bleeding","headline":"DAPT: major ischemic events 5.0 vs 6.5%; major bleeding 0.9 vs 0.4%","year":2018,"settings":["on-call","hospital","clinic"],"keywords":["DAPT","clopidogrel","aspirin","minor stroke","TIA"],"question":"What was the benefit–bleeding tradeoff of adding clopidogrel?","population":"4,881 adults with minor ischemic stroke (NIHSS ≤3) or high-risk TIA (ABCD² ≥4), randomized within 12 hours at 269 sites in 10 countries (82.8% in the US).","comparison":"Clopidogrel plus aspirin versus aspirin alone for the 90-day trial period.","result":"Major ischemic events (ischemic stroke, myocardial infarction or ischemic vascular death) occurred in 5.0% versus 6.5% at 90 days (HR 0.75; 95% CI 0.59–0.95). Major hemorrhage occurred in 0.9% versus 0.4% (HR 2.32; 95% CI 1.10–4.87).","limits":"Stopped early. Most ischemic events occurred in the first week; the 90-day design alone does not establish the optimal DAPT duration or eligibility for other stroke populations.","sources":[{"title":"POINT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/29766750/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract and PMC full text (PMC6193486) checked."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"sammpris","title":"SAMMPRIS — medical management versus intracranial stenting","headline":"Stenting worse: 30-day stroke/death 14.7 vs 5.8%","year":2011,"settings":["hospital","clinic"],"keywords":["sICAS","intracranial stenosis","Wingspan","stent"],"question":"Did adding Wingspan stenting improve outcomes in severe symptomatic intracranial stenosis?","population":"451 patients with recent TIA or stroke attributed to 70–99% stenosis of a major intracranial artery.","comparison":"Aggressive medical management plus angioplasty/Wingspan stenting versus aggressive medical management alone.","result":"Stroke or death by 30 days was 14.7% with stenting versus 5.8% with medical management. Estimated one-year primary-event rates were 20.0% versus 12.2%; that endpoint included early stroke/death and later qualifying-territory stroke.","limits":"Enrollment stopped for safety concerns. This tested a specified stent strategy; it does not directly test balloon angioplasty alone or every later device and selection strategy.","sources":[{"title":"SAMMPRIS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/21899409/","year":2011,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and corrected NEJM report read; source updated July 2012. Protocol and supplements not reviewed."}],"relatedTopic":"sicas"},{"id":"close","title":"CLOSE — PFO closure in selected cryptogenic stroke","headline":"PFO closure: stroke 0/238 vs 14/235; AF 4.6 vs 0.9%","year":2017,"settings":["hospital","clinic"],"keywords":["patent foramen ovale","PFO","atrial septal aneurysm","large shunt"],"question":"Does PFO closure reduce recurrent stroke in patients with high-risk PFO features?","population":"663 patients aged 16–60 with recent stroke attributed to PFO and an atrial septal aneurysm or large shunt.","comparison":"Closure plus antiplatelet therapy versus antiplatelets alone; the study also included a separate anticoagulation comparison.","result":"Over mean follow-up of 5.3 years, stroke occurred in 0/238 closure patients versus 14/235 antiplatelet-only patients (HR 0.03; 95% CI 0–0.26). Procedural complications occurred in 5.9%; AF occurred in 4.6% versus 0.9%.","limits":"Selected younger population with an attributed PFO mechanism. These findings do not make an incidental PFO an indication for closure or establish closure superiority to anticoagulation.","sources":[{"title":"CLOSE primary report","url":"https://pubmed.ncbi.nlm.nih.gov/28902593/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"pfo"},{"id":"treat-cad","title":"TREAT-CAD — aspirin versus anticoagulation for dissection","headline":"Aspirin not shown noninferior to VKA (23 vs 15%)","year":2021,"settings":["hospital","clinic"],"keywords":["cervical artery dissection","carotid","vertebral","aspirin","VKA"],"question":"Was aspirin noninferior to a vitamin K antagonist after cervical dissection?","population":"194 adults with symptomatic, MRI-confirmed cervical artery dissection within two weeks; 173 were analyzed per protocol.","comparison":"Aspirin versus a vitamin K antagonist for 90 days.","result":"The clinical/MRI composite occurred in 23% versus 15% (absolute difference 8 percentage points; 95% CI −4 to 21). Aspirin noninferiority was not established. Seven ischemic strokes occurred with aspirin and none with anticoagulation.","limits":"Small open-label trial; the primary composite included MRI lesions at 14 days and clinical outcomes through 90 days. Failure of noninferiority does not establish universal anticoagulant superiority; DOACs were not tested.","sources":[{"title":"TREAT-CAD primary report","url":"https://pubmed.ncbi.nlm.nih.gov/33765420/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"dissection"},{"id":"select2","title":"SELECT2 — thrombectomy in selected large-core stroke","headline":"Large core: generalized OR 1.51; mRS 0–2 20 vs 7%","year":2023,"settings":["on-call","hospital"],"keywords":["EVT","large core","ASPECTS","ICA","M1"],"question":"Does thrombectomy improve outcome in selected large-core anterior-circulation stroke?","population":"352 patients with ICA/M1 occlusion within 24 hours and ASPECTS 3–5 or imaging core ≥50 mL.","comparison":"Thrombectomy plus medical care versus medical care alone.","result":"The 90-day mRS distribution favored thrombectomy (generalized OR 1.51; 95% CI 1.20–1.89). Functional independence, a secondary outcome, was 20% versus 7%.","limits":"Stopped early for efficacy; vascular complications occurred. Review complete selection criteria. The 2024 correction clarified core-volume measurement substitutions and stated that outcome direction and significance were unchanged. At 1 year (Lancet 2024), the mRS distribution still favored thrombectomy (generalized OR 1.43; 95% CI 1.14–1.78); 1-year mortality was 45% vs 52% (RR 0.89; 95% CI 0.71–1.11).","sources":[{"title":"SELECT2 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/36762865/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and January 2024 publisher correction read; full trial report and supplements not reviewed."},{"title":"SELECT2 1-year outcomes","url":"https://pubmed.ncbi.nlm.nih.gov/38346442/","year":2024,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; 1-year follow-up of the original randomized population."}],"relatedTopic":"large-core-evt"},{"id":"angel-aspect","title":"ANGEL-ASPECT — thrombectomy for large infarct in China","headline":"Large core: GOR 1.37; sICH 6.1 vs 2.7%","year":2023,"settings":["on-call","hospital"],"keywords":["large core","ASPECTS","thrombectomy","EVT"],"question":"Does EVT help anterior LVO with ASPECTS 3–5 or core 70–100 mL within 24 hours?","population":"456 patients in China; about 28% received IVT.","comparison":"EVT plus medical management versus medical management alone.","result":"The 90-day mRS shifted toward better outcomes with EVT (generalized OR 1.37; 95% CI 1.11–1.69). Symptomatic ICH 6.1% vs 2.7%; any ICH 49.1% vs 17.3%.","limits":"Stopped early for efficacy; open-label, single-country trial. At 1 year (Stroke 2025; 425 of 455 analyzed), the mRS shift still favored EVT (generalized OR 1.25; 95% CI 1.01–1.56; mRS 0–2 30.4 vs 17.1%), with mortality 31.3 vs 26.5% (RR 1.12; 95% CI 0.82–1.53); the mRS 0–2 difference narrowed from 18.5 to 13.3 points as the medical arm improved.","sources":[{"title":"ANGEL-ASPECT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/36762852/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"ANGEL-ASPECT 1-year outcomes","url":"https://pubmed.ncbi.nlm.nih.gov/40854041/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; prespecified 1-year analysis of the original randomized population (complete-case, 425 of 455)."}],"relatedTopic":"large-core-evt"},{"id":"rescue-japan-limit","title":"RESCUE-Japan LIMIT — thrombectomy for ASPECTS 3–5","headline":"ASPECTS 3–5: mRS 0–3 31.0 vs 12.7%","year":2022,"settings":["on-call","hospital"],"keywords":["large core","ASPECTS","thrombectomy","EVT","Japan"],"question":"Does EVT help LVO with ASPECTS 3–5?","population":"203 patients in Japan within 6 hours, or within 24 hours without early FLAIR change; about 27% received alteplase (0.6 mg/kg).","comparison":"EVT plus medical care versus medical care alone.","result":"mRS 0–3 at 90 days occurred in 31.0% vs 12.7% (RR 2.43; 95% CI 1.35–4.37). Any ICH occurred in 58.0% vs 31.4%.","limits":"Small open-label trial; used the Japanese alteplase dose.","sources":[{"title":"RESCUE-Japan LIMIT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/35138767/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"large-core-evt"},{"id":"tension","title":"TENSION — thrombectomy for established large infarct","headline":"ASPECTS 3–5 ≤12 h: cOR 2.58; lower mortality","year":2023,"settings":["on-call","hospital"],"keywords":["large core","ASPECTS","thrombectomy","EVT","non-contrast CT"],"question":"Does EVT help anterior LVO with ASPECTS 3–5 selected mainly by non-contrast CT?","population":"253 patients in Europe and Canada within 12 hours of onset.","comparison":"EVT plus medical treatment versus medical treatment alone.","result":"The 90-day mRS shifted toward better outcomes (adjusted cOR 2.58; 95% CI 1.60–4.15) with lower mortality (HR 0.67; 95% CI 0.46–0.98). Symptomatic ICH 6% vs 5%.","limits":"Stopped early for efficacy after the first interim analysis; open-label.","sources":[{"title":"TENSION primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37837989/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"large-core-evt"},{"id":"laste","title":"LASTE — thrombectomy for large infarct of unrestricted size","headline":"ASPECTS ≤5 ≤6.5 h: median mRS 4 vs 6; mortality 36.1 vs 55.5%","year":2024,"settings":["on-call","hospital"],"keywords":["large core","ASPECTS 0-2","thrombectomy","EVT"],"question":"Does EVT help anterior LVO with ASPECTS ≤5, without a lower limit, within 6.5 hours?","population":"333 randomized patients (324 analyzed); about 35% received thrombolysis.","comparison":"EVT plus medical care versus medical care alone.","result":"Median 90-day mRS was 4 vs 6 (generalized OR 1.63; 95% CI 1.29–2.06). Mortality 36.1% vs 55.5% (adjusted RR 0.65; 95% CI 0.50–0.84). Symptomatic ICH 9.6% vs 5.7%.","limits":"Stopped early because similar trials favored EVT; benefit was mainly less severe disability and death.","sources":[{"title":"LASTE primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38718358/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"large-core-evt"},{"id":"ninds-tpa","title":"NINDS rt-PA — alteplase within 3 hours","headline":"Alteplase ≤3 h: favorable outcome OR 1.7; sICH 6.4 vs 0.6%","year":1995,"settings":["on-call","hospital"],"keywords":["alteplase","tPA","thrombolysis","3 hours","NINDS"],"question":"Does IV alteplase started within 3 hours improve outcome after ischemic stroke?","population":"624 patients in two parts (291 and 333) treated within 3 hours of onset.","comparison":"IV alteplase versus placebo, double-blind.","result":"Part 2 confirmed 3-month benefit (global OR for favorable outcome 1.7; 95% CI 1.2–2.6); alteplase patients were at least 30% more likely to have minimal or no disability. Symptomatic ICH within 36 hours was 6.4% vs 0.6%; 3-month mortality 17% vs 21% (P=0.30). Part 1 showed no difference in 24-hour neurological improvement.","limits":"Treatment within 3 hours only; the 24-hour primary outcome of part 1 was neutral. Higher sICH requires the full eligibility and BP protocol.","sources":[{"title":"NINDS rt-PA primary report","url":"https://pubmed.ncbi.nlm.nih.gov/7477192/","year":1995,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"acute-reperfusion"},{"id":"ecass-3","title":"ECASS III — alteplase at 3 to 4.5 hours","headline":"Alteplase 3–4.5 h: mRS 0–1 52.4 vs 45.2%; sICH 2.4 vs 0.2%","year":2008,"settings":["on-call","hospital"],"keywords":["alteplase","tPA","thrombolysis","4.5 hours","ECASS"],"question":"Does IV alteplase 3 to 4.5 hours after onset improve outcome?","population":"821 patients without brain hemorrhage or major infarction on CT; median treatment time 3 h 59 min.","comparison":"Alteplase 0.9 mg/kg versus placebo, double-blind.","result":"mRS 0–1 at 90 days occurred in 52.4% vs 45.2% (OR 1.34; 95% CI 1.02–1.76). Symptomatic ICH 2.4% vs 0.2%; any ICH 27.0% vs 17.6%. Mortality 7.7% vs 8.4%.","limits":"Excluded major infarction on CT; the trial population and exclusions shape applicability beyond 3 hours.","sources":[{"title":"ECASS III primary report","url":"https://pubmed.ncbi.nlm.nih.gov/18815396/","year":2008,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"acute-reperfusion"},{"id":"baoche","title":"BAOCHE — basilar thrombectomy at 6–24 hours","headline":"Basilar 6–24 h: mRS 0–3 46 vs 24%","year":2022,"settings":["on-call","hospital"],"keywords":["EVT","basilar artery occlusion","posterior circulation"],"question":"Does late-window basilar thrombectomy improve functional outcome?","population":"217 analyzed patients in China with basilar-artery stroke presenting 6–24 hours after symptom onset.","comparison":"Thrombectomy plus medical treatment versus medical treatment alone.","result":"At 90 days, mRS 0–3 occurred in 46% versus 24% (adjusted rate ratio 1.81; 95% CI 1.26–2.60). Symptomatic intracranial hemorrhage was 6% versus 1%; procedural complications occurred in 11% of thrombectomy recipients.","limits":"Stopped at an interim analysis. The primary endpoint changed from mRS 0–4 to 0–3; the original endpoint did not show a conclusive difference. Review the trial’s full clinical/imaging selection rather than applying its time window alone.","sources":[{"title":"BAOCHE primary report","url":"https://pubmed.ncbi.nlm.nih.gov/36239645/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"basilar-occlusion"},{"id":"attention","title":"ATTENTION — thrombectomy for basilar occlusion within 12 hours","headline":"Basilar ≤12 h: mRS 0–3 46 vs 23%; mortality 37 vs 55%","year":2022,"settings":["on-call","hospital"],"keywords":["basilar","posterior circulation","thrombectomy","EVT"],"question":"Does EVT within 12 hours improve outcome in basilar artery occlusion?","population":"340 patients at 36 Chinese centers; about one third received IVT.","comparison":"EVT versus best medical care (2:1 randomization).","result":"mRS 0–3 at 90 days occurred in 46% vs 23% (adjusted rate ratio 2.06; 95% CI 1.46–2.91). Mortality 37% vs 55%; symptomatic ICH 5% vs 0%; procedural complications 14%.","limits":"Single-country trial; it required NIHSS ≥10, PC-ASPECTS ≥6 and prestroke mRS 0–2, and for age ≥80 PC-ASPECTS ≥8 and prestroke mRS 0 (registry NCT04751708). At 3 years (JAMA Neurol 2026; 307 of 340 followed), mRS 0–3 was 38.4% vs 18.3% (adjusted RR 2.05; 95% CI 1.35–3.11) and cumulative mortality 55.7% vs 73.1%; in a prespecified subgroup, no treatment effect was demonstrated at age ≥70.","sources":[{"title":"ATTENTION primary report","url":"https://pubmed.ncbi.nlm.nih.gov/36239644/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"ATTENTION 3-year outcomes","url":"https://pubmed.ncbi.nlm.nih.gov/41460644/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; 3-year follow-up of the original randomized population (307 of 340 completed)."}],"relatedTopic":"basilar-occlusion"},{"id":"trace-5","title":"TRACE-5 — tenecteplase for basilar occlusion within 24 hours","headline":"Basilar ≤24 h: mRS 0–1/baseline 38 vs 29%","year":2026,"settings":["on-call","hospital"],"keywords":["basilar","tenecteplase","late window","thrombolysis"],"question":"Does tenecteplase within 24 hours improve outcome in basilar artery occlusion?","population":"452 Chinese adults with basilar occlusion and prestroke mRS ≤3; 49% went on to EVT and 35% of controls received alteplase.","comparison":"Tenecteplase 0.25 mg/kg (max 25 mg) versus standard medical treatment, with or without EVT.","result":"mRS 0–1 or return to baseline at 90 days occurred in 38% vs 29% (adjusted rate ratio 1.50; 95% CI 1.09–2.08). Symptomatic ICH 2% vs 3%; mortality 29% vs 31%.","limits":"Open-label, single-country trial; the control arm mixed alteplase and no thrombolysis.","sources":[{"title":"TRACE-5 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/41655588/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"basilar-occlusion"},{"id":"attention-late","title":"ATTENTION LATE — tenecteplase before EVT for basilar occlusion at 4.5–24 hours","headline":"Tenecteplase before EVT: no gain (mRS 0–2 30 vs 30%)","year":2026,"settings":["on-call","hospital"],"keywords":["basilar","tenecteplase","thrombectomy","bridging","late window"],"question":"Does tenecteplase before EVT help basilar occlusion presenting 4.5–24 hours after onset?","population":"330 patients with NIHSS ≥10 admitted directly to 40 EVT-capable Chinese centers.","comparison":"Tenecteplase 0.25 mg/kg followed by EVT versus EVT alone.","result":"mRS 0–2 at 90 days occurred in 30% vs 30% (adjusted rate ratio 0.92; 95% CI 0.67–1.25). Symptomatic ICH 5% vs 4%; mortality 40% vs 43%.","limits":"Open-label; applies to direct admission to EVT centers, not drip-and-ship.","sources":[{"title":"ATTENTION LATE primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42776543/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"basilar-occlusion"},{"id":"distal","title":"DISTAL — medium and distal vessel thrombectomy","headline":"MeVO EVT: no benefit (cOR 0.90); sICH 5.9 vs 2.6%","year":2025,"settings":["on-call","hospital"],"keywords":["EVT","MeVO","DMVO","M2","M3","ACA","PCA"],"question":"Does EVT improve disability after selected medium/distal vessel occlusion?","population":"543 participants within 24 hours; nondominant/codominant M2 or selected more distal MCA, ACA or PCA occlusions. Median NIHSS was 6.","comparison":"EVT plus best medical treatment versus best medical treatment alone.","result":"The 90-day mRS distribution did not improve significantly (common OR 0.90; 95% CI 0.67–1.22). Symptomatic intracranial hemorrhage was 5.9% versus 2.6%; mortality was 15.5% versus 14.0%.","limits":"A neutral trial in its selected vessel/severity population; it does not establish equivalence or settle every medium-vessel treatment question. Dominant M2 was outside the stated M2 population. At 12 months there was still no benefit (adjusted common OR for better mRS 0.81; 95% CI 0.59–1.12; Lancet Neurol 2026).","sources":[{"title":"DISTAL primary report","url":"https://pubmed.ncbi.nlm.nih.gov/39908430/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."},{"title":"DISTAL 12-month outcomes","url":"https://pubmed.ncbi.nlm.nih.gov/42105785/","year":2026,"type":"Report","checkedAt":"2026-10-22","access":"Primary abstract read via PubMed on 2026-10-22; 12-month follow-up of the original randomized population (524 of 543 with 12-month data)."}],"relatedTopic":"medium-distal-evt"},{"id":"escape-mevo","title":"ESCAPE-MeVO — thrombectomy benefit and safety","headline":"MeVO EVT: no benefit; mortality 13.3 vs 8.4%","year":2025,"settings":["on-call","hospital"],"keywords":["EVT","MeVO","medium vessel","MCA"],"question":"Does EVT improve excellent functional outcome after medium-vessel occlusion?","population":"530 patients in five countries within 12 hours of last known well, with favorable baseline imaging; most occlusions were MCA branches.","comparison":"EVT plus usual care versus usual care alone.","result":"At 90 days, mRS 0–1 occurred in 41.6% versus 43.1% (adjusted rate ratio 0.95; 95% CI 0.79–1.15). Mortality was 13.3% versus 8.4% (adjusted HR 1.82; 95% CI 1.06–3.12); symptomatic intracranial hemorrhage was 5.4% versus 2.2%.","limits":"No primary-outcome benefit in this population. Vessel definition, imaging and time window matter; do not extrapolate large-vessel benefit automatically or infer a universal rule from one trial.","sources":[{"title":"ESCAPE-MeVO primary report","url":"https://pubmed.ncbi.nlm.nih.gov/39908448/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"medium-distal-evt"},{"id":"discount","title":"DISCOUNT — thrombectomy for medium or distal occlusion","headline":"MeVO EVT: no benefit (mRS 0–2 62 vs 68%); sICH 11 vs 3% if treated","year":2026,"settings":["on-call","hospital"],"keywords":["MeVO","DMVO","distal","thrombectomy","EVT"],"question":"Does thrombectomy improve outcome after a primary isolated medium or distal occlusion?","population":"244 adults at 22 French centers (median age 75, NIHSS 8) within 8 hours, or within 24 hours if FLAIR-negative; 488 planned.","comparison":"Thrombectomy plus medical treatment versus medical treatment alone.","result":"mRS 0–2 at 3 months occurred in 62% vs 68% (OR 0.73; 95% CI 0.40–1.31). Patients who received thrombectomy vs those who did not: symptomatic ICH 11% vs 3%, SAH 13% vs 2% and embolus migration 5% vs 1%. Mortality 6% vs 8%.","limits":"Stopped at interim analysis for futility and excess sICH; open-label; 81% of the EVT arm received thrombectomy. The third neutral MeVO trial after DISTAL and ESCAPE-MeVO.","sources":[{"title":"DISCOUNT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42485024/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"medium-distal-evt"},{"id":"enrich","title":"ENRICH — early minimally invasive ICH evacuation","headline":"Early MIS (mainly lobar): utility-weighted mRS 0.458 vs 0.374","year":2024,"settings":["on-call","hospital"],"keywords":["lobar hemorrhage","ICH surgery","minimally invasive"],"question":"Does early minimally invasive evacuation improve recovery after selected ICH?","population":"300 adults aged 18–80 (GCS 5–14, NIHSS ≥5, premorbid mRS 0–1) with lobar or anterior basal ganglia ICH of 30–80 mL, randomized within 24 hours of last known well; primary thalamic, infratentorial and large-IVH cases excluded.","comparison":"Minimally invasive evacuation plus guideline-based medical management versus medical management alone.","result":"Mean utility-weighted mRS (0–1; higher is better) at 180 days was 0.458 versus 0.374 (difference 0.084; 95% Bayesian credible interval 0.005–0.163). The benefit appeared attributable to lobar hemorrhage; 30-day mortality was 9.3% versus 18.0%.","limits":"Adaptive enrollment later restricted inclusion to lobar ICH. Findings concern the tested technique, timing and selected population, not all ICH surgery. Postoperative rebleeding with deterioration occurred in 3.3%.","sources":[{"title":"ENRICH primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38598795/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract checked; registry eligibility (NCT02880878) checked 2026-10-17."}],"relatedTopic":"ich-surgery"},{"id":"annexa-i","title":"ANNEXA-I — hemostatic efficacy and thrombotic harm","headline":"Andexanet: hemostasis 67.0 vs 53.1%; thrombotic events 10.3 vs 5.6%","year":2024,"settings":["on-call","hospital"],"keywords":["andexanet","factor Xa","PCC","anticoagulant reversal","ICH"],"question":"What were andexanet’s efficacy and safety tradeoffs in factor Xa inhibitor-associated ICH?","population":"530 patients with acute ICH (0.5–60 mL; GCS ≥7; NIHSS ≤35; baseline scan within 6 h of onset; no surgery planned within 12 h) after factor Xa inhibitor use within 15 hours; the interim efficacy analysis included 452.","comparison":"Andexanet versus usual care; 85.5% of usual-care patients received PCC.","result":"Composite hemostatic efficacy was 67.0% versus 53.1% (adjusted difference 13.4 percentage points; 95% CI 4.6–22.2). Thrombotic events occurred in 10.3% versus 5.6%, including ischemic stroke in 6.5% versus 1.5%. No appreciable difference in 30-day mRS or mortality was reported.","limits":"Hemostatic efficacy is not functional benefit. NCS/SCCM 2026 conditionally recommends 4F-PCC rather than andexanet, and andexanet was withdrawn from the US market effective 22 December 2025.","sources":[{"title":"ANNEXA-I primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38749032/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract checked; registry eligibility (NCT03661528) checked 2026-10-17."}],"relatedTopic":"antithrombotic-reversal"},{"id":"prestige-af","title":"PRESTIGE-AF — anticoagulation after ICH with AF","headline":"DOAC after ICH: fewer ischemic strokes, more recurrent ICH","year":2025,"settings":["hospital","clinic"],"keywords":["DOAC","ICH survivor","atrial fibrillation","anticoagulation resumption"],"question":"How did DOACs change ischemic and hemorrhagic stroke risk after ICH?","population":"319 survivors of spontaneous ICH with AF, an anticoagulation indication and mRS ≤4; median follow-up 1.4 years.","comparison":"A DOAC versus no anticoagulation.","result":"First ischemic stroke favored DOACs (HR 0.05; 95% CI 0.01–0.36), while recurrent ICH noninferiority was not established (HR 10.89; 90% CI 1.95–60.72). All-event rates per 100 patient-years were 0.83 versus 8.60 for ischemic stroke and 5.00 versus 0.82 for ICH.","limits":"The ischemic benefit and hemorrhagic harm require individualized assessment; this trial does not establish a universal restart date. Two indexed corrections could not be fully accessed.","sources":[{"title":"PRESTIGE-AF primary report","url":"https://pubmed.ncbi.nlm.nih.gov/40023176/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract read via PubMed/NLM. March and June 2025 corrections identified; publisher correction bodies inaccessible (403). No full corrected-report review."}],"relatedTopic":"caa-ich-recurrence"},{"id":"mind","title":"MIND — minimally invasive evacuation at up to 72 hours","headline":"MIS ≤72 h: no 180-day mRS benefit (OR 1.03)","year":2025,"settings":["on-call","hospital"],"keywords":["ICH surgery","Artemis","deep hemorrhage","minimally invasive"],"question":"Did the Artemis evacuation strategy improve disability or survival?","population":"236 adults aged 18–80 with 20–80 mL supratentorial ICH, NIHSS ≥6 and GCS 5–15; 69.5% had primarily deep hemorrhage.","comparison":"Minimally invasive surgery within 72 hours plus medical management versus medical management alone.","result":"There was no demonstrated improvement in 180-day ordinal mRS (OR 1.03; 96% CI 0.62–1.72). Thirty-day mortality was 7.2% versus 9.8% (difference −2.5 percentage points; 95% CI −11.7 to 4.8).","limits":"Enrollment stopped early after a feasibility analysis. Imprecision limits conclusions; do not treat the result as proof of equivalence or interchange its technique and timing with ENRICH.","sources":[{"title":"MIND primary report","url":"https://pubmed.ncbi.nlm.nih.gov/40892424/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked."}],"relatedTopic":"ich-surgery"},{"id":"switch","title":"SWITCH — decompression for severe deep ICH","headline":"Decompression in deep ICH: mRS 5–6 44 vs 58% (p=0.057)","year":2024,"settings":["on-call","hospital"],"keywords":["hemicraniectomy","decompressive craniectomy","basal ganglia","thalamic hemorrhage"],"question":"Does decompressive craniectomy improve outcome in severe deep ICH?","population":"Adults aged 18–75 with severe basal ganglia or thalamic ICH (GCS 8–13, NIHSS 10–30, stable volume 30–100 mL) randomized within 66 hours of onset; 197 randomized participants gave delayed consent (median volume 57 mL).","comparison":"Decompressive craniectomy plus best medical treatment versus best medical treatment alone.","result":"At 180 days, mRS 5–6 occurred in 44% versus 58% (adjusted risk ratio 0.77; 95% CI 0.59–1.01; p=0.057). The report characterized the evidence as weak.","limits":"Stopped early for funding; survival often involved severe disability. This is a decompression study in deep ICH, not evidence for every hemorrhage location or evacuation technique. Two indexed correction bodies were inaccessible.","sources":[{"title":"SWITCH primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38761811/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract read via PubMed/NLM. June and July 2024 corrections identified; publisher correction bodies inaccessible (403). No full corrected-report review. Registry eligibility (NCT02258919) checked 2026-10-17."}],"relatedTopic":"ich-surgery"},{"id":"oriental-mevo","title":"ORIENTAL-MeVO — thrombectomy in selected medium-vessel stroke","headline":"MeVO EVT (China): mRS 0–2 58.6 vs 46.6%; sICH 4.7 vs 2.2%","year":2026,"settings":["on-call","hospital"],"keywords":["MeVO","medium vessel","thrombectomy","NIHSS"],"question":"Did thrombectomy improve function in moderate-to-severe MeVO stroke?","population":"563 adults at 48 Chinese centers; eligible NIHSS ≥6 and presentation within 24 hours.","comparison":"Thrombectomy plus medical management versus medical management.","result":"At 90 days, mRS 0–2 occurred in 58.6% versus 46.6% (adjusted rate ratio 1.24; 95% CI 1.07–1.44). Symptomatic intracranial hemorrhage was 4.7% versus 2.2%; mortality 11.1% versus 10.2%.","limits":"Open-label, single-country trial. The prespecified binary endpoint replaced ordinal mRS after its proportional-odds assumption failed. Interpret alongside neutral MeVO trials; selection differences do not establish a universal EVT rule.","sources":[{"title":"ORIENTAL-MeVO primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42127389/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"medium-distal-evt"},{"id":"sparcl","title":"SPARCL — atorvastatin after stroke or TIA","headline":"Atorvastatin 80: stroke 11.2 vs 13.1%; more hemorrhagic strokes","year":2006,"settings":["hospital","clinic"],"keywords":["statin","atorvastatin","lipids","LDL","secondary prevention"],"question":"Did high-dose atorvastatin reduce recurrent stroke?","population":"4,731 patients with stroke/TIA 1–6 months earlier, LDL 100–190 mg/dL and no known coronary heart disease.","comparison":"Atorvastatin 80 mg daily versus placebo.","result":"Over median 4.9 years, fatal/nonfatal stroke occurred in 11.2% versus 13.1% (adjusted HR 0.84; 95% CI 0.71–0.99). Hemorrhagic strokes numbered 55 versus 33. Liver-enzyme elevations were more common with atorvastatin; overall mortality was similar.","limits":"A selected secondary-prevention population. Net stroke benefit does not settle lipid treatment for every ICH survivor or establish a patient-specific hemorrhage risk.","sources":[{"title":"SPARCL primary report","url":"https://pubmed.ncbi.nlm.nih.gov/16899775/","year":2006,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract read via PubMed/NLM. Publisher 2018 correction checked: baseline Table 1 SE/SD labeling, with no outcome revision stated; full report and supplements not reviewed."}],"relatedTopic":"lipid-management"},{"id":"treat-stroke-to-target","title":"Treat Stroke to Target — LDL goals after atherosclerotic stroke","headline":"LDL <70: events 8.5 vs 10.9% (HR 0.78)","year":2020,"settings":["hospital","clinic"],"keywords":["TST","lipids","statin","ezetimibe","LDL","atherosclerosis"],"question":"Did a lower LDL target reduce major cardiovascular events?","population":"2,860 patients with recent ischemic stroke/TIA and cerebrovascular or coronary atherosclerosis in France and South Korea.","comparison":"LDL target below 70 versus 90–110 mg/dL, using statin, ezetimibe or both.","result":"Over median 3.5 years, ischemic stroke, MI, urgent coronary/carotid revascularization or cardiovascular death occurred in 8.5% versus 10.9% (adjusted HR 0.78; 95% CI 0.61–0.98). Intracranial hemorrhage and new diabetes did not differ significantly.","limits":"Stopped administratively before the planned event count. This composite is broader than recurrent stroke; nonsignificant safety differences do not prove equivalence. The trial did not test a target below 55 mg/dL.","sources":[{"title":"Treat Stroke to Target primary report","url":"https://pubmed.ncbi.nlm.nih.gov/31738483/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract read via PubMed/NLM; online publication 2019, print issue 2020. Full report and supplements not reviewed."}],"relatedTopic":"lipid-management"},{"id":"sps3-bp","title":"SPS3 — blood-pressure targets after lacunar stroke","headline":"SBP <130: all stroke HR 0.81 (NS); ICH HR 0.37","year":2013,"settings":["hospital","clinic"],"keywords":["blood pressure","SBP","lacunar","small vessel","hypertension"],"question":"Did a systolic target below 130 reduce recurrent stroke?","population":"3,020 patients with recent MRI-defined symptomatic lacunar infarction; mean follow-up 3.7 years.","comparison":"Systolic BP below 130 versus 130–149 mmHg; achieved means at one year were 127 and 138 mmHg.","result":"The primary all-stroke reduction was not statistically significant (HR 0.81; 95% CI 0.64–1.03). Intracerebral hemorrhage was reduced (HR 0.37; 95% CI 0.15–0.95). Treatment-related serious adverse events were infrequent.","limits":"Open-label factorial trial. The ICH component does not convert the neutral primary endpoint into proven all-stroke benefit. This is the BP comparison, separate from the SPS3 antiplatelet comparison and from acute BP management.","sources":[{"title":"SPS3 blood-pressure comparison primary report","url":"https://pubmed.ncbi.nlm.nih.gov/23726159/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract read via PubMed/NLM. Indexed correction identifies addition of an author; full report and supplements not reviewed."}],"relatedTopic":"bp-prevention"},{"id":"progress","title":"PROGRESS — blood-pressure lowering after stroke or TIA","headline":"Perindopril ± indapamide: stroke 10 vs 14%","year":2001,"settings":["hospital","clinic"],"keywords":["blood pressure","perindopril","indapamide","secondary prevention"],"question":"Did a perindopril-based regimen reduce recurrent stroke?","population":"6,105 people with previous stroke/TIA, including hypertensive and non-hypertensive participants.","comparison":"Perindopril-based treatment, with indapamide at clinician discretion, versus matching placebo.","result":"Over four years, fatal/nonfatal stroke occurred in 307/3,051 (10%) versus 420/3,054 (14%): relative risk reduction 28% (95% CI 17–38). Mean BP fell by 9/4 mmHg relative to placebo. Perindopril plus indapamide lowered BP by 12/5 mmHg and stroke by 43% (30–54); perindopril alone (5/3 mmHg) produced no discernible stroke reduction.","limits":"A long-term regimen trial, not an acute BP target. Combination and single-drug strata were not a randomized comparison with each other. The abstract does not quantify detailed harms; indexed correction bodies were not fully accessible.","sources":[{"title":"PROGRESS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/11589932/","year":2001,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract read via PubMed/NLM. Corrections indexed in Lancet 2001;358:1556 and 2002;359:2120 were not fully reviewed; detailed tolerability and correction effects remain unverified."}],"relatedTopic":"bp-prevention"},{"id":"trident","title":"TRIDENT — low-dose triple antihypertensive pill after ICH","headline":"Triple pill after ICH: recurrent stroke 4.6 vs 7.4%","year":2026,"settings":["hospital","clinic"],"keywords":["blood pressure","ICH","polypill","secondary prevention","telmisartan","amlodipine","indapamide"],"question":"Does a low-dose triple antihypertensive pill added to usual care reduce recurrent stroke after ICH?","population":"1,670 patients with prior ICH and SBP 130–160 who completed a 2-week active run-in (mean age 58).","comparison":"Telmisartan 20 mg, amlodipine 2.5 mg and indapamide 1.25 mg in one pill versus placebo.","result":"Recurrent stroke over a median 2.5 years: 4.6% vs 7.4% (HR 0.61; 95% CI 0.41–0.92). Mean SBP 127 vs 138; major cardiovascular events 6.6% vs 9.8%. Discontinuation for adverse events 13.6% vs 6.0%, most often a creatinine rise ≥20%.","limits":"Run-in design selects tolerant patients; renal monitoring is needed.","sources":[{"title":"TRIDENT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42019018/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"bp-prevention"},{"id":"navigate-esus","title":"NAVIGATE ESUS — rivaroxaban versus aspirin","headline":"ESUS rivaroxaban: no benefit, more major bleeding","year":2018,"settings":["hospital","clinic"],"keywords":["ESUS","cryptogenic","rivaroxaban","anticoagulation","embolism"],"question":"Did rivaroxaban prevent recurrent stroke in ESUS?","population":"7,213 patients with recent presumed embolic stroke without arterial stenosis, lacune or an identified cardioembolic source.","comparison":"Rivaroxaban 15 mg daily versus aspirin 100 mg daily.","result":"Over median 11 months, recurrent stroke/systemic embolism was 5.1% versus 4.8% per year (HR 1.07; 95% CI 0.87–1.33). Major bleeding was 1.8% versus 0.7% per year (HR 2.72; 95% CI 1.68–4.39).","limits":"Stopped early for lack of efficacy and excess bleeding. This ESUS result does not address established AF or another definite anticoagulation indication.","sources":[{"title":"NAVIGATE ESUS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/29766772/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"stroke-workup"},{"id":"respect-esus","title":"RE-SPECT ESUS — dabigatran versus aspirin","headline":"ESUS dabigatran: no significant benefit (HR 0.85)","year":2019,"settings":["hospital","clinic"],"keywords":["ESUS","cryptogenic","dabigatran","anticoagulation","embolism"],"question":"Did dabigatran reduce recurrent stroke after ESUS?","population":"5,390 patients with an embolic stroke of undetermined source; median follow-up 19 months.","comparison":"Dabigatran 150 or 110 mg twice daily versus aspirin 100 mg daily.","result":"Recurrent stroke was 4.1% versus 4.8% per year (HR 0.85; 95% CI 0.69–1.03); superiority was not demonstrated. Major bleeding was 1.7% versus 1.4% per year (HR 1.19; 95% CI 0.85–1.66); clinically relevant nonmajor bleeding was 1.6% versus 0.9% per year.","limits":"Neutral superiority is not equivalence. The result does not establish benefit in retrospectively selected subgroups or apply to known AF.","sources":[{"title":"RE-SPECT ESUS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/31091372/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"stroke-workup"},{"id":"arcadia","title":"ARCADIA — atrial cardiopathy without AF","headline":"Atrial cardiopathy apixaban: no benefit (4.4%/yr each)","year":2024,"settings":["hospital","clinic"],"keywords":["ESUS","cryptogenic","atrial cardiopathy","apixaban","NT-proBNP"],"question":"Did apixaban reduce recurrent stroke in atrial cardiopathy without AF?","population":"1,015 patients with cryptogenic stroke and atrial cardiopathy defined by ECG, NT-proBNP or indexed left-atrial diameter; no AF at randomization.","comparison":"Apixaban, with dose reduction when indicated, versus aspirin 81 mg daily.","result":"Recurrent stroke was 4.4% per year in both groups (HR 1.00; 95% CI 0.64–1.55). Symptomatic intracranial hemorrhage occurred in 0 versus 7 patients; other major hemorrhage in 5 versus 5.","limits":"Stopped for futility; mean follow-up 1.8 years. A 2026 secondary bleeding analysis reported fewer intracranial hemorrhages with apixaban than aspirin (annualized difference −1.4% in the on-treatment safety sample; −1.0% by intention to treat); the symptomatic ICH difference was not significant by intention to treat, other major and minor bleeding did not differ, and event counts were small, so this does not establish a safety advantage or change the neutral efficacy result. Biomarker-defined atrial cardiopathy is distinct from documented AF.","sources":[{"title":"ARCADIA primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38324415/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."},{"title":"ARCADIA hemorrhage analysis","url":"https://pubmed.ncbi.nlm.nih.gov/41741942/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; secondary analysis (primary safety sample censored at permanent study-drug discontinuation; intention-to-treat sensitivity analysis)."}],"relatedTopic":"stroke-workup"},{"id":"crystal-af","title":"CRYSTAL AF — prolonged monitoring after cryptogenic stroke","headline":"Implantable monitor: AF 12.4 vs 2.0% at 12 months","year":2014,"settings":["hospital","clinic"],"keywords":["cryptogenic","rhythm monitoring","loop recorder","atrial fibrillation","ICM"],"question":"Did an insertable monitor increase AF detection?","population":"441 patients aged at least 40 with cryptogenic stroke, no AF on at least 24-hour ECG monitoring, randomized within 90 days.","comparison":"Insertable cardiac monitor versus conventional follow-up.","result":"The primary endpoint, detection of AF lasting over 30 seconds within six months, occurred in 8.9% versus 1.4% (HR 6.4; 95% CI 1.9–21.7). At 12 months, detection was 12.4% versus 2.0%.","limits":"This was a detection trial, not proof of reduced recurrent stroke or a universal anticoagulation threshold for every device-detected episode. The abstract does not detail implantation harms.","sources":[{"title":"CRYSTAL AF primary report","url":"https://pubmed.ncbi.nlm.nih.gov/24963567/","year":2014,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"stroke-workup"},{"id":"crest-2","title":"CREST-2 — revascularization for asymptomatic carotid stenosis","headline":"Asymptomatic: stenting 2.8 vs 6.0%; CEA 3.7 vs 5.3% (NS)","year":2026,"settings":["clinic","hospital"],"keywords":["carotid","stenting","endarterectomy","asymptomatic","intensive medical management"],"question":"Did adding revascularization improve outcomes on intensive medical therapy?","population":"Two parallel trials of ≥70% stenosis without carotid-territory stroke, TIA or amaurosis fugax for 180 days: 1,245 in the stenting trial and 1,240 in the endarterectomy trial.","comparison":"Each procedure plus intensive medical management versus intensive medical management alone.","result":"The four-year composite of stroke/death through day 44 or later ipsilateral ischemic stroke was 2.8% versus 6.0% with stenting (P=0.02), and 3.7% versus 5.3% with endarterectomy (P=0.24). Early events included seven strokes and one death with stenting versus none medically; nine versus three strokes in the endarterectomy trial. Prespecified cognitive outcomes (2,165 US patients, up to 4 years) did not differ with either procedure (composite z-score differences 0.03 and 0.02).","limits":"Separate trials did not compare stenting directly with endarterectomy. Only certified high-volume operators took part, and 17–18% of medical-therapy patients later underwent revascularization. Results concern selected asymptomatic disease and include procedural harms; they do not establish a universal procedure choice.","sources":[{"title":"CREST-2 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/41269206/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"PMC full text (PMC13148431) read 2026-10-21; online publication 2025, print issue 2026. Supplement not reviewed."},{"title":"CREST-2 cognitive outcomes","url":"https://pubmed.ncbi.nlm.nih.gov/42747844/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; prespecified secondary outcomes of both randomized trials."},{"title":"CREST-H hemodynamic-impairment substudy","url":"https://pubmed.ncbi.nlm.nih.gov/42747834/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; randomized substudy of CREST-2."}],"relatedTopic":"carotid"},{"id":"ecst-2","title":"ECST-2 — two-year interim carotid revascularization evidence","headline":"Lower-risk carotid stenosis: no difference at 2 years","year":2025,"settings":["clinic","hospital"],"keywords":["carotid","endarterectomy","stenting","asymptomatic","low risk","interim"],"question":"Did revascularization add benefit in lower-risk carotid stenosis?","population":"429 randomized patients with ≥50% asymptomatic or symptomatic stenosis and CAR-score predicted five-year ipsilateral stroke risk below 20%.","comparison":"Optimized medical therapy alone versus medical therapy plus revascularization.","result":"At two years, the hierarchical composite of periprocedural death/fatal stroke/fatal MI, nonfatal stroke, nonfatal MI and new silent infarction showed no difference (medical/procedure win ratio 1.01; 95% CI 0.60–1.70). One periprocedural death followed endarterectomy.","limits":"Interim analysis with wide uncertainty, a selected risk population and an endpoint that includes silent infarction. It does not establish equivalence or negate benefit in higher-risk symptomatic disease.","sources":[{"title":"ECST-2 interim analysis primary report","url":"https://pubmed.ncbi.nlm.nih.gov/40252662/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract read via PubMed/NLM. January 2026 publisher correction checked: two appendix investigator names corrected; no outcome change stated. Full report and supplements not reviewed."}],"relatedTopic":"carotid"},{"id":"vns-rehab","title":"VNS-REHAB — paired stimulation for chronic arm weakness","headline":"Paired VNS: Fugl-Meyer +5.0 vs +2.4","year":2021,"settings":["clinic"],"keywords":["rehabilitation","recovery","upper limb","vagus nerve stimulation","motor","Fugl-Meyer"],"question":"Did paired vagus stimulation improve chronic upper-limb impairment?","population":"108 patients with moderate-to-severe arm weakness at least nine months after ischemic stroke.","comparison":"Implanted active versus sham vagus stimulation paired with six weeks of rehabilitation; all participants received implants.","result":"The primary Fugl-Meyer upper-extremity improvement immediately after therapy was 5.0 versus 2.4 points (difference 2.6; 95% CI 1.0–4.2). One serious surgery-related vocal-cord paresis occurred in the sham group.","limits":"Small, selected chronic-stroke trial. The endpoint measures impairment, not independent living; both arms carried implantation risks. Trial efficacy does not establish individual candidacy, device availability or coverage. A 2026 Cochrane review (10 RCTs, 7 transcutaneous; mostly high risk of bias) rated the arm-motor evidence very uncertain; 2-year gains (post hoc) are uncontrolled because both arms then received active stimulation.","sources":[{"title":"VNS-REHAB primary report","url":"https://pubmed.ncbi.nlm.nih.gov/33894832/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."},{"title":"VNS-REHAB 2-year follow-up (post hoc)","url":"https://pubmed.ncbi.nlm.nih.gov/42447422/","year":2026,"type":"Report","checkedAt":"2026-10-21","access":"Primary abstract read."},{"title":"Cochrane review of VNS for post-stroke motor function","url":"https://pubmed.ncbi.nlm.nih.gov/41823357/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract read."}],"relatedTopic":"motor-recovery"},{"id":"avert","title":"AVERT — dose and timing of early mobilization","headline":"Very early high-dose mobilization: mRS 0–2 46 vs 50% (harm)","year":2015,"settings":["hospital"],"keywords":["rehabilitation","mobilization","mobilisation","early recovery","stroke unit"],"question":"Did a higher-dose mobilization protocol within 24 hours improve recovery?","population":"2,104 adults with ischemic or hemorrhagic stroke meeting physiological criteria at 56 stroke units.","comparison":"Frequent, higher-dose very early mobilization plus usual care versus usual stroke-unit care.","result":"At three months, mRS 0–2 was less frequent with the intervention: 46% versus 50% (adjusted OR 0.73; 95% CI 0.59–0.90). Mortality was 8% versus 7% (OR 1.34; 95% CI 0.93–1.93). Nonfatal serious adverse events were 19% versus 20%.","limits":"This tests a timing-and-dose package, not a mandate for bed rest or an isolated timing threshold. Most usual-care patients also mobilized within 24 hours. Detailed protocol and 2015 correction effects remain unverified.","sources":[{"title":"AVERT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/25892679/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract read via PubMed/NLM. The 2017 correction changes licensing only; the 2015 correction body was inaccessible. Full protocol and supplements not reviewed."}],"relatedTopic":"inpatient-care"},{"id":"hermes","title":"HERMES — pooled early thrombectomy evidence","headline":"EVT ≤12 h (5 RCTs, most ≤6 h): mRS shift cOR 2.49; NNT 2.6","year":2016,"settings":["on-call","hospital"],"keywords":["MR CLEAN","ESCAPE","REVASCAT","SWIFT PRIME","EXTEND-IA","large vessel occlusion","meta-analysis"],"question":"What did the five foundational thrombectomy trials show together?","population":"1,287 participants from five randomized trials of proximal anterior-circulation occlusion.","comparison":"Thrombectomy plus standard care versus standard care alone, within the individual trial windows.","result":"The 90-day mRS distribution favored thrombectomy (adjusted common odds ratio 2.49; 95% CI 1.76–3.53). The reported NNT of 2.6 means one additional person improves by at least one mRS category. Mortality and symptomatic intracranial hemorrhage did not differ significantly.","limits":"The NNT is not for functional independence. Trial-specific selection varied; this pooled result does not establish benefit for every vessel, infarct size or time window.","sources":[{"title":"HERMES primary report","url":"https://pubmed.ncbi.nlm.nih.gov/26898852/","year":2016,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"evt-selection"},{"id":"dawn","title":"DAWN — clinical–core mismatch at 6–24 hours","headline":"6–24 h clinical–core mismatch: mRS 0–2 49 vs 13%","year":2018,"settings":["on-call","hospital"],"keywords":["thrombectomy","late window","clinical core mismatch"],"question":"Did selected patients benefit from thrombectomy up to 24 hours?","population":"206 participants with intracranial ICA or proximal MCA occlusion, last known well 6–24 hours earlier, and age-dependent mismatch between clinical deficit and infarct volume.","comparison":"Thrombectomy plus standard care versus standard care alone.","result":"At 90 days, the coprimary outcomes favored thrombectomy: utility-weighted mRS (0–10 scale) 5.5 versus 3.4 and mRS 0–2 in 49% versus 13% (adjusted difference 33 percentage points; 95% credible interval 24–44). Symptomatic intracranial hemorrhage was 6% versus 3%; mortality was 19% versus 18%, without significant differences.","limits":"Stopped early after a prespecified interim analysis. Age, deficit and core criteria matter; clinical–core mismatch is not interchangeable with perfusion mismatch.","sources":[{"title":"DAWN primary report","url":"https://pubmed.ncbi.nlm.nih.gov/29129157/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"evt-selection"},{"id":"defuse-3","title":"DEFUSE 3 — perfusion selection at 6–16 hours","headline":"6–16 h perfusion mismatch: mRS 0–2 45 vs 17%","year":2018,"settings":["on-call","hospital"],"keywords":["thrombectomy","late window","perfusion mismatch"],"question":"Did perfusion-selected patients benefit beyond six hours?","population":"182 participants with ICA or proximal MCA occlusion, last known well 6–16 hours earlier, core <70 mL and perfusion lesion-to-core ratio ≥1.8.","comparison":"Thrombectomy plus standard medical therapy versus medical therapy alone.","result":"The primary 90-day mRS shift favored thrombectomy (odds ratio 2.77; P<0.001). Functional independence was 45% versus 17%; mortality 14% versus 26% (P=0.05). Symptomatic intracranial hemorrhage was 7% versus 4% (P=0.75).","limits":"Stopped early for efficacy. This is a selected mismatch population; the abbreviated criteria here do not replace the complete imaging and eligibility protocol.","sources":[{"title":"DEFUSE 3 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/29364767/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"evt-selection"},{"id":"swift-direct","title":"SWIFT DIRECT — thrombectomy alone versus alteplase plus thrombectomy","headline":"EVT alone not noninferior: mRS 0–2 57 vs 65%","year":2022,"settings":["on-call","hospital"],"keywords":["bridging","direct thrombectomy","alteplase","EVT"],"question":"Is thrombectomy alone noninferior to alteplase plus thrombectomy?","population":"408 analyzed patients with LVO admitted to endovascular centers in Europe and Canada.","comparison":"Stent-retriever thrombectomy alone versus IV alteplase plus thrombectomy.","result":"mRS 0–2 at 90 days occurred in 57% vs 65% (adjusted risk difference −7.3%), crossing the 12% noninferiority margin. Symptomatic ICH 2% vs 3%; successful reperfusion 91% vs 96%.","limits":"Open-label; tested one stent-retriever device and alteplase.","sources":[{"title":"SWIFT DIRECT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/35810756/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"evt-selection"},{"id":"mr-clean-no-iv","title":"MR CLEAN-NO IV — thrombectomy with or without alteplase","headline":"EVT alone neither superior nor noninferior (cOR 0.84)","year":2021,"settings":["on-call","hospital"],"keywords":["bridging","direct thrombectomy","alteplase","EVT"],"question":"Is EVT alone superior or noninferior to alteplase followed by EVT?","population":"539 European patients presenting directly to EVT-capable hospitals.","comparison":"EVT alone versus IV alteplase plus EVT.","result":"Median mRS was 3 vs 2 (adjusted cOR 0.84; 95% CI 0.62–1.15): neither superiority nor noninferiority. Mortality 20.5% vs 15.8%; symptomatic ICH 5.9% vs 5.3%.","limits":"Open-label; direct admissions only.","sources":[{"title":"MR CLEAN-NO IV primary report","url":"https://pubmed.ncbi.nlm.nih.gov/34758251/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"evt-selection"},{"id":"direct-mt","title":"DIRECT-MT — thrombectomy with or without alteplase in China","headline":"EVT alone noninferior (cOR 1.07), less reperfusion","year":2020,"settings":["on-call","hospital"],"keywords":["bridging","direct thrombectomy","alteplase","EVT"],"question":"Is EVT alone noninferior to alteplase plus EVT?","population":"656 Chinese patients with anterior-circulation LVO at 41 academic centers.","comparison":"EVT alone versus IV alteplase within 4.5 hours followed by EVT.","result":"EVT alone was noninferior for the mRS distribution (adjusted cOR 1.07; 95% CI 0.81–1.40) with a 20% margin, but successful reperfusion was lower before EVT (2.4% vs 7.0%) and overall (79.4% vs 84.5%). Mortality 17.7% vs 18.8%.","limits":"Wide noninferiority margin; European and Canadian trials (SWIFT DIRECT, MR CLEAN-NO IV) did not confirm noninferiority.","sources":[{"title":"DIRECT-MT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/32374959/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"evt-selection"},{"id":"bridge-tnk","title":"BRIDGE-TNK — tenecteplase before thrombectomy","headline":"Tenecteplase before EVT: mRS 0–2 52.9 vs 44.1%","year":2025,"settings":["on-call","hospital"],"keywords":["bridging","tenecteplase","thrombectomy","EVT","TNK"],"question":"Does tenecteplase before EVT improve outcome in LVO within 4.5 hours?","population":"550 Chinese patients with LVO eligible for thrombolysis within 4.5 hours.","comparison":"IV tenecteplase followed by EVT versus EVT alone.","result":"mRS 0–2 at 90 days occurred in 52.9% vs 44.1% (RR 1.20; 95% CI 1.01–1.43). Symptomatic ICH within 48 hours 8.5% vs 6.7%; mortality 22.3% vs 19.9%.","limits":"Open-label, single-country trial; the margin of benefit was modest.","sources":[{"title":"BRIDGE-TNK primary report","url":"https://pubmed.ncbi.nlm.nih.gov/40396577/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"evt-selection"},{"id":"mild-mt","title":"MILD-MT — thrombectomy for mild stroke with large-vessel occlusion","headline":"NIHSS <6 LVO (China): mRS 0–1 69.4 vs 50.0%; serious procedural complications 13.2%","year":2026,"settings":["on-call","hospital"],"keywords":["EVT","thrombectomy","mild stroke","low NIHSS","LVO","perfusion mismatch","MILD-MT"],"question":"Does EVT help mild (NIHSS <6) anterior-circulation LVO stroke with a small core and a large perfusion mismatch within 24 hours?","population":"304 randomized in China (300 in the modified intention-to-treat analysis: 144 EVT, 156 medical) within 24 hours of onset or last known well, with NIHSS <6 and ICA, M1 or M2 occlusion, core ≤50 mL and perfusion mismatch ≥50 mL (protocol); the registry also lists age 18–80, prestroke mRS 0 and ASPECTS ≥6.","comparison":"EVT plus medical management versus medical management alone.","result":"mRS 0–1 at 90 days occurred in 69.4% vs 50.0% (OR 2.32; 95% CI 1.41–3.81). Symptomatic ICH within 48 h occurred in 3 patients in each group; serious procedure-related complications occurred in 19 EVT patients (13.2%); one death overall (EVT group).","limits":"Open-label (blinded endpoint per protocol), single-country and perfusion-selected. It postdates AHA/ASA 2026, whose graded anterior-circulation EVT recommendations require NIHSS ≥6, so it is not a graded recommendation. Serious procedural complications were frequent. Eligibility is from the registry and protocol abstract; the full NEJM report was not reviewed.","sources":[{"title":"MILD-MT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42929671/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; NEJM full text not reachable. Registry eligibility (NCT06179017) read 2026-10-31."},{"title":"MILD-MT protocol","url":"https://pubmed.ncbi.nlm.nih.gov/41974578/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31."}],"relatedTopic":"evt-selection"},{"id":"late-mt","title":"LATE-MT — thrombectomy 24 to 72 hours after onset","headline":"24–72 h LVO (China): mRS cOR 1.74; sICH 4.8 vs 0%; 90-day mortality 6.0 vs 1.8%","year":2026,"settings":["on-call","hospital"],"keywords":["EVT","thrombectomy","very late window","beyond 24 hours","CT perfusion","LVO","LATE-MT"],"question":"Does EVT help anterior-circulation LVO with salvageable tissue 24–72 hours after onset or last known well?","population":"336 patients in the intention-to-treat population (168 per group) at comprehensive stroke centers in China with anterior-circulation LVO and imaging-identified salvageable tissue at 24–72 h (median 38.5 h to randomization). Registry: age ≥18, ICA (including extracranial segment) to M1/M2, NIHSS ≥6 at randomization, major prestroke disability (mRS ≥2) excluded, CTP core <50 mL with mismatch ratio ≥1.8 and mismatch volume ≥15 mL.","comparison":"EVT plus standard medical care versus standard medical care alone.","result":"The 90-day mRS distribution favored EVT (common OR 1.74; 95% CI 1.19–2.55). Symptomatic ICH 4.8% vs 0%; 90-day case fatality 6.0% vs 1.8%.","limits":"Open-label with blinded outcome assessment; single country; CTP selection required. Benefit came with more intracranial hemorrhage and death. Postdates AHA/ASA 2026, whose graded EVT recommendations extend only to 24 h; not a graded recommendation. Eligibility is from the registry; the full NEJM report was not reviewed.","sources":[{"title":"LATE-MT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42929656/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; NEJM full text not reachable. Registry eligibility (NCT05326932) read 2026-10-31."}],"relatedTopic":"evt-selection"},{"id":"act","title":"AcT — tenecteplase versus alteplase","headline":"Tenecteplase noninferior: mRS 0–1 36.9 vs 34.8%","year":2022,"settings":["on-call","hospital"],"keywords":["TNK","tenecteplase","alteplase","noninferiority"],"question":"Was tenecteplase noninferior to alteplase in routine thrombolysis candidates?","population":"1,600 adults randomized in Canada with disabling ischemic stroke within 4.5 hours and eligibility under Canadian thrombolysis criteria; 1,577 entered the intention-to-treat population.","comparison":"Tenecteplase 0.25 mg/kg (maximum 25 mg) versus alteplase 0.9 mg/kg (maximum 90 mg).","result":"mRS 0–1 at 90–120 days occurred in 36.9% versus 34.8% (risk difference 2.1 percentage points; 95% CI −2.6 to 6.9), meeting the prespecified −5-point noninferiority margin. Symptomatic intracerebral hemorrhage within 24 hours was 3.4% versus 3.2%.","limits":"Noninferiority is not superiority or identical safety. Open-label pragmatic trial; results concern this dose and standard-window eligible population, not every thrombolytic regimen.","sources":[{"title":"AcT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/35779553/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"thrombolytic-choice"},{"id":"trace-2","title":"TRACE-2 — tenecteplase versus alteplase in China","headline":"Tenecteplase noninferior: mRS 0–1 62 vs 58%","year":2023,"settings":["on-call","hospital"],"keywords":["tenecteplase","alteplase","noninferiority","TNK"],"question":"Is tenecteplase noninferior to alteplase within 4.5 hours in patients not having EVT?","population":"1,430 Chinese adults, NIHSS 5–25, prestroke mRS ≤1, ineligible for or declining EVT.","comparison":"Tenecteplase 0.25 mg/kg (max 25 mg) versus alteplase 0.9 mg/kg (max 90 mg).","result":"mRS 0–1 at 90 days occurred in 62% vs 58% (RR 1.07; 95% CI 0.98–1.16), meeting noninferiority. Symptomatic ICH 2% in each group; mortality 7% vs 5%.","limits":"Open-label with blinded outcome; excluded EVT candidates.","sources":[{"title":"TRACE-2 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/36774935/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"thrombolytic-choice"},{"id":"original","title":"ORIGINAL — tenecteplase versus alteplase within 4.5 hours","headline":"Tenecteplase noninferior: mRS 0–1 72.7 vs 70.3%","year":2024,"settings":["on-call","hospital"],"keywords":["tenecteplase","alteplase","noninferiority","TNK"],"question":"Is tenecteplase 0.25 mg/kg noninferior to alteplase within 4.5 hours?","population":"1,489 randomized Chinese patients with NIHSS 1–25 (1,465 analyzed).","comparison":"Tenecteplase 0.25 mg/kg versus alteplase 0.9 mg/kg.","result":"mRS 0–1 at 90 days occurred in 72.7% vs 70.3% (RR 1.03; 95% CI 0.97–1.09), meeting noninferiority. Symptomatic ICH 1.2% in each group; mortality 4.6% vs 5.8%.","limits":"Open-label, single-country trial including mild strokes.","sources":[{"title":"ORIGINAL primary report","url":"https://pubmed.ncbi.nlm.nih.gov/39264623/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"thrombolytic-choice"},{"id":"extend","title":"EXTEND — perfusion-selected alteplase beyond 4.5 hours","headline":"Perfusion-selected 4.5–9 h: mRS 0–1 35.4 vs 29.5%; sICH 6.2 vs 0.9%","year":2019,"settings":["on-call","hospital"],"keywords":["alteplase","perfusion mismatch","wake-up","late window"],"question":"Did alteplase help selected patients beyond the standard window?","population":"225 participants with salvageable tissue on automated perfusion imaging, 4.5–9 hours after onset or waking with symptoms within nine hours of the sleep midpoint.","comparison":"Alteplase versus placebo.","result":"mRS 0–1 at 90 days occurred in 35.4% versus 29.5% (adjusted risk ratio 1.44; 95% CI 1.01–2.06). Symptomatic intracerebral hemorrhage occurred in 6.2% versus 0.9%. The secondary ordinal mRS analysis did not show a significant difference.","limits":"Stopped before planned enrollment after external evidence changed equipoise. Imaging-selected trial, not a time-only extension. A 2021 correction changes tertiary neurologic-improvement results; those values are not reproduced here.","sources":[{"title":"EXTEND primary report","url":"https://pubmed.ncbi.nlm.nih.gov/31067369/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices read via PubMed/NLM. Publisher correction text reviewed; full trial report and supplements not reviewed."},{"title":"EXTEND correction: tertiary neurologic-improvement calculations","url":"https://www.nejm.org/doi/full/10.1056/NEJMx200014","year":2021,"type":"Report","checkedAt":"2026-10-01","access":"Publisher correction text recovered in web search; direct page fetch returned 403. The notice concerns tertiary neurologic-improvement results and associated tables."}],"relatedTopic":"extended-window-ivt"},{"id":"wake-up","title":"WAKE-UP — MRI-guided alteplase for unknown onset","headline":"DWI–FLAIR mismatch: mRS 0–1 53.3 vs 41.8%","year":2018,"settings":["on-call","hospital"],"keywords":["wake-up","unknown onset","DWI-FLAIR mismatch","alteplase","MRI"],"question":"Does alteplase help unknown-onset stroke with DWI–FLAIR mismatch?","population":"503 patients with unknown onset, a DWI lesion and no marked FLAIR change; patients with planned thrombectomy excluded.","comparison":"IV alteplase versus placebo.","result":"mRS 0–1 at 90 days occurred in 53.3% vs 41.8% (adjusted OR 1.61; 95% CI 1.09–2.36). Deaths 4.1% vs 1.2% and symptomatic ICH 2.0% vs 0.4% (both not significant).","limits":"Stopped early for lack of funding (503 of 800 planned). Applies to MRI mismatch selection, not perfusion or CT-only selection.","sources":[{"title":"WAKE-UP primary report","url":"https://pubmed.ncbi.nlm.nih.gov/29766770/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."}],"relatedTopic":"extended-window-ivt"},{"id":"trace-iii","title":"TRACE-III — tenecteplase at 4.5–24 hours without thrombectomy","headline":"LVO 4.5–24 h, no EVT: mRS 0–1 33.0 vs 24.2%; sICH 3.0 vs 0.8%","year":2024,"settings":["on-call","hospital"],"keywords":["tenecteplase","late window","LVO","perfusion","no EVT access"],"question":"Does tenecteplase help LVO with salvageable tissue at 4.5–24 hours when EVT is not available?","population":"516 Chinese patients with MCA or ICA occlusion and perfusion mismatch, 4.5–24 hours from last known well; under 2% had rescue EVT.","comparison":"Tenecteplase 0.25 mg/kg (max 25 mg) versus standard medical treatment.","result":"mRS 0–1 at 90 days occurred in 33.0% vs 24.2% (relative rate 1.37; 95% CI 1.04–1.81). Mortality 13.3% vs 13.1%; symptomatic ICH within 36 hours 3.0% vs 0.8%.","limits":"Single-country trial without EVT access; it does not apply when EVT is available (see TIMELESS).","sources":[{"title":"TRACE-III primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38884324/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"extended-window-ivt"},{"id":"timeless","title":"TIMELESS — tenecteplase at 4.5–24 hours before planned EVT","headline":"Late tenecteplase with EVT: no benefit (cOR 1.13)","year":2024,"settings":["on-call","hospital"],"keywords":["tenecteplase","late window","LVO","perfusion","thrombectomy"],"question":"Does tenecteplase at 4.5–24 hours improve outcome in perfusion-selected MCA or ICA occlusion?","population":"458 patients; 77.3% went on to thrombectomy; median time to randomization about 12–13 hours.","comparison":"Tenecteplase 0.25 mg/kg versus placebo, double-blind.","result":"Median 90-day mRS was 3 in both groups (adjusted cOR 1.13; 95% CI 0.82–1.57). Mortality 19.7% vs 18.2%; symptomatic ICH 3.2% vs 2.3%.","limits":"Most patients received EVT, which may have masked any thrombolytic effect.","sources":[{"title":"TIMELESS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38329148/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"extended-window-ivt"},{"id":"chance","title":"CHANCE — short initial dual antiplatelet therapy","headline":"DAPT 21 days: stroke 8.2 vs 11.7%","year":2013,"settings":["on-call","hospital","clinic"],"keywords":["clopidogrel","aspirin","DAPT","minor stroke","TIA"],"question":"Did an initial dual-antiplatelet course reduce recurrent stroke?","population":"5,170 participants in China with minor ischemic stroke or high-risk TIA, randomized within 24 hours.","comparison":"Clopidogrel for 90 days with aspirin during the first 21 days versus aspirin for 90 days.","result":"Stroke by 90 days occurred in 8.2% versus 11.7% (hazard ratio 0.68; 95% CI 0.57–0.81). Moderate or severe hemorrhage was 0.3% in each group.","limits":"The combination lasted 21 days, not 90. Selected minor-stroke/TIA population in China; the low observed bleeding rate is not proof of no bleeding risk or justification for long-term dual therapy.","sources":[{"title":"CHANCE primary report","url":"https://pubmed.ncbi.nlm.nih.gov/23803136/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"thales","title":"THALES — ticagrelor plus aspirin after mild-to-moderate stroke","headline":"Ticagrelor + aspirin: stroke/death 5.5 vs 6.6%; severe bleeding 0.5 vs 0.1%","year":2020,"settings":["on-call","hospital","clinic"],"keywords":["ticagrelor","aspirin","DAPT","NIHSS 5","TIA"],"question":"What were the benefits and harms of 30-day ticagrelor–aspirin?","population":"11,016 participants with noncardioembolic stroke (NIHSS ≤5) or qualifying TIA, treated within 24 hours; thrombolysis and thrombectomy recipients were excluded.","comparison":"Ticagrelor plus aspirin versus aspirin alone for 30 days.","result":"Stroke or death at 30 days occurred in 5.5% versus 6.6% (hazard ratio 0.83; 95% CI 0.71–0.96). Severe bleeding occurred in 0.5% versus 0.1%. Disability did not differ significantly.","limits":"This trial did not compare ticagrelor with clopidogrel. Review the qualifying TIA criteria and bleeding exclusions; do not extrapolate to reperfusion-treated patients or long-term dual therapy.","sources":[{"title":"THALES primary report","url":"https://pubmed.ncbi.nlm.nih.gov/32668111/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"chance-2","title":"CHANCE-2 — antiplatelet choice in CYP2C19 loss-of-function carriers","headline":"CYP2C19 LOF: ticagrelor 6.0 vs clopidogrel 7.6%","year":2021,"settings":["hospital","clinic"],"keywords":["CYP2C19","genotype","ticagrelor","clopidogrel","DAPT"],"question":"Did ticagrelor improve outcomes in selected clopidogrel-metabolism genotypes?","population":"6,412 participants in China with minor stroke or TIA and CYP2C19 loss-of-function alleles, randomized within 24 hours; 98% were Han Chinese.","comparison":"Ticagrelor versus clopidogrel for 90 days; both groups received aspirin for the first 21 days.","result":"Stroke by 90 days occurred in 6.0% versus 7.6% (hazard ratio 0.77; 95% CI 0.64–0.94). Moderate or severe bleeding was 0.3% in each group, but any bleeding was 5.3% versus 2.5%.","limits":"Genotype-selected trial with limited population diversity. It does not establish the preferred drug for every patient or the value of universal genotyping.","sources":[{"title":"CHANCE-2 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/34708996/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"oceanic-stroke","title":"OCEANIC-STROKE — asundexian added to antiplatelets","headline":"Asundexian: ischemic stroke 6.2 vs 8.4%; major bleeding 1.9 vs 1.7%","year":2026,"settings":["on-call","hospital","clinic"],"keywords":["factor XI","asundexian","secondary prevention","noncardioembolic"],"question":"Does asundexian added to antiplatelet therapy prevent recurrent ischemic stroke?","population":"12,327 patients within 72 hours of noncardioembolic ischemic stroke or high-risk TIA with atherosclerosis or nonlacunar infarct.","comparison":"Asundexian 50 mg daily versus placebo, on top of single or dual antiplatelet therapy.","result":"Ischemic stroke 6.2% vs 8.4% (cause-specific HR 0.74; 95% CI 0.65–0.84). Major bleeding 1.9% vs 1.7% (HR 1.10; 95% CI 0.85–1.44); lower gastrointestinal bleeding 1.7% vs 1.0% (csHR 1.75).","limits":"Industry-funded; regulatory status and availability are separate questions. Asundexian was inferior to apixaban in AF (OCEANIC-AF). Milvexian, a different factor XIa inhibitor, was stopped for futility after acute coronary syndrome (LIBREXIA-ACS: cardiovascular death, MI or ischemic stroke 5.4 vs 5.1%; HR 1.05). Its stroke trial (LIBREXIA-STROKE) had not reported as of October 2026.","sources":[{"title":"OCEANIC-STROKE primary report","url":"https://pubmed.ncbi.nlm.nih.gov/41985132/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"OCEANIC-STROKE bleeding report","url":"https://pubmed.ncbi.nlm.nih.gov/42866879/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"LIBREXIA-ACS (milvexian after acute coronary syndrome)","url":"https://pubmed.ncbi.nlm.nih.gov/42670965/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; ACS population, not stroke. LIBREXIA-STROKE registry NCT05702034 checked 2026-10-31: active, not recruiting, no results."}],"relatedTopic":"research-adjuncts"},{"id":"most","title":"MOST — adjunctive argatroban or eptifibatide after IV thrombolysis","headline":"Adjunct argatroban/eptifibatide: no benefit; mortality 24% and 12% vs 8%","year":2024,"settings":["on-call","hospital"],"keywords":["argatroban","eptifibatide","thrombolysis","adjunct"],"question":"Does adding IV argatroban or eptifibatide to thrombolysis reduce disability?","population":"514 patients given IVT within 3 hours at 57 US sites; 44% had EVT.","comparison":"Argatroban or eptifibatide versus placebo, within 75 minutes of thrombolysis.","result":"Neither improved utility-weighted mRS (0–10): 5.2 with argatroban, 6.3 with eptifibatide, 6.8 with placebo. Symptomatic ICH 4%, 3% and 2%; mortality 24%, 12% and 8%.","limits":"Adaptive design with a small argatroban arm; results do not support routine adjunctive antithrombotics. In the prespecified thrombectomy cohort (254 planned for EVT), neither agent improved reperfusion or 90-day outcome.","sources":[{"title":"MOST primary report","url":"https://pubmed.ncbi.nlm.nih.gov/39231343/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"MOST thrombectomy-cohort analysis (preplanned)","url":"https://pubmed.ncbi.nlm.nih.gov/40824660/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (PMC12362272 not read)."}],"relatedTopic":"research-adjuncts"},{"id":"inspires","title":"INSPIRES — dual antiplatelets started within 72 hours","headline":"DAPT up to 72 h: stroke 7.3 vs 9.2%; moderate-to-severe bleeding 0.9 vs 0.4%","year":2023,"settings":["on-call","hospital","clinic"],"keywords":["clopidogrel","aspirin","DAPT","atherosclerosis","72 hours"],"question":"Did a selected population benefit when antiplatelet treatment began later?","population":"6,100 participants in China with mild ischemic stroke or high-risk TIA attributed to presumed atherosclerosis, without thrombolysis or thrombectomy; 87.2% were randomized after 24 through 72 hours.","comparison":"Clopidogrel for 90 days plus aspirin for 21 days versus aspirin for 90 days.","result":"New stroke by 90 days occurred in 7.3% versus 9.2% (hazard ratio 0.79; 95% CI 0.66–0.94). Moderate-to-severe bleeding was 0.9% versus 0.4% (hazard ratio 2.08; 95% CI 1.07–4.04).","limits":"This was an atherosclerosis-selected factorial trial. Results do not extend the treatment window for every stroke mechanism, severity or reperfusion-treated patient.","sources":[{"title":"INSPIRES primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38157499/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"aramis","title":"ARAMIS — DAPT versus alteplase for minor non-disabling stroke","headline":"Non-disabling minor stroke: DAPT noninferior (mRS 0–1 93.8 vs 91.4%)","year":2023,"settings":["on-call","hospital"],"keywords":["minor stroke","nondisabling","DAPT","alteplase","clopidogrel"],"question":"Is DAPT noninferior to alteplase for minor non-disabling stroke within 4.5 hours?","population":"760 Chinese patients with NIHSS ≤5 and ≤1 point on key items (median NIHSS 2).","comparison":"Clopidogrel plus aspirin for 12 days then guideline antiplatelets, versus alteplase followed by antiplatelets after 24 hours.","result":"mRS 0–1 at 90 days occurred in 93.8% vs 91.4% (risk difference 2.3%; 95% CI −1.5 to 6.2), meeting noninferiority. Symptomatic ICH 0.3% vs 0.9%.","limits":"Open-label, single-country trial with a −4.5% margin; applies only to non-disabling deficits.","sources":[{"title":"ARAMIS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37367978/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"tempo-2","title":"TEMPO-2 — tenecteplase for minor stroke with occlusion","headline":"Minor stroke with occlusion: no benefit; deaths 5 vs 1%","year":2024,"settings":["on-call","hospital"],"keywords":["minor stroke","tenecteplase","occlusion","thrombolysis"],"question":"Does tenecteplase help minor stroke (NIHSS 0–5) with intracranial occlusion or a focal perfusion abnormality?","population":"886 patients with NIHSS 0–5 and intracranial occlusion or focal perfusion abnormality at 48 hospitals in 10 countries, enrolled within 12 hours.","comparison":"Tenecteplase 0.25 mg/kg versus non-thrombolytic standard care.","result":"Return to baseline mRS at 90 days occurred in 72% vs 75% (RR 0.96; 95% CI 0.88–1.04). Deaths 5% vs 1% (adjusted HR 3.8; 1.4–10.2); symptomatic ICH 2% vs <1%.","limits":"Stopped early for futility; open-label. In a secondary analysis (JAMA Neurol 2025), the 100 patients with disabling deficits (TREAT Task Force definition) showed no benefit either (return to baseline 54.7 vs 68.1%; aRR 0.81, 0.60–1.10; interaction P=.32), but most were treated after 4.5 h (median onset to treatment 411 min), so it says little about disabling deficits within 4.5 h. A prespecified analysis by baseline occlusion (Eur Stroke J 2026; 881 patients) found no benefit with complete occlusion (aRR 1.00, 0.89–1.12), near occlusion (0.85, 0.71–1.01) or a perfusion deficit without visible occlusion (1.03, 0.90–1.18); it was not powered for subgroups, and most occlusions were medium-vessel (LVO about 1 in 6), so it says little about minor stroke with LVO.","sources":[{"title":"TEMPO-2 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38768626/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"TEMPO-2 secondary analysis by disabling deficit (TREAT Task Force definition)","url":"https://pubmed.ncbi.nlm.nih.gov/41143808/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; secondary analysis of the original randomized population (884 analyzed), not a new trial; PMC full text (PMC12560024) not reviewed."},{"title":"TEMPO-2 secondary analysis by baseline occlusion status","url":"https://pubmed.ncbi.nlm.nih.gov/42734928/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PMC full text (PMC13573578) read 2026-10-31; prespecified secondary analysis of the original randomized population, not a new trial."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"tapis","title":"TAPIS — aspirin plus ticagrelor started with IV thrombolysis","headline":"DAPT within 6 h of onset with IVT: mRS 0–1 68.7 vs 62.0%","year":2026,"settings":["on-call","hospital"],"keywords":["DAPT","ticagrelor","thrombolysis","early antiplatelet","moderate stroke"],"question":"Does oral aspirin plus ticagrelor within 6 hours improve outcome in IVT-treated stroke?","population":"1,382 Chinese patients treated with IVT, NIHSS 4–10.","comparison":"Aspirin plus ticagrelor started before, during or after IVT (ticagrelor through day 7) versus placebo; open-label aspirin from day 2.","result":"mRS 0–1 at 90 days occurred in 68.7% vs 62.0% (RR 1.11; 95% CI 1.03–1.20). Symptomatic ICH within 36 hours 0.9% vs 0.7% (RR 1.20; 95% CI 0.37–3.93).","limits":"Single-country trial; the wide sICH confidence interval cannot exclude harm, and it challenges the usual 24-hour wait after IVT.","sources":[{"title":"TAPIS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42114550/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"artesia","title":"ARTESiA — apixaban for device-detected subclinical AF","headline":"Subclinical AF apixaban: stroke 0.78 vs 1.24%/yr; more bleeding","year":2024,"settings":["hospital","clinic"],"keywords":["device detected","subclinical AF","apixaban","aspirin","atrial fibrillation"],"question":"How did anticoagulation affect stroke and bleeding in subclinical AF?","population":"4,012 participants with subclinical AF lasting six minutes to 24 hours; mean CHA₂DS₂-VASc 3.9.","comparison":"Apixaban versus aspirin; trial therapy stopped and anticoagulation begun if AF exceeded 24 hours or clinical AF developed.","result":"Over mean follow-up of 3.5 years, stroke or systemic embolism was 0.78% versus 1.24% per patient-year (hazard ratio 0.63; 95% CI 0.45–0.88; intention-to-treat). Major bleeding was 1.71% versus 0.94% per patient-year (hazard ratio 1.80; 95% CI 1.26–2.57; on-treatment). Prespecified subanalyses: with prior stroke or TIA (346 patients; intention to treat), stroke or systemic embolism was 1.20 vs 3.14% per year (HR 0.40; 95% CI 0.17–0.95) and major bleeding 2.26 vs 1.16% per year (HR 1.94; 95% CI 0.77–4.87). In the on-treatment bleeding analysis, intracranial (0.33 vs 0.40 per 100 patient-years; HR 0.82) and fatal bleeding were similar, gastrointestinal bleeding was higher with apixaban (0.89 vs 0.40; HR 2.23), and most major bleeds were nonemergency hemoglobin drops of ≥2 g/dL.","limits":"Benefit and harm use different analysis populations. These are annualized rates, not cumulative risks; findings concern selected subclinical AF and require individualized risk assessment.","sources":[{"title":"ARTESiA primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37952132/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."},{"title":"ARTESiA prior stroke or TIA subgroup","url":"https://pubmed.ncbi.nlm.nih.gov/39862882/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; prespecified subgroup (346 participants), intention to treat."},{"title":"ARTESiA major bleeding subanalysis","url":"https://pubmed.ncbi.nlm.nih.gov/41222953/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (PMC12613090 not read); prespecified on-treatment subanalysis (3,961 patients)."}],"relatedTopic":"af-prevention"},{"id":"noah-afnet6","title":"NOAH-AFNET 6 — edoxaban for atrial high-rate episodes","headline":"Device-detected AHRE edoxaban: no benefit, more harm","year":2023,"settings":["hospital","clinic"],"keywords":["device detected","atrial high rate episodes","AHRE","edoxaban","subclinical AF"],"question":"Did device-detected atrial high-rate episodes justify edoxaban?","population":"2,536 participants aged ≥65 years with implanted-device episodes ≥6 minutes and another stroke risk factor, without ECG-documented AF.","comparison":"Edoxaban versus placebo.","result":"Cardiovascular death, stroke or systemic embolism was 3.2% versus 4.0% per patient-year (hazard ratio 0.81; 95% CI 0.60–1.08). Death or major bleeding was 5.9% versus 4.5% per patient-year (hazard ratio 1.31; 95% CI 1.02–1.67). Stroke was about 1% per year in both groups.","limits":"Stopped early for safety concerns and futility assessment. Its composite efficacy and safety endpoints differ from ARTESiA; it does not test anticoagulation for established clinical AF.","sources":[{"title":"NOAH-AFNET 6 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37622677/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"af-prevention"},{"id":"invictus","title":"INVICTUS — anticoagulation in rheumatic heart disease with AF","headline":"Rheumatic AF: rivaroxaban worse than VKA","year":2022,"settings":["hospital","clinic"],"keywords":["rheumatic","mitral stenosis","rivaroxaban","warfarin","vitamin K antagonist"],"question":"Could rivaroxaban replace a vitamin K antagonist in rheumatic AF?","population":"4,531 analyzed participants with AF, echocardiographic rheumatic heart disease and trial-defined thromboembolic risk features.","comparison":"Rivaroxaban versus a dose-adjusted vitamin K antagonist.","result":"The composite of stroke, systemic embolism, myocardial infarction, or vascular/unknown-cause death occurred in 560 versus 446 participants. Restricted mean event-free survival was 76 days shorter with rivaroxaban (95% CI 31–121 days shorter). Death was also more frequent; major bleeding did not differ significantly.","limits":"Survival curves were nonproportional, and rivaroxaban discontinuation was more frequent. Do not extrapolate routine nonvalvular-AF DOAC evidence to this rheumatic-heart-disease population.","sources":[{"title":"INVICTUS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/36036525/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"af-prevention"},{"id":"re-align","title":"RE-ALIGN — dabigatran in mechanical heart valves","headline":"Mechanical valves: dabigatran worse than warfarin","year":2013,"settings":["hospital","clinic"],"keywords":["mechanical valve","dabigatran","warfarin","DOAC"],"question":"Could dabigatran replace warfarin after mechanical valve replacement?","population":"252 participants with mechanical aortic or mitral valves, either implanted within seven days or at least three months earlier.","comparison":"Kidney-function- and concentration-adjusted dabigatran versus warfarin.","result":"This phase 2 study, whose primary endpoint was dabigatran trough concentration, stopped early for excess thromboembolism and bleeding. In the as-treated analysis, ischemic or unspecified stroke occurred in nine dabigatran recipients versus none with warfarin; major bleeding occurred in seven versus two.","limits":"A dose-validation study with adverse clinical outcomes, not a successful clinical noninferiority trial. Findings in ordinary AF cannot be transferred to mechanical valves.","sources":[{"title":"RE-ALIGN primary report","url":"https://pubmed.ncbi.nlm.nih.gov/23991661/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"cardiac-sources"},{"id":"proact-xa","title":"PROACT Xa — apixaban in an On-X mechanical aortic valve","headline":"On-X valve: apixaban worse than warfarin","year":2023,"settings":["hospital","clinic"],"keywords":["mechanical valve","On-X","apixaban","warfarin","DOAC"],"question":"Was apixaban noninferior to warfarin with this mechanical aortic valve?","population":"863 participants with an On-X mechanical aortic valve implanted at least three months earlier; 94% also took aspirin.","comparison":"Apixaban versus warfarin targeting INR 2.0–3.0.","result":"Stopped early for excess thromboembolic events. Valve thrombosis or valve-related thromboembolism occurred at 4.2% versus 1.3% per patient-year (rate difference 2.9 percentage points per year; 95% CI 0.8–5.0), failing noninferiority. Major bleeding was 3.6% versus 4.5% per patient-year.","limits":"These are event rates, not percentages of participants: 20 events occurred in 16 apixaban recipients versus six events in six warfarin recipients. Results do not support replacing warfarin with apixaban in this valve population.","sources":[{"title":"PROACT Xa primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38320162/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"cardiac-sources"},{"id":"interact2","title":"INTERACT2 — acute ICH blood-pressure lowering","headline":"ICH SBP <140: primary outcome NS (OR 0.87); ordinal shift favored","year":2013,"settings":["on-call","hospital"],"keywords":["ICH","blood pressure","SBP","INTERACT"],"question":"Did early intensive BP lowering improve 90-day function?","population":"2,839 patients with spontaneous ICH within six hours and elevated systolic BP; 2,794 had primary-outcome data.","comparison":"SBP target <140 mmHg within one hour versus <180 mmHg, using clinician-selected agents.","result":"Death or major disability (mRS 3–6) was 52.0% versus 55.6% (OR 0.87; 95% CI 0.75–1.01; P=0.06). The prespecified ordinal analysis favored intensive treatment (OR for greater disability 0.87; 95% CI 0.77–1.00; P=0.04). Mortality was 11.9% versus 12.0%; nonfatal serious adverse events were similar.","limits":"The dichotomous primary outcome was not statistically significant. Distinguish the tested early ICH strategy from post-EVT BP targets and from more aggressive lowering in ATACH-2.","sources":[{"title":"INTERACT2 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/23713578/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"ich-management"},{"id":"atach-2","title":"ATACH-2 — intensive BP lowering and renal adverse events","headline":"ICH SBP 110–139: no benefit; renal events 9.0 vs 4.0%","year":2016,"settings":["on-call","hospital"],"keywords":["ICH","blood pressure","nicardipine","renal injury"],"question":"Was an SBP target of 110–139 better than 140–179 mmHg?","population":"1,000 patients with acute ICH <60 cm³ and GCS ≥5; IV nicardipine began within 4.5 hours of symptom onset.","comparison":"SBP target 110–139 versus 140–179 mmHg.","result":"Death or disability (mRS 4–6) at three months was 38.7% versus 37.7% (adjusted RR 1.04; 95% CI 0.85–1.27). Renal adverse events within seven days were more frequent with intensive treatment: 9.0% versus 4.0% (P=0.002).","limits":"Stopped for futility. The selected volume/GCS population and different BP targets limit comparison with INTERACT2; these results do not support pushing all acute ICH patients to the lower tested range.","sources":[{"title":"ATACH-2 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/27276234/","year":2016,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"ich-management"},{"id":"interact3","title":"INTERACT3 — coordinated acute ICH care bundle","headline":"ICH care bundle: better mRS (cOR 0.86)","year":2023,"settings":["on-call","hospital"],"keywords":["ICH","care bundle","blood pressure","glucose","temperature","warfarin"],"question":"Did implementing a coordinated physiological-care bundle improve function?","population":"7,036 adults with spontaneous ICH within six hours at 121 hospitals in ten countries; 6,255 had primary-outcome data.","comparison":"Hospital implementation of early BP lowering, glucose and temperature management, and warfarin reversal for abnormal values versus usual care; stepped-wedge cluster randomization.","result":"At six months the bundle improved the ordinal mRS distribution (common OR for worse outcome 0.86; 95% CI 0.76–0.97). Serious adverse events occurred in 16.0% versus 20.1%.","limits":"A hospital-level implementation trial, predominantly in low- and middle-income settings with inconsistent existing protocols. Benefit cannot be assigned to BP lowering or another single component; missing outcomes and site withdrawals require attention.","sources":[{"title":"INTERACT3 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37245517/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked. July 2023 correction body read: investigator-name spellings in the appendix were corrected."},{"title":"INTERACT3 correction","url":"https://pubmed.ncbi.nlm.nih.gov/37453751/","year":2023,"type":"Report","checkedAt":"2026-10-01","access":"Correction body read: two appendix investigator names corrected; no outcome change stated."}],"relatedTopic":"ich-management"},{"id":"fastest","title":"FASTEST — recombinant factor VIIa within 2 hours of ICH","headline":"rFVIIa: less growth (−3.7 mL), no functional benefit; more thromboembolism","year":2026,"settings":["on-call","hospital"],"keywords":["factor VIIa","hemostatic","hematoma expansion","ICH"],"question":"Does recombinant factor VIIa within 2 hours improve outcome after spontaneous ICH?","population":"626 adults aged 18–80 with ICH 2–60 mL, limited IVH, GCS ≥8, treated within 2 hours.","comparison":"Recombinant factor VIIa 80 µg/kg versus placebo.","result":"No difference in 180-day mRS (adjusted cOR 1.09; 95% CI 0.79–1.51); stopped for futility. Life-threatening thromboembolism within 4 days: RR 3.41 (1.14–10.15). ICH growth was 3.7 mL less at 24 hours.","limits":"Excluded recent anticoagulation and large hematomas; slowed growth did not translate into function.","sources":[{"title":"FASTEST primary report","url":"https://pubmed.ncbi.nlm.nih.gov/41653933/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"ich-expansion-ivh"},{"id":"enchanted2-mt","title":"ENCHANTED2/MT — avoid extrapolating aggressive post-EVT BP lowering","headline":"Post-EVT SBP <120: worse outcome (OR 1.37)","year":2022,"settings":["on-call","hospital"],"keywords":["EVT","thrombectomy","reperfusion","SBP","blood pressure"],"question":"What happened with SBP <120 after successful thrombectomy?","population":"821 randomized adults in China with persistent SBP ≥140 mmHg after successful reperfusion for intracranial large-vessel occlusion; 810 had primary-outcome data.","comparison":"SBP <120 versus 140–180 mmHg, reached within one hour and maintained for 72 hours.","result":"Intensive treatment worsened the 90-day ordinal mRS outcome (common OR for worse outcome 1.37; 95% CI 1.07–1.76) and increased early neurological deterioration (common OR 1.53; 95% CI 1.18–1.97). Symptomatic ICH and mortality did not differ significantly.","limits":"Stopped early for efficacy/safety concerns. These are selected successfully reperfused patients; neither the comparator nor this result establishes one BP target for every reperfusion grade or clinical situation.","sources":[{"title":"ENCHANTED2/MT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/36341753/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked. December 2022 correction is indexed; its body was inaccessible, so the scope of that correction remains unverified."},{"title":"ENCHANTED2/MT indexed correction","url":"https://pubmed.ncbi.nlm.nih.gov/36463906/","year":2022,"type":"Report","checkedAt":"2026-10-01","access":"Correction identity and link verified in NLM; publisher body inaccessible and correction scope not determined."}],"relatedTopic":"acute-bp"},{"id":"optimal-bp","title":"OPTIMAL-BP — functional outcomes after post-EVT BP reduction","headline":"Post-EVT SBP <140: mRS 0–2 39.4 vs 54.4%","year":2023,"settings":["on-call","hospital"],"keywords":["EVT","thrombectomy","successful reperfusion","blood pressure"],"question":"Did SBP <140 improve function after successful EVT?","population":"306 randomized patients with large-vessel ischemic stroke, mTICI ≥2b reperfusion and SBP ≥140 mmHg on two readings within 2 h of recanalization, at 19 South Korean centers; 305 were confirmed eligible.","comparison":"SBP <140 versus 140–180 mmHg for 24 hours after enrollment.","result":"Three-month independence (mRS 0–2) was 39.4% versus 54.4% (adjusted OR 0.56; 95% CI 0.33–0.96). Symptomatic ICH was 9.0% versus 8.1%; the difference was not significant. Stroke-related death was 7.7% versus 5.4%, also not significantly different.","limits":"Stopped early for safety concerns. The result concerns the tested lowering strategy after successful reperfusion; it does not establish a universal target for unsuccessful EVT or individualized reperfusion-guided management. At 1 year (Stroke 2026; 294 of 306 followed), mRS 0–2 was 40.5% with SBP <140 vs 52.7% with 140–180 (adjusted OR 0.59; 95% CI 0.34–1.00; P=.051; per-protocol 41.1 vs 54.7%, adjusted OR 0.56; 95% CI 0.32–0.97); 1-year mortality did not differ.","sources":[{"title":"OPTIMAL-BP primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37668619/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."},{"title":"OPTIMAL-BP 1-year outcomes","url":"https://pubmed.ncbi.nlm.nih.gov/42212393/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; 1-year follow-up extension of the original randomized population (294 of 306 completed)."}],"relatedTopic":"acute-bp"},{"id":"hope-post-evt-bp","title":"HOPE (post-EVT BP) — reperfusion-guided blood pressure targets","headline":"Reperfusion-guided SBP: mRS 0–2 60.0 vs 47.1%","year":2026,"settings":["on-call","hospital"],"keywords":["blood pressure","post EVT","mTICI","reperfusion-guided"],"question":"Do reperfusion-guided SBP targets after successful EVT improve outcome?","population":"440 previously independent adults (prestroke mRS 0–2) with anterior-circulation LVO and mTICI ≥2b after EVT within 24 h at 11 Spanish centers (mean age 75); elevated SBP was not required.","comparison":"SBP 140–160 for mTICI 2b or 100–140 for 2c/3 for 72 hours, using antihypertensives or vasopressors as needed, versus guideline management (SBP <180).","result":"mRS 0–2 at 90 days occurred in 60.0% vs 47.1% (difference 13.3 points; 95% CI 4.1–22.6). Hemorrhagic transformation 22.3% vs 31.6%; symptomatic ICH 3.5% vs 3.9%; mortality 15.4% vs 15.6% (abstract figures).","limits":"Open-label, single-country, stopped early for lack of funding (446 of 786 planned; 440 analyzed). Only 9.8% had mTICI 2b, with no clear benefit in that subgroup. The authors call it hypothesis-generating. It postdates AHA/ASA 2026 (COR 3: Harm for SBP <140 after mTICI 2b–3) and does not change that guidance.","sources":[{"title":"HOPE (post-EVT BP) primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42258192/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract and PMC full text (PMC13247842) read."}],"relatedTopic":"acute-bp"},{"id":"interact4","title":"INTERACT4 — ambulance BP lowering in undifferentiated stroke","headline":"Prehospital SBP lowering: overall neutral; harm in ischemic stroke (cOR 1.30)","year":2024,"settings":["on-call","hospital"],"keywords":["prehospital","blood pressure","ambulance","undifferentiated stroke"],"question":"Does ambulance-delivered BP lowering improve outcome in suspected acute stroke?","population":"2,404 Chinese patients with a motor deficit and SBP ≥150 within 2 hours; 46.5% of confirmed strokes were hemorrhagic.","comparison":"Immediate lowering to SBP 130–140 versus usual care.","result":"No overall difference in 90-day mRS (cOR 1.00; 95% CI 0.87–1.15). Hemorrhagic stroke: cOR 0.75 (0.60–0.92); ischemic stroke: cOR 1.30 (1.06–1.60), i.e., worse outcome.","limits":"Subgroup effects by stroke type; a very high hemorrhage proportion limits transfer to other regions.","sources":[{"title":"INTERACT4 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38752650/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"acute-bp"},{"id":"clots-3","title":"CLOTS 3 — intermittent pneumatic compression after stroke","headline":"IPC: proximal DVT 8.5 vs 12.1%","year":2013,"settings":["on-call","hospital"],"keywords":["DVT","VTE","IPC","immobility","compression"],"question":"Did intermittent pneumatic compression reduce proximal DVT?","population":"2,876 acute stroke patients unable to walk to the toilet without another person’s help, enrolled during admission days 0–3 at 94 UK centers.","comparison":"Intermittent pneumatic compression plus routine care versus no IPC.","result":"Proximal DVT, detected by screening ultrasound or symptomatic imaging within 30 days, occurred in 8.5% versus 12.1% (absolute reduction 3.6 percentage points; 95% CI 1.4–5.8). Skin breaks were more frequent with IPC: 3% versus 1%. The 30-day mortality difference was not statistically significant.","limits":"The endpoint includes asymptomatic DVT. This evaluates IPC rather than graduated compression stockings; device suitability and skin monitoring remain important.","sources":[{"title":"CLOTS 3 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/23727163/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked. Two corrections are indexed (Lancet 2013;382:506 and 1020); their full bodies could not be retrieved, so correction scope is unresolved."}],"relatedTopic":"vte-prevention"},{"id":"food-feeding-route","title":"FOOD — PEG versus nasogastric feeding after stroke","headline":"PEG vs nasogastric: more death or poor outcome (+7.8 points)","year":2005,"settings":["hospital"],"keywords":["dysphagia","nutrition","enteral feeding","PEG","nasogastric"],"question":"Should PEG routinely replace nasogastric feeding early after stroke?","population":"321 dysphagic stroke patients in the feeding-route randomization at 47 hospitals in 11 countries.","comparison":"Percutaneous endoscopic gastrostomy (PEG) versus nasogastric feeding.","result":"At six months, PEG increased death or poor outcome by 7.8 percentage points (95% CI 0.0–15.5; P=0.05). The mortality difference alone was 1.0 percentage point higher with PEG (95% CI −10.0 to 11.9), without statistical significance.","limits":"The report contains a separate early-versus-delayed feeding trial; do not mix its population or outcomes with this route comparison. The results do not establish that later PEG for persistent dysphagia is never appropriate.","sources":[{"title":"FOOD primary report","url":"https://pubmed.ncbi.nlm.nih.gov/15733717/","year":2005,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"poststroke-dysphagia"},{"id":"shine","title":"SHINE — intensive glucose control in acute ischemic stroke","headline":"Intensive insulin: no benefit; severe hypoglycemia 2.6%","year":2019,"settings":["on-call","hospital"],"keywords":["glucose","hyperglycemia","insulin","hypoglycemia"],"question":"Did intensive insulin treatment improve 90-day function?","population":"1,151 adults with hyperglycemic ischemic stroke enrolled within 12 hours at 63 US sites.","comparison":"IV insulin targeting glucose 80–130 mg/dL versus subcutaneous sliding-scale insulin targeting 80–179 mg/dL for up to 72 hours.","result":"Severity-adjusted favorable 90-day mRS outcome occurred in 20.5% versus 21.6% (adjusted RR 0.97; 95% CI 0.87–1.08). Severe hypoglycemia occurred only with intensive treatment: 15 patients (2.6%).","limits":"Stopped for futility. The outcome threshold depended on baseline stroke severity. Failure of this intensive strategy does not support leaving marked hyperglycemia untreated or attributing QASC’s bundle benefit to tight glucose control.","sources":[{"title":"SHINE primary report","url":"https://pubmed.ncbi.nlm.nih.gov/31334795/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked. November 2019 correction body read; reversed figure-arm labels and demographic/minor text values were corrected. The card avoids the uncorrected demographic values still present in the indexed abstract."},{"title":"SHINE correction","url":"https://pubmed.ncbi.nlm.nih.gov/31688865/","year":2019,"type":"Report","checkedAt":"2026-10-01","access":"Full correction read: figure treatment labels, demographics, missing-data percentage, race/ethnicity values and investigator spelling corrected."}],"relatedTopic":"inpatient-medical-complications"},{"id":"qasc","title":"QASC — implementing fever, glucose and swallowing care","headline":"Nurse fever/glucose/swallow protocols: death or dependency 42 vs 58%","year":2011,"settings":["hospital"],"keywords":["nursing","stroke unit","dysphagia","fever","glucose","care bundle"],"question":"Did organized implementation improve stroke-unit outcomes?","population":"19 Australian stroke units, with 687 patients before and 1,009 after implementation; adults with ischemic stroke or ICH presenting within 48 hours.","comparison":"Nurse-initiated fever, glucose and swallowing protocols plus multidisciplinary implementation workshops versus abridged guideline provision; units were randomized.","result":"At 90 days, death or dependency (mRS ≥2) was 42% versus 58% in post-intervention cohorts (adjusted absolute difference 15.7 percentage points; 95% CI 5.8–25.4). Mortality alone did not differ significantly.","limits":"Cluster randomization and pre/post cohorts differ from individual patient randomization. This supports implementation of the package; it cannot isolate which component produced benefit or establish an intensive glucose target.","sources":[{"title":"QASC primary report","url":"https://pubmed.ncbi.nlm.nih.gov/21996470/","year":2011,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"stroke-unit-nursing"},{"id":"destiny-ii","title":"DESTINY II — hemicraniectomy in older patients","headline":"Hemicraniectomy 61–82 y: survival with mRS 0–4 38 vs 18%","year":2014,"settings":["on-call","hospital"],"keywords":["decompression","hemicraniectomy","malignant MCA","goals of care","disability"],"question":"What survival and disability tradeoff accompanied surgery after age 60?","population":"112 patients aged 61–82 with malignant middle-cerebral-artery infarction, randomized within 48 hours; median age 70.","comparison":"Hemicraniectomy versus conservative intensive-care treatment.","result":"At six months, survival with mRS 0–4 was 38% versus 18% (OR 2.91; 95% CI 1.06–7.49). Mortality was 33% versus 70%. No participant achieved mRS 0–2; most survivors needed help with bodily needs. Infections were more frequent after surgery.","limits":"The primary endpoint included mRS 4 and must not be described as functional independence. Discuss the full disability distribution and the person’s acceptable outcomes; age alone is not a complete selection rule.","sources":[{"title":"DESTINY II primary report","url":"https://pubmed.ncbi.nlm.nih.gov/24645942/","year":2014,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"malignant-edema"},{"id":"restart","title":"RESTART — antiplatelet therapy after antithrombotic-associated ICH","headline":"Antiplatelet restart after ICH: recurrent ICH 4 vs 9% (NS)","year":2019,"settings":["hospital","clinic"],"keywords":["ICH","antiplatelet","aspirin","recurrence","secondary prevention"],"question":"Did restarting antiplatelet therapy increase recurrent ICH?","population":"537 ICH survivors previously taking antithrombotic therapy for occlusive vascular disease; randomized a median of 76 days after ICH.","comparison":"Start versus avoid antiplatelet therapy.","result":"Over a median two years, recurrent symptomatic ICH occurred in 12/268 (4%) versus 23/268 (9%) (adjusted HR 0.51; 95% CI 0.25–1.03). Major hemorrhagic events were 7% versus 9%; major occlusive events were 15% versus 14%, without significant differences.","limits":"The confidence interval does not prove antiplatelets prevent recurrent ICH. This selected survivor cohort does not establish immediate restart timing, safety for every CAA phenotype, or anticoagulant resumption. The smaller STATICH-Antiplatelets trial (Stroke 2026; 69 ICH survivors with an antiplatelet indication; stopped early for slow recruitment) had numerically more recurrent ICH with antiplatelets (5/34 [15%] vs 1/35 [3%]) and fewer major ischemic events (3/34 [9%] vs 7/35 [20%]), with wide confidence intervals.","sources":[{"title":"RESTART primary report","url":"https://pubmed.ncbi.nlm.nih.gov/31128924/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."},{"title":"STATICH-Antiplatelets randomized trial","url":"https://pubmed.ncbi.nlm.nih.gov/42312355/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; full text not read. Stopped early for slow recruitment (69 of 500 planned)."}],"relatedTopic":"caa-ich-recurrence"},{"id":"earlydrain","title":"EARLYDRAIN — lumbar CSF drainage after secured aSAH","headline":"Lumbar drain after aSAH: mRS 3–6 32.6 vs 44.8%","year":2023,"settings":["on-call","hospital"],"keywords":["SAH","lumbar drain","CSF","delayed ischemia","infarction"],"question":"Did early lumbar drainage improve outcome after aneurysm treatment?","population":"287 analyzable adults with aneurysmal SAH across clinical grades; aneurysms were clipped or coiled within 48 hours.","comparison":"Additional lumbar drainage at 5 mL/hour, begun within 72 hours, versus standard care.","result":"Six-month mRS 3–6 occurred in 32.6% versus 44.8% (RR 0.73; 95% CI 0.52–0.98). Secondary infarction at discharge was 28.5% versus 39.9%. Drain complications included a pressure gradient stopping drainage, a local skin infection needing excision and a torn-off drain needing surgical removal.","limits":"Lumbar-drain contraindications included absent/compressed basal cisterns and therapeutic anticoagulation. Use the full neurosurgical drainage and pressure-monitoring protocol; this was not unrestricted drainage for every SAH presentation.","sources":[{"title":"EARLYDRAIN primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37330974/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract, full-report eligibility and adverse-event passages read via NLM/Europe PMC. August 2023 correction body read: lumbar-drain mRS-5 figure count changed from 24 to 9. Supplementary protocol not comprehensively reviewed."},{"title":"EARLYDRAIN figure correction","url":"https://pubmed.ncbi.nlm.nih.gov/37578477/","year":2023,"type":"Report","checkedAt":"2026-10-01","access":"Full correction read: the lumbar-drain group’s six-month mRS-5 value in Figure 2 changed from 24 to 9."}],"relatedTopic":"sah-critical-care"},{"id":"sahara","title":"SAHaRA — liberal versus restrictive transfusion in aSAH","headline":"Liberal transfusion in aSAH: no benefit (33.5 vs 37.7%)","year":2025,"settings":["on-call","hospital"],"keywords":["SAH","anemia","hemoglobin","transfusion","red cells"],"question":"Did a more liberal transfusion threshold improve neurological outcome?","population":"742 critically ill adults with acute aneurysmal SAH and anemia at 23 centers; 725 contributed to the primary analysis.","comparison":"Mandatory red-cell transfusion at hemoglobin ≤10 g/dL versus optional transfusion at ≤8 g/dL.","result":"At 12 months, unfavorable outcome (mRS ≥4) occurred in 33.5% versus 37.7% (RR 0.88; 95% CI 0.72–1.09; P=0.22). Functional-independence and quality-of-life measures did not show significant differences; adverse-event incidence was similar.","limits":"No superiority was demonstrated; the confidence interval does not establish equivalence. The restrictive strategy allowed clinical discretion and must not be recast as mandatory transfusion at 8 g/dL or a universal rule for all acute brain injuries.","sources":[{"title":"SAHaRA primary report","url":"https://pubmed.ncbi.nlm.nih.gov/39655786/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"sah-critical-care"},{"id":"cadiss","title":"CADISS — antiplatelet versus anticoagulant treatment for dissection","headline":"Dissection: antiplatelet vs anticoagulant, few events (3 vs 1)","year":2015,"settings":["on-call","hospital","clinic"],"keywords":["cervical artery dissection","carotid","vertebral","antiplatelet","anticoagulation"],"question":"Did antithrombotic strategy alter early stroke recurrence?","population":"250 patients with symptomatic extracranial carotid or vertebral dissection within seven days; central imaging review did not confirm dissection in 52.","comparison":"Clinician-selected antiplatelet versus anticoagulant treatment for three months.","result":"Ipsilateral stroke or death occurred in 3/126 versus 1/124 patients (P=0.63); there were no deaths. One major bleed, a subarachnoid hemorrhage, occurred with anticoagulation.","limits":"Very few events and wide uncertainty prevent an equivalence conclusion. This extracranial-dissection study does not settle intracranial dissection management or which individual drug is best; consider it alongside TREAT-CAD.","sources":[{"title":"CADISS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/25684164/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked. June 2015 correction is indexed; its publisher body was inaccessible and the scope remains unverified."},{"title":"CADISS indexed correction","url":"https://pubmed.ncbi.nlm.nih.gov/25987273/","year":2015,"type":"Report","checkedAt":"2026-10-01","access":"Correction identity and link verified in NLM; publisher body inaccessible and correction scope not determined."}],"relatedTopic":"dissection"},{"id":"respect","title":"RESPECT — PFO closure, extended follow-up","headline":"PFO closure: recurrent stroke HR 0.55 over 5.9 years","year":2017,"settings":["hospital","clinic"],"keywords":["PFO","closure","cryptogenic stroke"],"question":"Does PFO closure reduce recurrent stroke after cryptogenic stroke over long-term follow-up?","population":"980 patients aged 18–60 with PFO and cryptogenic ischemic stroke (mean age 45.9), followed a median 5.9 years.","comparison":"PFO closure versus medical therapy (antiplatelet or warfarin).","result":"Recurrent ischemic stroke 0.58 vs 1.07 per 100 patient-years (HR 0.55; 95% CI 0.31–0.999); stroke of undetermined cause HR 0.38 (0.18–0.79). Venous thromboembolism was more common with closure.","limits":"Extended follow-up analysis was exploratory; unequal dropout between groups.","sources":[{"title":"RESPECT extended follow-up primary report","url":"https://pubmed.ncbi.nlm.nih.gov/28902590/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"pfo"},{"id":"to-act","title":"TO-ACT — endovascular treatment for severe CVT","headline":"Severe CVT EVT: no benefit (mRS 0–1 67 vs 68%)","year":2020,"settings":["on-call","hospital"],"keywords":["cerebral venous thrombosis","EVT","thrombectomy","intrasinus thrombolysis"],"question":"Did adding EVT improve outcome in severe CVT?","population":"67 adults with CVT and at least one poor-outcome risk feature: mental-status change, coma, ICH or deep cerebral venous thrombosis.","comparison":"Mechanical thrombectomy and/or local thrombolysis plus medical care versus medical care alone; EVT within 24 hours of randomization.","result":"At 12 months, mRS 0–1 occurred in 67% versus 68% (RR 0.99; 95% CI 0.71–1.38). Mortality was 12% versus 3% and symptomatic ICH 3% versus 9%; neither difference was significant.","limits":"Stopped early for futility and too small to exclude important benefit or harm. Mixed endovascular techniques and selected severe CVT limit extrapolation; the trial does not establish routine EVT or resolve every rescue situation.","sources":[{"title":"TO-ACT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/32421159/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"cvt"},{"id":"respect-cvt","title":"RE-SPECT CVT — dabigatran versus warfarin for cerebral venous thrombosis","headline":"CVT: no recurrent VTE; major bleeding 1.7 vs 3.3%","year":2019,"settings":["hospital","clinic"],"keywords":["CVT","dabigatran","DOAC","warfarin","anticoagulation"],"question":"Is dabigatran as safe and effective as warfarin after CVT?","population":"120 adults with acute CVT, stable after 5–15 days of parenteral heparin; ICH from the CVT was allowed.","comparison":"Dabigatran 150 mg twice daily versus dose-adjusted warfarin for 24 weeks.","result":"No recurrent venous thromboembolism in either group. Major bleeding 1.7% (1, intestinal) vs 3.3% (2, intracranial); recanalization 60.0% vs 67.3%.","limits":"Small exploratory open-label trial with blinded adjudication.","sources":[{"title":"RE-SPECT CVT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/31479105/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"cvt"}],"calculators":[{"id":"abcd2","name":"ABCD²","category":"TIA & secondary prevention","fn":"calculateReviewedABCD2","module":"supplementary-calculators","route":"#/tools/abcd2","sourceEndpoint":"data/sources.json","sourceIds":["abcd2-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/17258668/","sourceLabel":"Johnston et al., Lancet 2007","limits":"For a clinically diagnosed TIA. Use the first recorded BP after the TIA, with the event symptoms and duration. Later treatment BP is separate. The score does not diagnose TIA or determine disposition.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"ABCD2 TIA","fields":[{"key":"tiaConfirmed","label":"Clinical TIA diagnosis confirmed","type":"truth"},{"key":"initialSystolic","label":"First BP after TIA: systolic (mmHg)","type":"number","min":1,"max":400},{"key":"initialDiastolic","label":"First BP after TIA: diastolic (mmHg)","type":"number","min":1,"max":300},{"key":"clinicalFeatures","label":"TIA clinical features","type":"select","options":[["weakness","Unilateral weakness (2)"],["speech","Speech disturbance without weakness (1)"],["other","Neither feature (0)"]]},{"key":"duration","label":"TIA symptom duration","type":"select","options":[["under10","Less than 10 min (0)"],["10to59","10–59 min (1)"],["60plus","At least 60 min (2)"]]},{"key":"diabetes","label":"History of diabetes","type":"truth"}],"reviewedAt":"2026-10-01","reviewScope":"Point assignments and score completeness only; no absolute risk, outcome prediction or treatment-selection review.","shared":["age"],"verificationUrl":"https://www.ahajournals.org/doi/10.1161/STROKEAHA.109.571844"},{"id":"chadsvasc","name":"CHA₂DS₂-VASc","category":"TIA & secondary prevention","fn":"calculateReviewedCHADS2VASc","module":"supplementary-calculators","route":"#/tools/chadsvasc","sourceEndpoint":"data/sources.json","sourceIds":["chadsvasc-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/19762550/","sourceLabel":"Lip et al., Chest 2010","limits":"For nonvalvular atrial fibrillation. Sex category follows the original instrument; no annual risk estimate or anticoagulant choice is generated. The 2023 ACC/AHA/ACCP/HRS AF guideline names CHA₂DS₂-VASc as a validated score; the 2024 ESC AF guideline uses CHA₂DS₂-VA, which omits the sex category and is not calculated here.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"CHA2DS2VASc CHADS VASC atrial fibrillation AF stroke risk","fields":[{"key":"afConfirmed","label":"Nonvalvular atrial fibrillation confirmed","type":"truth"},{"key":"chf","label":"Heart failure / LV dysfunction","type":"truth"},{"key":"hypertension","label":"History of hypertension","type":"truth"},{"key":"diabetes","label":"History of diabetes","type":"truth"},{"key":"strokeTia","label":"History of stroke / TIA / systemic thromboembolism","type":"truth"},{"key":"vascular","label":"Vascular disease: prior MI, peripheral arterial disease or aortic plaque","type":"truth"}],"reviewedAt":"2026-10-21","reviewScope":"Point assignments and score completeness only. Components and doubled age ≥75 and stroke/TIA weights rechecked on 2026-10-21 against the 2023 ACC/AHA/ACCP/HRS AF guideline (full text); the ESC 2024 change is from a secondary full-text report. No absolute risk, outcome prediction or treatment-selection review.","shared":["age","sex"],"verificationUrl":"https://academic.oup.com/europace/article/12/9/1349/530959"},{"id":"has-bled","name":"HAS-BLED","category":"TIA & secondary prevention","fn":"calculateReviewedHASBLED","module":"supplementary-calculators","route":"#/tools/has-bled","sourceEndpoint":"data/sources.json","sourceIds":["has-bled-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/20299623/","sourceLabel":"Pisters et al., Chest 2010","limits":"Original AF bleeding instrument. Review its definitions, including renal/liver impairment and labile INR. A score does not justify withholding anticoagulation; no bleeding probability is generated.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"HASBLED bleeding risk atrial fibrillation AF","fields":[{"key":"afConfirmed","label":"Atrial fibrillation confirmed","type":"truth"},{"key":"uncontrolledHypertension","label":"Uncontrolled hypertension: systolic BP over 160 mmHg","type":"truth"},{"key":"renal","label":"Renal: dialysis, kidney transplant, or creatinine ≥200 µmol/L (about 2.26 mg/dL)","type":"truth"},{"key":"liver","label":"Liver: chronic hepatic disease (e.g. cirrhosis), or bilirubin >2× ULN with AST/ALT/ALP >3× ULN","type":"truth"},{"key":"stroke","label":"History of stroke","type":"truth"},{"key":"bleeding","label":"Bleeding history or predisposition (including anemia)","type":"truth"},{"key":"labileINR","label":"Labile INR / time in therapeutic range below 60%","type":"truth"},{"key":"drugs","label":"Concomitant antiplatelet or NSAID use","type":"truth"},{"key":"alcohol","label":"Excess alcohol: ≥8 drinks/week","type":"truth"}],"reviewedAt":"2026-10-01","reviewScope":"Input definitions and points checked in Methods/Table 2; no absolute bleeding risk or treatment recommendation.","shared":["age"],"verificationUrl":"https://www.acforum-excellence.org/sites/default/files/Pisters.HAS-BLED.pdf"},{"id":"rope","name":"RoPE","category":"PFO assessment","fn":"calculateReviewedRoPE","module":"supplementary-calculators","route":"#/tools/rope","sourceEndpoint":"data/sources.json","sourceIds":["rope-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/23864310/","sourceLabel":"Kent et al., Neurology 2013","limits":"For otherwise cryptogenic ischemic stroke with PFO, not undifferentiated symptoms or TIA. The score does not establish causality or recommend closure.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"risk of paradoxical embolism PFO patent foramen ovale","fields":[{"key":"cryptogenicStrokeWithPfo","label":"Otherwise cryptogenic ischemic stroke with PFO confirmed","type":"truth"},{"key":"hypertension","label":"History of hypertension","type":"truth"},{"key":"diabetes","label":"History of diabetes","type":"truth"},{"key":"priorStrokeTia","label":"Prior stroke / TIA","type":"truth"},{"key":"smoker","label":"Smoker","type":"truth"},{"key":"corticalInfarct","label":"Cortical infarct on imaging","type":"truth"}],"reviewedAt":"2026-10-01","reviewScope":"Point assignments and score completeness only; no absolute risk, outcome prediction or treatment-selection review.","shared":["age"],"verificationUrl":"https://www.ncbi.nlm.nih.gov/books/NBK592989/table/tbl001/"},{"id":"pascal","name":"PASCAL","category":"PFO assessment","fn":"classifyReviewedPASCAL","module":"supplementary-calculators","route":"#/tools/pascal","sourceEndpoint":"data/sources.json","sourceIds":["pascal-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/34905030/","sourceLabel":"Kent et al., JAMA 2021 / SCOPE study","limits":"Simplified three-category classification for the source population aged 18–60 with otherwise cryptogenic stroke and PFO. Shunt/ASA definitions require specialist review; category does not establish individual causality or closure benefit. In pooled trial data, closure reduced stroke in possible/probable but not unlikely categories; AF after day 45 rose with closure in unlikely (+4.4%) and possible (+1.5%).","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"PFO patent foramen ovale associated stroke causal likelihood","fields":[{"key":"largeShunt","label":"Large shunt under source definition (over 20 LA bubbles on TEE)","type":"truth"},{"key":"atrialSeptalAneurysm","label":"Atrial septal aneurysm under source definition (excursion at least 10 mm)","type":"truth"}],"reviewedAt":"2026-10-01","reviewScope":"Point assignments and score completeness only; no absolute risk, outcome prediction or treatment-selection review.","shared":["age"],"verificationUrl":"https://www.ncbi.nlm.nih.gov/books/NBK592989/table/tbl001/"},{"id":"phases","name":"PHASES","category":"Aneurysm & SAH","fn":"calculateReviewedPHASES","module":"supplementary-calculators","route":"#/tools/phases","sourceEndpoint":"data/sources.json","sourceIds":["phases-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/24290159/","sourceLabel":"Greving et al., Lancet Neurology 2014","limits":"For an unruptured saccular intracranial aneurysm. Geographic groups follow the original cohorts and must be explicitly selected. Score only; no rupture probability or management recommendation.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"aneurysm unruptured intracranial rupture","fields":[{"key":"unrupturedSaccular","label":"Unruptured saccular intracranial aneurysm confirmed","type":"truth"},{"key":"population","label":"PHASES source population","type":"select","options":[["northAmericaEurope","North America / Europe other than Finland (0)"],["japanese","Japanese (3)"],["finnish","Finnish (5)"]]},{"key":"hypertension","label":"Hypertension under PHASES source definition","type":"truth"},{"key":"sizeMm","label":"Maximum aneurysm diameter (mm)","type":"number","min":0,"step":"any"},{"key":"earlierSAH","label":"Earlier SAH from another aneurysm","type":"truth"},{"key":"site","label":"Aneurysm site","type":"select","options":[["ica","ICA (0)"],["mca","MCA (2)"],["acaPcommPosterior","ACA / PCom / posterior circulation (4)"]]}],"reviewedAt":"2026-10-01","reviewScope":"Point assignments and score completeness only; no absolute risk, outcome prediction or treatment-selection review.","shared":["age"],"verificationUrl":"https://square.umin.ac.jp/~ucas-j/data/2014_TLN_PHASES%20score.pdf"},{"id":"mrs-descriptors","name":"Modified Rankin scale descriptors","category":"Disability & grading","fn":"describeReviewedMRS","module":"supplementary-calculators","route":"#/tools/mrs-descriptors","sourceEndpoint":"data/sources.json","sourceIds":["mrs-descriptors-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/3363593/","sourceLabel":"van Swieten et al., Stroke 1988","limits":"Describes the existing baseline mRS entry; does not assign a grade from an interview or forecast recovery. Original descriptor wording retained in paraphrase; primary full-text review remains limited. Grade 6 (death) is the outcome-reporting convention added to the original 0–5 scale.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"mRS modified Rankin scale disability","fields":[],"shared":["mrs"],"reviewedAt":null,"reviewScope":"Existing descriptor aid retained; no new questionnaire or prognostic validation."},{"id":"hunt-hess","name":"Hunt–Hess grade","category":"Aneurysm & SAH","fn":"describeReviewedHuntHess","module":"supplementary-calculators","route":"#/tools/hunt-hess","sourceEndpoint":"data/sources.json","sourceIds":["hunt-hess-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/5635959/","sourceLabel":"Hunt and Hess, J Neurosurg 1968","limits":"Clinician-assigned SAH grade. Descriptions are an aid, not an examination or individualized prognosis; clinical confounders require review.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"Hunt Hess subarachnoid hemorrhage SAH","fields":[{"key":"sahConfirmed","label":"Subarachnoid hemorrhage confirmed","type":"truth"},{"key":"grade","label":"Clinician-assigned Hunt–Hess grade","type":"select","options":[["1","1: Asymptomatic or mild headache with slight neck stiffness."],["2","2: Moderate to severe headache and neck stiffness; no neurologic deficit except a cranial nerve palsy."],["3","3: Drowsiness, confusion or a mild focal neurologic deficit."],["4","4: Stupor with moderate to severe weakness; early decerebrate posturing may be present."],["5","5: Deep coma with decerebrate posturing."]]}],"reviewedAt":"2026-10-01","reviewScope":"Grade descriptors checked against the Joint Commission data-element definition; original paper full text was unavailable.","verificationUrl":"https://manual.jointcommission.org/bin/view/releases/TJC2024A1/DataElem0555.html"},{"id":"wfns","name":"WFNS grade","category":"Aneurysm & SAH","fn":"calculateReviewedWFNS","module":"supplementary-calculators","route":"#/tools/wfns","sourceEndpoint":"data/sources.json","sourceIds":["wfns-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/3131498/","sourceLabel":"WFNS Committee, J Neurosurg 1988","limits":"SAH grade from complete Encounter GCS and reviewed motor deficit. The original table leaves GCS 15 with motor deficit unclassified here. No mortality or recovery prediction.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"World Federation of Neurosurgical Societies subarachnoid hemorrhage SAH","fields":[{"key":"sahConfirmed","label":"Subarachnoid hemorrhage confirmed","type":"truth"},{"key":"motorDeficit","label":"Motor deficit present","type":"truth"}],"shared":["gcs"],"reviewedAt":"2026-10-01","reviewScope":"Grade bands cross-checked in a primary 2008 validation study; original committee full text was unavailable.","verificationUrl":"https://doi.org/10.1161/STROKEAHA.107.498345"},{"id":"modified-fisher","name":"Modified Fisher grade","category":"Aneurysm & SAH","fn":"calculateReviewedModifiedFisher","module":"supplementary-calculators","route":"#/tools/modified-fisher","sourceEndpoint":"data/sources.json","sourceIds":["modified-fisher-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/16823296/","sourceLabel":"Frontera et al., Neurosurgery 2006, Table 1","limits":"For aneurysmal SAH: select SAH and its aneurysmal cause in Encounter. Grade the admission CT using clinician-reviewed blood thickness and IVH. No numerical thickness cutoff, vasospasm probability or prognosis is assigned.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"modified Fisher CT blood subarachnoid hemorrhage SAH IVH","fields":[{"key":"bloodThickness","label":"Admission CT subarachnoid blood","type":"select","options":[["absent","No visible subarachnoid blood"],["thin","Thin blood"],["thick","Thick blood"]]},{"key":"ivh","label":"Admission CT intraventricular blood present","type":"truth"}],"shared":["sahCause"],"reviewedAt":"2026-10-01","reviewScope":"Original report Table 1 and grading methods checked in an accessible primary-paper copy; grade mapping only.","verificationUrl":"https://cmp-manual.wbs.cz/skaly/prediction_of_symptomatic_vasospasm_after_subarachnoid_hemorrhage_-_the_modified_fisher_scale.pdf"},{"id":"mtici","name":"mTICI reperfusion grade","category":"Imaging","fn":"describeReviewedMTICI","module":"supplementary-calculators","route":"#/tools/mtici","sourceEndpoint":"data/sources.json","sourceIds":["mtici-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/23390038/","sourceLabel":"Goyal et al., J Neurointerv Surg 2014, Table 3","limits":"Describes the recorded mTICI grade in an acute ischemic Encounter. Uses the revision including 2c; this is not eTICI. Confirm the angiographic report and grading system. No grade is inferred from imaging text or used to predict recovery.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"TICI reperfusion thrombectomy angiography","fields":[],"shared":["mtici"],"reviewedAt":"2026-10-01","reviewScope":"Descriptors checked against the indexed primary manuscript and revised grading table; no outcome or procedural recommendation review.","verificationUrl":"https://pmc.ncbi.nlm.nih.gov/articles/PMC4156591/"},{"id":"nascet","name":"NASCET carotid stenosis","category":"Imaging","fn":"calculateReviewedNASCET","module":"supplementary-calculators","route":"#/tools/nascet","sourceEndpoint":"data/sources.json","sourceIds":["nascet-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/16418349/","sourceLabel":"Bartlett et al., AJNR 2006; NASCET measurement method","limits":"Patent extracranial ICA only. Use minimum residual lumen and normal distal ICA diameters from the same side, measured perpendicular to the vessel; the distal reference must be beyond bulb tapering. Excludes occlusion and suspected near-occlusion. Formula: 100 × (1 − minimum/distal). Rounded to 0.1%; values above 99.9% remain below complete occlusion. No revascularization recommendation.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"carotid stenosis ICA diameter","fields":[{"key":"side","label":"Measured ICA side","type":"select","options":[["left","Left"],["right","Right"]]},{"key":"minimumDiameterMm","label":"Minimum residual lumen diameter (mm)","type":"number","min":0,"step":"any"},{"key":"distalDiameterMm","label":"Normal distal ICA diameter (mm)","type":"number","min":0,"step":"any"},{"key":"patentExtracranialICA","label":"Patent extracranial ICA and suitable distal reference confirmed","type":"truth"},{"key":"nearOcclusion","label":"Near-occlusion suspected or present","type":"truth"}],"reviewedAt":"2026-10-01","reviewScope":"Primary methods checked for the diameter ratio, distal reference and near-occlusion exclusion; measurement arithmetic only.","verificationUrl":"https://pmc.ncbi.nlm.nih.gov/articles/PMC7976065/"},{"id":"aspects-regions","name":"ASPECTS regional worksheet","category":"Imaging","fn":"calculateReviewedRegionalASPECTS","module":"supplementary-calculators","route":"#/tools/aspects-regions","sourceEndpoint":"data/sources.json","sourceIds":["aspects-regions-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/10905241/","sourceLabel":"Barber et al., Lancet 2000","limits":"One MCA hemisphere on source-appropriate imaging. All ten regions require explicit review. Worksheet arithmetic is separate from image interpretation and EVT eligibility.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"Alberta stroke program early CT score anterior","fields":[{"key":"hemisphere","label":"ASPECTS hemisphere","type":"select","options":[["left","Left"],["right","Right"]]}],"reviewedAt":"2026-10-01","reviewScope":"Ten regions and subtraction cross-checked against the original ASPECTS investigators’ 2001 methods report; no image interpretation or treatment-threshold review.","verificationUrl":"https://pmc.ncbi.nlm.nih.gov/articles/PMC7974585/","regions":[{"key":"C","label":"Caudate","weight":1},{"key":"L","label":"Lentiform nucleus","weight":1},{"key":"IC","label":"Internal capsule","weight":1},{"key":"I","label":"Insular ribbon","weight":1},{"key":"M1","label":"M1","weight":1},{"key":"M2","label":"M2","weight":1},{"key":"M3","label":"M3","weight":1},{"key":"M4","label":"M4","weight":1},{"key":"M5","label":"M5","weight":1},{"key":"M6","label":"M6","weight":1}]},{"id":"pc-aspects-regions","name":"pc-ASPECTS regional worksheet","category":"Imaging","fn":"calculateReviewedRegionalPCASPECTS","module":"supplementary-calculators","route":"#/tools/pc-aspects-regions","sourceEndpoint":"data/sources.json","sourceIds":["pc-aspects-regions-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/18617663/","sourceLabel":"Puetz et al., Stroke 2008","limits":"Original posterior-circulation CT/CTA-source-image instrument. All eight regions require explicit review; pons and midbrain each subtract two points. No universal treatment cutoff or prognosis.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"posterior circulation ASPECTS basilar vertebrobasilar","fields":[],"reviewedAt":"2026-10-01","reviewScope":"Point assignments and score completeness only; no absolute risk, outcome prediction or treatment-selection review.","regions":[{"key":"pons","label":"Pons","weight":2},{"key":"midbrain","label":"Midbrain","weight":2},{"key":"cerebellumLeft","label":"Left cerebellum","weight":1},{"key":"cerebellumRight","label":"Right cerebellum","weight":1},{"key":"pcaLeft","label":"Left PCA territory","weight":1},{"key":"pcaRight","label":"Right PCA territory","weight":1},{"key":"thalamusLeft","label":"Left thalamus","weight":1},{"key":"thalamusRight","label":"Right thalamus","weight":1}]},{"id":"phq2","name":"PHQ-2","category":"Follow-up screening","fn":"calculateReviewedPHQ2","module":"supplementary-calculators","route":"#/tools/phq2","sourceEndpoint":"data/sources.json","sourceIds":["phq2-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/14583691/","sourceLabel":"Kroenke et al., Medical Care 2003","limits":"Two-week symptom-frequency screening, not a depression diagnosis. Both responses must be entered; no management plan is generated. The source identified a score of 3 or more as the optimal screening cutpoint for major depression (sensitivity 83%, specificity 92%) in primary care and obstetrics-gynecology clinics, not a stroke population.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"PHQ2 patient health questionnaire depression","fields":[{"key":"phq2_q1","label":"Over the last 2 weeks: little interest or pleasure in doing things","type":"select","options":[["0","Not at all (0)"],["1","Several days (1)"],["2","More than half the days (2)"],["3","Nearly every day (3)"]]},{"key":"phq2_q2","label":"Over the last 2 weeks: feeling down, depressed or hopeless","type":"select","options":[["0","Not at all (0)"],["1","Several days (1)"],["2","More than half the days (2)"],["3","Nearly every day (3)"]]}],"reviewedAt":"2026-10-21","reviewScope":"Item scoring (0–3 each, total 0–6) and the 3-point cutpoint rechecked against the primary abstract on 2026-10-21. No diagnostic, management or post-stroke validation review.","verificationUrl":"https://www.ihs.gov/sites/crs/themes/responsive2017/display_objects/documents/phq_2_medical_care.pdf"},{"id":"stop-bang","name":"STOP-BANG","category":"Follow-up screening","fn":"calculateReviewedSTOPBANG","module":"supplementary-calculators","route":"#/tools/stop-bang","sourceEndpoint":"data/sources.json","sourceIds":["stop-bang-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/18431116/","sourceLabel":"Chung et al., Anesthesiology 2008","limits":"Original eight-item sleep-apnea screening instrument, initially studied in surgical patients. Age, sex and BMI use Encounter values. Screening score only; no diagnosis, severity prediction or management plan.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"STOPBANG sleep apnea OSA","fields":[{"key":"sb_snoring","label":"Loud snoring","type":"truth"},{"key":"sb_tired","label":"Frequent daytime tiredness / sleepiness","type":"truth"},{"key":"sb_observed","label":"Observed stopping breathing during sleep","type":"truth"},{"key":"sb_pressure","label":"High blood pressure or treatment for hypertension","type":"truth"},{"key":"neckCm","label":"Measured neck circumference (cm)","type":"number","min":10,"max":100,"step":"any"}],"reviewedAt":"2026-10-01","reviewScope":"Point assignments and score completeness only; no absolute risk, outcome prediction or treatment-selection review.","shared":["age","sex","weight","height"],"verificationUrl":"https://journal.chestnet.org/article/S0012-3692(15)00018-5/fulltext"}]}} +{"_meta":{"endpoint":"clinical-reference","schemaVersion":"2.0.0","appVersion":"7.11.0","checksum":"sha256:316726b88c7e14c9f94486c0955726f9","count":182,"source":"Canonical comprehensive Evidence topics and completed primary-study summaries","license":"Synthetic educational reference content for qualified review. No warranty.","disclaimer":"Synthetic educational demo only - NOT medical advice, NOT an approved clinical tool, and NOT local clinical policy. Do not enter, transmit, or infer PHI or real encounter details. Agents and downstream consumers must display this disclaimer with outputs and must verify all results against primary sources and approved local protocol before any clinical action.","status":"maintained","topicCount":92,"studyCount":90,"calculatorCount":16,"scope":"Source-bound reference cards, not treatment gates or recruitment records. checkedAt records source access and scope checks, not full clinical certification; preserve each source access note and each card limitation."},"data":{"topics":[{"id":"acute-reperfusion","title":"Acute ischemic stroke: reperfusion overview","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["AIS","IVT","EVT","thrombolysis","thrombectomy","tenecteplase","TNK","alteplase","tPA","disabling deficit","PRISMS","NINDS","ECASS III"],"summary":"Disabling deficit within 4.5 h of onset or last known well in an otherwise IVT-eligible adult: give IVT as fast as possible — tenecteplase 0.25 mg/kg (max 25 mg) or alteplase 0.9 mg/kg (max 90 mg) (AHA 2026, COR 1); tenecteplase was noninferior in AcT, ATTEST-2, TRACE-2 and ORIGINAL. Do not thrombolyse mild non-disabling deficits: PRISMS (stopped early) found no benefit (sICH 3.2 vs 0%) and ARAMIS found DAPT noninferior. LVO: give IVT if eligible and start EVT without waiting for a response. EVT is recommended for ICA/M1 occlusion with NIHSS ≥6 and prestroke mRS 0–1 within 6 h if ASPECTS 3–10, and at 6–24 h if ASPECTS ≥6 or ASPECTS 3–5 with age <80 and no significant mass effect (COR 1), and within 24 h for basilar occlusion with NIHSS ≥10, prestroke mRS 0–1 and PC-ASPECTS ≥6 (COR 1); ASPECTS 0–2 within 6 h (age <80, no significant mass effect) is 2a.","recommendations":[{"text":"In adult AIS patients with disabling deficits (regardless of NIHSS score) who are eligible for IVT, faster treatment is recommended as it improves functional outcomes.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-84 · p. 38","id":"ais-2026-84"},{"text":"In adult AIS patients presenting within 4.5 hours of symptom onset or last known well who are eligible for IVT, tenecteplase 0.25 mg/kg (max 25 mg) or alteplase 0.9 mg/kg (max 90 mg) is recommended to improve functional outcomes.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-98 · p. 42","id":"ais-2026-98"},{"text":"In eligible adult AIS patients presenting with mild, non-disabling stroke deficits (e.g., isolated sensory syndrome) within 4.5 hours of symptom onset or last known well, IVT is not recommended as it has not shown superiority over dual antiplatelet treatment for improving functional outcomes.","cor":"3: No Benefit","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-91 · p. 38","id":"ais-2026-91"},{"text":"In AIS patients eligible for both IVT and EVT, IVT is recommended to be administered as rapidly as possible without waiting to observe clinical response or delaying EVT initiation, to improve treatment times and clinical outcomes.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-113 · p. 48","id":"ais-2026-113"}],"consider":["Is the deficit disabling regardless of the NIHSS total? If not (e.g., isolated sensory symptoms), IVT is not recommended (COR 3: No Benefit); use antithrombotics instead: DAPT is COR 1 for noncardioembolic minor stroke (NIHSS ≤3) within 24 h, and NIHSS 4–5 options carry lower grades (see the minor-stroke card).","Do not wait for coagulation results unless an abnormality is suspected, or for MRI to count microbleeds (AHA 2026).","Minor stroke with a visible occlusion: TEMPO-2 found no benefit from tenecteplase and more deaths (5 vs 1%). A 2025 meta-analysis of 4 RCTs limited to minor stroke (NIHSS ≤5, mostly non-disabling; published after the AHA 2026 literature cutoff) also found no gain in mRS 0–1 with IVT (OR 0.85, 0.70–1.03) and higher odds of sICH and death; its authors call for trials in mildly disabling deficits.","Wake-up stroke, large core, basilar, MeVO and the late window have dedicated cards."],"caution":"Use the ischemic protocol for contraindications and dosing, including recent DOAC intake (IVT after DOAC intake within 48 h: observational cohorts only); this overview is not an eligibility checklist.","sources":[{"title":"AHA/ASA 2026 acute ischemic stroke guideline — official summary","url":"https://professional.heart.org/en/science-news/2026-guideline-for-the-early-management-of-patients-with-acute-ischemic-stroke/top-things-to-know","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"PRISMS: alteplase vs aspirin for minor non-disabling stroke","url":"https://pubmed.ncbi.nlm.nih.gov/29998337/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"IVT after recent DOAC intake (cohort)","url":"https://pubmed.ncbi.nlm.nih.gov/36807495/","year":2023,"type":"Observational study","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed (retrospective, off-label use; no eligibility inferred)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"SELECT2 — Trial of Endovascular Thrombectomy for Large Ischemic Strokes.","url":"https://pubmed.ncbi.nlm.nih.gov/36762865/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ANGEL-ASPECT — Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct.","url":"https://pubmed.ncbi.nlm.nih.gov/36762852/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"RESCUE-Japan LIMIT — Endovascular Therapy for Acute Stroke with a Large Ischemic Region.","url":"https://pubmed.ncbi.nlm.nih.gov/35138767/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"TENSION — Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37837989/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"LASTE — Trial of Thrombectomy for Stroke with a Large Infarct of Unrestricted Size.","url":"https://pubmed.ncbi.nlm.nih.gov/38718358/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ATLAS — Endovascular thrombectomy for patients with large-core ischaemic stroke presenting up to 24 h after onset (ATLAS): a systematic review and individual patient data meta-analysis with central imaging adjudication.","url":"https://pubmed.ncbi.nlm.nih.gov/42107392/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"DIRECT ANGIO — Safety and efficacy of direct versus conventional transfer to angiography suite in patients with severe acute stroke treated with thrombectomy (DIRECT ANGIO) in France: a multicentre, open-label, blinded-endpoint, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41864232/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"TEMPO-2 — Tenecteplase versus standard of care for minor ischaemic stroke with proven occlusion (TEMPO-2): a randomised, open label, phase 3 superiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38768626/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ARAMIS — Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke: The ARAMIS Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37367978/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"MR CLEAN — A randomized trial of intraarterial treatment for acute ischemic stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25517348/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ESCAPE — Randomized assessment of rapid endovascular treatment of ischemic stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25671798/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"EXTEND-IA — Endovascular therapy for ischemic stroke with perfusion-imaging selection.","url":"https://pubmed.ncbi.nlm.nih.gov/25671797/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SWIFT PRIME — Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25882376/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"REVASCAT — Thrombectomy within 8 hours after symptom onset in ischemic stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25882510/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"HERMES — Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.","url":"https://pubmed.ncbi.nlm.nih.gov/26898852/","year":2016,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"TESLA — Thrombectomy for Stroke With Large Infarct on Noncontrast CT: The TESLA Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39374319/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"TENSION antithrombotic analysis — Large Core Stroke Thrombectomy Is Safe and Effective Regardless of Prior Antithrombotic or Thrombolytic Treatment: A Secondary Analysis of the Randomized TENSION Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42261979/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. Secondary analysis; prior antithrombotic treatment was not the randomized intervention."},{"title":"LASTE ASPECTS 0-2 — Endovascular Thrombectomy in Patients With Largest Baseline Infarcts (ASPECTS 0-2): An Ancillary Analysis of the LASTE Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41979451/","year":2026,"type":"Report","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. Ancillary analysis of the randomized trial population."},{"title":"ANGEL-ASPECT HMCAS analysis — Effects of Computed Tomography Hyperdense Middle Cerebral Artery Sign on the Efficacy of Endovascular Therapy in Acute Ischemic Stroke With Large Infarcts: A Subgroup Analysis of the ANGEL-ASPECT Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41914357/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. Subgroup analysis; the imaging sign was not a randomized exposure."},{"title":"EVA-TRISP prior-APT analysis — Previous Antiplatelet Therapy and Outcomes of Acute Ischemic Stroke With Large Vessel Occlusion Treated With Direct Endovascular Therapy.","url":"https://pubmed.ncbi.nlm.nih.gov/41671526/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Minor-stroke IVT meta-analysis — Meta-Analysis of Randomized Controlled Trials on IV Thrombolysis in Patients With Minor Acute Ischemic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/40674672/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."}],"related":[{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"},{"label":"Current NIHSS","href":"#/encounter/nihss"},{"label":"Thrombectomy selection","href":"#/evidence/evt-selection"},{"label":"Wake-up and late-window IVT","href":"#/evidence/extended-window-ivt"},{"label":"Minor stroke DAPT","href":"#/evidence/minor-stroke-antiplatelets"}]},{"id":"code-stroke-activation","title":"Code stroke activation and prehospital LVO scales","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["code stroke","stroke alert","RACE","LVO scale","prehospital","EMS","mobile stroke unit","RACECAT","triage","transfer","door to needle"],"summary":"Activate the stroke team for any acute focal deficit — EVT can be offered up to 24 h from last known well. Check glucose, and do not wait for creatinine before CTA/CTP. EMS should use a validated scale, pre-notify, and go to the closest stroke-capable hospital (AHA 2026, COR 1). RACE (face 0–2, arm 0–2, leg 0–2, gaze 0–1, aphasia or agnosia 0–2) ≥5 detected LVO with 85% sensitivity and 68% specificity in its 2013 validation, but 75% and 76% pooled across EMS studies (2026 meta-analysis). In nonurban Catalonia, bypassing the local stroke center for a thrombectomy center did not improve outcome (RACECAT, cOR 1.03): fewer received IVT (47.5 vs 60.4%) and more had EVT (48.8 vs 39.4%).","recommendations":[{"text":"For patients with suspected stroke transported by ambulance, use of a brief validated stroke assessment tool by prefacility personnel is recommended to improve early stroke identification, including detection of large vessel occlusion.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-9 · p. 12","id":"ais-2026-9"},{"text":"For patients with suspected acute stroke, EMS transport is recommended to the closest appropriate stroke-capable facility (ASRH, PSC, TSC, or CSC) to minimize time to treatment, rather than to a non-stroke-capable facility.","cor":"1","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-15 · p. 14","id":"ais-2026-15"}],"consider":["Aim to image as fast as possible (for example within 25 minutes).","Children: suspect stroke with any sudden focal deficit, including a first seizure.","Where available, mobile stroke units are recommended over conventional EMS for thrombolytic-eligible patients: faster treatment and better outcome (COR 1, LOE A). On one Melbourne MSU (MSU-TELEMED, n=275, randomized by day; published after the AHA 2026 literature cutoff, not graded), a telemedicine neurologist versus an onboard neurologist had similar safety events (13 vs 12%) and a longer scene-to-decision time (median 19 vs 13 min; adjusted difference 4 min); the prespecified composite of safety, decision time and neurologist time favored telemedicine (win odds 3.5).","A seizure, hypoglycemia or apparent mimic can coexist with stroke; keep the stroke pathway open until a clinician has reassessed."],"caution":"Prehospital scales triage; they neither exclude LVO nor decide treatment.","sources":[{"title":"RACE scale: design and prospective validation to predict large arterial occlusion","url":"https://pubmed.ncbi.nlm.nih.gov/24281224/","year":2013,"type":"Observational study","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"RACECAT: direct transport to a thrombectomy center vs local stroke center","url":"https://pubmed.ncbi.nlm.nih.gov/35510397/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"Prehospital LVO scales applied by EMS: systematic review and meta-analysis","url":"https://pubmed.ncbi.nlm.nih.gov/42333681/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed (43 studies, October 2016–July 2024; RACE ≥5 pooled)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"MSU-TELEMED — A Randomized Trial of Telemedicine Models of Care on a Mobile Stroke Unit.","url":"https://pubmed.ncbi.nlm.nih.gov/41429047/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Single Melbourne MSU per the ClinicalTrials.gov registry record NCT05991310."}],"related":[{"label":"Current NIHSS","href":"#/encounter/nihss"},{"label":"Stroke mimics","href":"#/evidence/stroke-mimics-ivt"},{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"}]},{"id":"stroke-mimics-ivt","title":"Suspected stroke mimics and thrombolysis","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["mimic","FABS","seizure","Todd paralysis","migraine","functional","hypoglycemia","conversion"],"summary":"Do not delay IVT for a disabling, otherwise eligible deficit to exclude every mimic: in 9 series (392 mimics among 8,942 IVT-treated patients), sICH was 0.5% and orolingual edema 0.3% in mimics, a lower sICH risk than in true stroke (RR 0.33). Check glucose first; if a disabling deficit persists after correcting hypo- or hyperglycemia, IVT is recommended (AHA 2026, COR 1). FABS ≥3 (no facial droop, no AF history, age <50, SBP <150, seizure history, isolated sensory symptoms) identified mimics with 90% sensitivity and 91% specificity after a negative CT.","recommendations":[{"text":"In suspected ischemic stroke patients with severe hypoglycemia or hyperglycemia, if disabling stroke symptoms persist despite correction to normoglycemia, IVT administration is recommended to improve functional outcomes.","cor":"1","loe":"C-LD","source":"AHA/ASA AIS 2026 · ais-2026-89 · p. 38","id":"ais-2026-89"}],"consider":["Look for seizure onset, prior identical episodes, migraine aura, functional signs and toxic-metabolic causes.","If the diagnosis stays uncertain and the deficit is disabling, the low harm in mimics favors treatment within standard eligibility.","Obtain MRI DWI afterwards and record whether stroke was confirmed."],"caution":"Mimic data are observational and mostly alteplase-era; they do not override contraindications or a structural lesion on imaging.","sources":[{"title":"Safety of IVT in stroke mimics: prospective study and meta-analysis","url":"https://pubmed.ncbi.nlm.nih.gov/25791717/","year":2015,"type":"Meta-analysis","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"FABS: screening tool for stroke mimics in the emergency department","url":"https://pubmed.ncbi.nlm.nih.gov/27491733/","year":2016,"type":"Observational study","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."}],"related":[{"label":"Functional seizures","href":"#/evidence/functional-seizures"},{"label":"Stroke chameleons","href":"#/evidence/stroke-chameleons"},{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"}]},{"id":"stroke-chameleons","title":"Stroke chameleons: commonly missed presentations","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["chameleon","missed stroke","misdiagnosis","cerebellar","decreased consciousness","coma","dizziness"],"summary":"In one university emergency department (Lausanne), 47 of 2,200 ischemic strokes (2.1%) were missed, more often in younger patients and in cerebellar, very mild or very severe strokes. Missed patients also had fewer vascular risk factors and less eye deviation. They were labeled as another neurological illness (43%), a non-neurological illness (17%), unexplained decreased consciousness (21%) or a coexisting disease (19%), and had worse 12-month outcomes and higher mortality.","consider":["Acute dizziness or imbalance: examine gait and eye movements; cerebellar strokes are over-represented among misses.","Unexplained decreased consciousness was a common label — image the brain and vessels, including the posterior circulation.","A coexisting illness masked about one in five misses: a persistent deficit still needs a stroke review."],"caution":"These are single-center retrospective data; the absence of these features does not exclude stroke.","sources":[{"title":"Acute stroke chameleons in a university hospital: risk factors, circumstances and outcomes","url":"https://pubmed.ncbi.nlm.nih.gov/26180146/","year":2015,"type":"Observational study","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"related":[{"label":"Acute dizziness","href":"#/evidence/dizziness"},{"label":"Code stroke activation","href":"#/evidence/code-stroke-activation"},{"label":"Stroke mimics","href":"#/evidence/stroke-mimics-ivt"}]},{"id":"post-ivt-complications","title":"Post-thrombolysis hemorrhage and angioedema","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["sICH","hemorrhagic transformation","post-lytic","cryoprecipitate","fibrinogen","angioedema","orolingual"],"summary":"Neurological worsening during or after IVT: stop any running thrombolytic and get an emergent CT. If hemorrhage is suspected or seen, follow the post-lytic ICH protocol: send urgent labs including fibrinogen, and correct the fibrinolytic coagulopathy early — the mainstay of treatment, though based on expert opinion (AHA 2017). Angioedema occurred in about 1% (6 patients per arm) with tenecteplase or alteplase in ATTEST-2; assess the airway first. Teams must be ready to treat bleeding and angioedema (AHA 2026, COR 1).","recommendations":[{"text":"Healthcare professionals are recommended to be prepared to treat potential emergent adverse effects of IVT, including bleeding complications and angioedema (which may cause partial airway obstruction), to reduce poor clinical outcomes.","cor":"1","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-86 · p. 38","id":"ais-2026-86"}],"consider":["Take cryoprecipitate, antifibrinolytic and angioedema drug doses from the protected protocol; this card adds no doses.","Angioedema: protect the airway early, hold ACE inhibitors and follow the angioedema protocol.","Involve neurosurgery and hematology early; manage BP, glucose and temperature as for ICH."],"caution":"No randomized evidence supports a specific sICH reversal regimen.","sources":[{"title":"AHA/ASA statement: treatment and outcome of hemorrhagic transformation after IV alteplase","url":"https://pubmed.ncbi.nlm.nih.gov/29097489/","year":2017,"type":"Scientific statement","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed; dosing tables not reproduced."},{"title":"ATTEST-2: tenecteplase vs alteplase within 4.5 h","url":"https://pubmed.ncbi.nlm.nih.gov/39424558/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."}],"related":[{"label":"Post-lytic ICH protocol","href":"#/protocols/ischemic/post-lytic"},{"label":"Angioedema protocol","href":"#/protocols/ischemic/angioedema"},{"label":"Reversal","href":"#/evidence/antithrombotic-reversal"}]},{"id":"ct-perfusion","title":"CT perfusion and collateral imaging for late-window selection","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["CT perfusion","CTP","Tmax","rCBF","core","penumbra","mismatch","RAPID","collaterals","MR CLEAN-LATE","DAWN","DEFUSE 3","PRACTISE"],"summary":"Perfusion maps estimate hypoperfused tissue (Tmax >6 s) and core (markedly reduced relative CBF; below about 31% of the contralateral side best matched DWI in the derivation study), but within 4.5 h IVT must not wait for them (AHA 2026, COR 1). DEFUSE 3 target mismatch at 6–16 h: core <70 mL, hypoperfused-to-core ratio ≥1.8 and mismatch volume ≥15 mL. DAWN used clinical–core mismatch instead: core <21 mL at age ≥80 with NIHSS ≥10; <31 mL under 80 with NIHSS ≥10; <51 mL under 80 with NIHSS ≥20. Collateral flow on CTA alone selected patients who still benefited from EVT at 6–24 h in MR CLEAN-LATE (cOR 1.67; sICH 7 vs 2%).","recommendations":[{"text":"In adult AIS patients eligible for IVT within 4.5 hours of symptom onset, treatment is recommended to be initiated as quickly as possible while ensuring safe administration, avoiding potential delays from additional multimodal neuroimaging (CTA/MRA, CT/MR perfusion).","cor":"1","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-85 · p. 38","id":"ais-2026-85"},{"text":"In patients with suspected AIS who awaken with symptoms or have unknown time of onset 4.5 to 24 hours from last known well, CTP or MR DWI-PWI selection with automated postprocessing software can be useful to determine eligibility for extended-window IVT.","cor":"2a","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-53 · p. 27","id":"ais-2026-53"}],"consider":["Check for artifact: a poor contrast bolus or leukoaraiosis can make non-infarcted white matter look like core.","EVT at 6–24 h can be selected on NCCT ASPECTS (AHA 2026, COR 1); perfusion is adjunctive when immediately available (2a).","AHA 2026 grades perfusion-selected IVT for EVT-ineligible patients at 4.5–9 h from LKW or within 9 h of the sleep midpoint (2a, ais-2026-101); up to 24 h from onset or LKW, wake-up included, only LVO with salvageable penumbra that cannot receive EVT is graded (2b, ais-2026-102; TRACE-III). The 2a for CTP or DWI-PWI after wake-up or unknown onset (ais-2026-53) grades imaging selection, not IVT itself. Large-core trials also accepted CTP cores (e.g., SELECT2 ≥50 mL).","Within 4.5 h, adding CTA and CTP to non-contrast CT (PRACTISE: 11 UK sites, 2015–2018, stopped at 271 of 400 planned; published after the AHA 2026 literature cutoff) lowered thrombolysis use (49.1 vs 67.6% of patients without a CT contraindication). Among treated patients, decision and needle times did not differ (decisions not to treat took longer); 90-day outcomes did not differ significantly, but the trial was not powered for them, and whether untreated patients were mimics or missed strokes is uncertain."],"caution":"Software thresholds estimate tissue fate; they are not exact infarct volumes or stand-alone exclusions.","sources":[{"title":"DEFUSE 3: perfusion-selected thrombectomy at 6–16 h (methods: Tmax >6 s, mismatch criteria)","url":"https://pubmed.ncbi.nlm.nih.gov/29364767/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Full text (PMC) read for imaging definitions."},{"title":"Cerebral blood flow is the optimal CT perfusion parameter for infarct core","url":"https://pubmed.ncbi.nlm.nih.gov/21980202/","year":2011,"type":"Observational study","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"MR CLEAN-LATE: collateral-selected EVT at 6–24 h","url":"https://pubmed.ncbi.nlm.nih.gov/37003289/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"ESO annual stroke evidence update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41706824/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PMC full text (PMC12915583) read 2026-10-31. ESO Guideline Board evidence review; its practice implications are the authors' interpretation, not guideline recommendations."},{"title":"PRACTISE — Randomised, controlled Trial of CT perfusion and angiography compared to CT alone in thrombolysis-eligible acute ischaemic stroke patients: The penumbra and recanalisation acute computed tomography in ischaemic stroke evaluation (PRACTISE) trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41614492/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PMC full text (PMC12866261) read 2026-10-31; bibliographic record checked; first published online 2025-09-19 (PMID 40970508)."}],"related":[{"label":"DAWN screen","href":"#/encounter/dawn"},{"label":"DEFUSE 3 screen","href":"#/encounter/defuse3"},{"label":"Thrombectomy selection","href":"#/evidence/evt-selection"},{"label":"Large core","href":"#/evidence/large-core-evt"}]},{"id":"tia-evaluation","title":"TIA: evaluation and disposition","category":"Acute ischemic stroke","settings":["on-call","hospital","clinic"],"keywords":["transient ischemic attack","ABCD2","transient symptoms","DWI","vascular imaging","rapid follow-up"],"summary":"Treat TIA as a stroke warning: MRI with DWI ideally within 24 h (about 40% show infarction, which makes it a stroke), head-and-neck vessel imaging in the ED regardless of ABCD2, and ECG, telemetry and troponin for all. Admit presumed symptomatic >50% extracranial or intracranial stenosis. Noncardioembolic high-risk TIA (ABCD2 ≥4) or minor stroke (NIHSS ≤3) within 24 h, without IVT: aspirin plus clopidogrel with a loading dose for 21 days, then one agent (AHA 2026, COR 1). Discharge only with the workup arranged and TIA-clinic review, preferably within 48 h.","recommendations":[{"text":"Multimodal brain MRI is the preferred method to evaluate for acute ischemic infarct and ideally should be obtained within 24 hours of symptom onset. In cases where MRI with DWI can be obtained without delay, NCCT can be safely avoided in a stable patient with completely resolved symptoms.","cor":"Statement","loe":"Ungraded","source":"AHA TIA Statement 2023 · tia-ed-2023-12","id":"tia-ed-2023-12"},{"text":"Vessel imaging in the emergency department is warranted regardless of ABCD2 score or likelihood of admission.","cor":"Statement","loe":"Ungraded","source":"AHA TIA Statement 2023 · tia-ed-2023-44","id":"tia-ed-2023-44"},{"text":"Presumed symptomatic (>50%) extracranial or intracranial stenosis warrants hospital admission.","cor":"Statement","loe":"Ungraded","source":"AHA TIA Statement 2023 · tia-ed-2023-50","id":"tia-ed-2023-50"}],"consider":["Does the story fit focal ischemia (abrupt, maximal at onset, usually <60 min) or a mimic (marching symptoms, positive visual phenomena, migraine, seizure)?","ABCD2 omits posterior-circulation signs and stenosis; dual or crescendo TIA is high risk and may warrant admission whatever the score.","Suspected cardioembolism: arrange prolonged rhythm monitoring (30 days) within 6 months."],"caution":"A normal CT does not exclude infarction; persisting or recurrent deficits need acute stroke reassessment.","sources":[{"title":"AHA 2023 TIA diagnosis, workup and risk reduction statement — official summary","url":"https://professional.heart.org/en/science-news/diagnosis-workup-risk-reduction-of-transient-ischemic-attack-in-the-emergency-department-setting/top-things-to-know","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack","url":"https://pubmed.ncbi.nlm.nih.gov/34414299/","year":2021,"type":"Guideline","checkedAt":"2026-10-17","access":"PubMed abstract verified; full recommendations not reviewed. Interpret with newer evidence."},{"title":"Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/36655570/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Key-point statements (ungraded) from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards."}],"related":[{"label":"DAPT calculator","href":"#/encounter/dapt"},{"label":"ABCD2","href":"#/tools/abcd2"},{"label":"Carotid revascularization timing","href":"#/evidence/carotid"},{"label":"Minor stroke DAPT","href":"#/evidence/minor-stroke-antiplatelets"},{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"}]},{"id":"ich-management","title":"Spontaneous ICH: first-hour targets","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital"],"keywords":["intracerebral hemorrhage","hematoma expansion","anticoagulation reversal","blood pressure","neurocritical care","DNAR"],"summary":"Run the care bundle in the first hours (INTERACT3: better 6-month mRS, cOR 0.86): SBP <140 started early and reached within 1 h (stop lowering at 130); glucose 6.1–7.8 mmol/L (≈110–140 mg/dL; 7.8–10.0 mmol/L ≈140–180 mg/dL with diabetes); temperature ≤37.5 °C; INR <1.5 after warfarin. Do not acutely lower SBP below 130 in mild-to-moderate ICH presenting with SBP >150 (AHA 2022, harm; ATACH-2 at 110–139 gave no benefit and more renal adverse events, 9.0 vs 4.0%). Reverse anticoagulation immediately (see the reversal card). Severity scores frame discussion but must not alone limit care; defer new DNAR orders until at least the second full day.","recommendations":[{"text":"Initiating acute BP treatment within 2 hours of ICH onset and reaching the target within 1 hour can be beneficial to reduce hemorrhage expansion risk and improve functional outcome.","cor":"2a","loe":"C-LD","source":"AHA/ASA ICH 2022 · ich-2022-22 · p. 16","id":"ich-2022-22"},{"text":"For patients with mild to moderate spontaneous ICH presenting with SBP 150-220 mm Hg, acutely lowering SBP to a target of 140 mm Hg (maintaining 130-150 mm Hg range) is safe and may be reasonable for improving functional outcomes.","cor":"2b","loe":"B-R","source":"AHA/ASA ICH 2022 · ich-2022-23 · p. 17","id":"ich-2022-23"},{"text":"Acute lowering of SBP to <130 mm Hg is potentially harmful in patients with mild to moderate spontaneous ICH presenting with SBP >150 mm Hg.","cor":"3: Harm","loe":"B-R","source":"AHA/ASA ICH 2022 · ich-2022-25 · p. 17","id":"ich-2022-25"},{"text":"For patients with spontaneous ICH who lack preexisting documented wishes to limit life-sustaining therapy, aggressive care with postponement of new DNAR orders or withdrawal of support until at least the second full day of inpatient stay is reasonable to decrease mortality and improve functional outcome.","cor":"2a","loe":"B-NR","source":"AHA/ASA ICH 2022 · ich-2022-95 · p. 45","id":"ich-2022-95"}],"consider":["Repeat CT within 24 h, sooner if the GCS falls, for expansion, hydrocephalus or swelling; early CTA can flag expansion risk. Vascular imaging (CTA ± venography) for lobar ICH <70 y, deep/posterior fossa ICH <45 y, or 45–70 y without hypertension (AHA 2022, COR 1).","Cerebellar ICH, hydrocephalus or a large hematoma: call neurosurgery now (see the ICH surgery card).","No prophylactic antiseizure drugs; continuous EEG for unexplained or fluctuating mental status.","Post-guideline pooled analyses (hypothesis-generating; AHA 2022 grades unchanged): in INTERACT1–4 (11,312 patients; INTERACT3 tested a care bundle), intensive SBP lowering (<140 within 1 h) reduced mRS 3–6 (OR 0.85); in its CT substudy (2,921) the effect declined with time from onset and crossed no effect at 3 h. Whether the effect differs by hematoma location is unsettled: an individual-patient pool of INTERACT1–4 and ATACH-2 (11,288; 81.5% deep, 10.1% lobar) found effect modification by location (interaction P=0.033), with clear benefit only in deep ICH (aOR 0.81, 0.74–0.89), whereas a study-level meta-analysis of ATACH-2, INTERACT2 and INTERACT3 (7,917 deep, 1,105 lobar) found no significant benefit in deep (OR 0.82, 0.57–1.18; I² 60%) or lobar ICH (OR 0.97, 0.76–1.24). Neither tested location-specific BP targets, and the AHA 2022 recommendations above do not differ by location."],"caution":"Intensive targets are less certain with SBP >220 mm Hg, hematomas >30 mL or planned evacuation; avoid SBP drops >70 mm Hg or below 110 (ESO 2025 consensus).","sources":[{"title":"AHA/ASA 2022 spontaneous ICH guideline — official summary","url":"https://professional.heart.org/en/science-news/2022-guideline-for-the-management-of-patients-with-spontaneous-intracerebral-hemorrhage/top-things-to-know","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"2025 update to European Stroke Organisation (ESO) guideline on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/42095756/","year":2026,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (against intensive SBP lowering <140 in the first 24 h after successful thrombectomy, high certainty); other recommendations from the archived full-text transcription (reviewed 2026-09-30). Published in 2026 under a 2025-update title."},{"title":"European Stroke Organisation (ESO) and European Association of Neurosurgical Societies (EANS) guideline on stroke due to spontaneous intracerebral haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/40401775/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"NLM title, PMID, DOI and abstract checked; abstract and plain-language summary re-read 2026-10-31 from the PMC record (PMC12098356), whose body is empty, so recommendation tables and individual strengths were not read; the ICH surgery line uses the abstract's list of interventions with weaker evidence. The BP consensus on the ICH card (>70 mm Hg, 110, >220, >30 mL, evacuation) is from the archived transcription. Interpret with newer evidence."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"Treatment of Antithrombotic-Associated Intracranial Hemorrhage in Adults: A Focused Guideline Update from the Neurocritical Care Society and the Society of Critical Care Medicine","url":"https://pubmed.ncbi.nlm.nih.gov/42786382/","year":2026,"type":"Guideline","checkedAt":"2026-10-17","access":"Recommendations with GRADE strength and certainty from the archived full publisher text (reviewed 2026-09-30); quoted in the topic cards. Abstract rechecked 2026-10-17."},{"title":"INTERACT3 — The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37245517/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ANNEXA-I — Andexanet for Factor Xa Inhibitor-Associated Acute Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/38749032/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"INTERACT2 — Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/23713578/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ATACH-2 — Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/27276234/","year":2016,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"TRIDENT — Three Low-Dose Antihypertensive Agents in a Single Pill after Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/42019018/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"Hyponatremia & ICH — Severity-Stratified Hyponatremia Is Associated with Increased Mortality and Complications in Nontraumatic Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/42194925/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ANNEXA-4 — Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors.","url":"https://pubmed.ncbi.nlm.nih.gov/30730782/","year":2019,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"INTERACT1-4 pooled — Effects of blood pressure lowering in relation to time in acute intracerebral haemorrhage: a pooled analysis of the four INTERACT trials.","url":"https://pubmed.ncbi.nlm.nih.gov/40541207/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; individual-patient pooled analysis of four randomized trials, not a new trial. INTERACT3 (7,036 of 11,312 patients) tested a care bundle, and the time-from-onset effect comes from the CT substudy (2,921 patients)."},{"title":"Deep vs lobar ICH BP meta-analysis — Functional Outcomes After Intensive Blood Pressure Reduction in Deep and Lobar Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/41962119/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked. Study-level stepwise meta-analysis (ATACH-2 individual data; INTERACT2 and INTERACT3 published pooled results); poor outcome was mRS 4–6 in ATACH-2 and INTERACT3 and 3–6 in INTERACT2, and INTERACT3 tested a care bundle."},{"title":"BP lowering by hematoma location (INTERACT1–4 and ATACH-2 IPD) — Effects of Blood Pressure Lowering by Hematoma Location in Acute Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/42848972/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; individual-patient pooled analysis of five randomized trials, not a new trial; full text not reviewed."},{"title":"Andexanet vs 4F-PCC meta-analysis — Efficacy and Safety of Andexanet Alfa Versus Four Factor Prothrombin Complex Concentrate for Emergent Reversal of Factor Xa Inhibitor Associated Intracranial Hemorrhage: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/39379749/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"RECAP-ICH — Intensive blood pressure lowering after spontaneous intracerebral haemorrhage for secondary stroke prevention (RECAP-ICH): a systematic review and individual participant data meta-analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42586098/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (2,944 participants; recurrent stroke HR 0.62, recurrent ICH HR 0.39); bibliographic record checked; full text not read. Individual-participant meta-analysis of 4 trials of BP-lowering treatment vs placebo or standard care, not a test of the <130/80 target. Included trials are not named in the abstract; overlap with TRIDENT not confirmed."}],"related":[{"label":"ICH protocol","href":"#/protocols/ich"},{"label":"Reversal","href":"#/evidence/antithrombotic-reversal"},{"label":"ICH volume","href":"#/encounter/ich-volume"},{"label":"GCS","href":"#/encounter/gcs"}]},{"id":"ich-surgery","title":"ICH: when to revisit surgical options","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital"],"keywords":["minimally invasive surgery","MIS","ENRICH","MIND","lobar","deep hemorrhage","cerebellar","hydrocephalus"],"summary":"Cerebellar ICH with deterioration, brainstem compression, hydrocephalus or volume ≥15 mL: immediate evacuation with or without EVD (AHA 2022, COR 1). Supratentorial ICH >20–30 mL with GCS 5–12: minimally invasive evacuation can reduce mortality (2a). ENRICH (lobar or anterior basal ganglia, 30–80 mL, within 24 h) improved 180-day utility-weighted mRS, mainly in lobar ICH; MIND (mostly deep, within 72 h) and SWITCH (decompression for severe deep ICH) were not conclusive. Large IVH with reduced consciousness: EVD (COR 1).","recommendations":[{"text":"For patients with cerebellar ICH who are deteriorating neurologically, have brainstem compression and/or hydrocephalus from ventricular obstruction, or have cerebellar ICH volume ≥15 mL, immediate surgical removal of the hemorrhage with or without EVD is recommended in preference to medical management alone to reduce mortality.","cor":"1","loe":"B-NR","source":"AHA/ASA ICH 2022 · ich-2022-89 · p. 42","id":"ich-2022-89"},{"text":"Minimally invasive hematoma evacuation (endoscopic or stereotactic aspiration, with or without thrombolytic use) can be useful to reduce mortality compared with medical management alone for patients with supratentorial ICH >20-30 mL and GCS 5-12.","cor":"2a","loe":"B-R","source":"AHA/ASA ICH 2022 · ich-2022-79 · p. 37","id":"ich-2022-79"},{"text":"EVD is recommended over medical management alone for patients with spontaneous ICH, large IVH, and impaired level of consciousness to reduce mortality.","cor":"1","loe":"B-NR","source":"AHA/ASA ICH 2022 · ich-2022-82 · p. 39","id":"ich-2022-82"}],"consider":["Location, volume, GCS, premorbid function and hours from onset decide which trial applies. Agree on realistic goals with the family before surgery.","Craniotomy is a lifesaving option for deteriorating supratentorial ICH (2b); decompressive craniectomy may be considered to reduce mortality in supratentorial ICH with coma, a large hematoma with significant midline shift, or refractory ICP (2b).","Cochrane 2025 (24 RCTs): minimally invasive evacuation may improve good function (RR 1.36, low certainty) and probably lowers mortality (RR 0.71, moderate certainty); most trials had high risk of bias.","ESO/EANS 2025 (GRADE-based) places craniotomy or minimally invasive surgery for supratentorial ICH, decompressive surgery for deep supratentorial ICH and evacuation of cerebellar ICH >15 mL among treatments with weaker supporting evidence; it made strong recommendations for only a few interventions. Individual recommendation strengths are in the full guideline."],"caution":"Lower mortality is not the same as better function; do not extend lobar-ICH results to deep or infratentorial bleeds.","sources":[{"title":"AHA 2026 minimally invasive ICH evacuation advisory — official summary","url":"https://professional.heart.org/en/science-news/evidence-update-for-minimally-invasive-surgical-evacuation-of-supratentorial-spontaneous-intracerebr/top-things-to-know","year":2026,"type":"Science advisory","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"AHA/ASA 2022 spontaneous ICH guideline — official summary","url":"https://professional.heart.org/en/science-news/2022-guideline-for-the-management-of-patients-with-spontaneous-intracerebral-hemorrhage/top-things-to-know","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"Surgery for spontaneous supratentorial ICH (Cochrane review)","url":"https://pubmed.ncbi.nlm.nih.gov/40673401/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-17","access":"Primary abstract checked via PubMed."},{"title":"Evidence Update for Minimally Invasive Surgical Evacuation of Supratentorial Spontaneous Intracerebral Hemorrhage: A Science Advisory From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/42634945/","year":2026,"type":"Science advisory","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"European Stroke Organisation (ESO) and European Association of Neurosurgical Societies (EANS) guideline on stroke due to spontaneous intracerebral haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/40401775/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"NLM title, PMID, DOI and abstract checked; abstract and plain-language summary re-read 2026-10-31 from the PMC record (PMC12098356), whose body is empty, so recommendation tables and individual strengths were not read; the ICH surgery line uses the abstract's list of interventions with weaker evidence. The BP consensus on the ICH card (>70 mm Hg, 110, >220, >30 mL, evacuation) is from the archived transcription. Interpret with newer evidence."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"ENRICH — Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/38598795/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"MISTIE III — Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/30739747/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"MIND — Minimally Invasive Surgery vs Medical Management Alone for Intracerebral Hemorrhage: The MIND Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40892424/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SWITCH — Decompressive craniectomy plus best medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracerebral haemorrhage: a randomised controlled clinical trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38761811/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 2 corrections or notices; check them before applying results."},{"title":"STICH — Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/15680453/","year":2005,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"STICH II — Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/23726393/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 2 corrections or notices; check them before applying results."}],"related":[{"label":"ICH protocol","href":"#/protocols/ich"},{"label":"ICH volume","href":"#/encounter/ich-volume"}]},{"id":"sah","title":"Aneurysmal SAH: coordinated specialist care","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital","clinic"],"keywords":["subarachnoid hemorrhage","aneurysm","thunderclap","DCI","vasospasm","nimodipine","hydrocephalus"],"summary":"Secure the aneurysm as early as feasible, preferably within 24 h (AHA 2023, COR 1; ESO 2026 consensus), at a high-volume center. Start enteral nimodipine early (COR 1). Until it is secured: frequent BP checks with short-acting agents, avoiding hypotension, hypertension and swings; ESO 2026 expert consensus suggests targeting about 160 if SBP stays >160–180 after analgesia and nimodipine. Good grade and equally suitable for both: coil rather than clip. No routine antifibrinolytics, statins, magnesium, endothelin-receptor antagonists or prophylactic hypervolemia. Urgent CSF diversion (EVD and/or lumbar drain) for acute symptomatic hydrocephalus (COR 1).","recommendations":[{"text":"Surgical or endovascular treatment of the ruptured aneurysm is recommended as early as feasible after presentation, preferably within 24 hours of onset, to improve outcome.","cor":"1","loe":"B-NR","source":"AHA/ASA aSAH 2023 · sah-2023-16 · p. 14","id":"sah-2023-16"},{"text":"Early initiation of enteral nimodipine is recommended in aSAH patients to prevent DCI and improve functional outcomes.","cor":"1","loe":"A","source":"AHA/ASA aSAH 2023 · sah-2023-54 · p. 26","id":"sah-2023-54"},{"text":"Frequent blood pressure monitoring and management with short-acting agents is recommended in aSAH patients with an unsecured aneurysm, targeting avoidance of severe hypotension, hypertension, and BP variability.","cor":"1","loe":"C-EO","source":"AHA/ASA aSAH 2023 · sah-2023-13 · p. 13","id":"sah-2023-13"},{"text":"For good-grade aSAH from anterior circulation aneurysms equally suitable for primary coiling and clipping, primary coiling is recommended over clipping to improve 1-year functional outcome.","cor":"1","loe":"A","source":"AHA/ASA aSAH 2023 · sah-2023-24 · p. 14","id":"sah-2023-24"}],"consider":["New decline: think rebleeding, hydrocephalus, DCI/vasospasm or seizures — urgent CT ± CTA/CTP.","Seizure prophylaxis: AHA 2023 allows it only with high-risk features (MCA aneurysm, high grade, ICH, hydrocephalus, cortical infarct; 2b) and lists phenytoin as harmful; NCS 2026 is conditional (ASM or no ASM; either agent and duration), its expert guidance favoring levetiracetam for ≤3 days unless seizures or EEG features suggest ongoing risk. Seizure at onset: AHA 2023 supports treatment for no more than 7 days (2a).","Keep euvolemia; liberal transfusion (Hb ≤10 g/dL) did not improve 12-month outcome (SAHaRA).","In a Stockholm register cohort of 544 aSAH survivors younger than 40 (index events 1967–2014; observational), de novo aneurysms reached a cumulative incidence of 30% at 40 years without a plateau; female sex, smoking and family history raised the risk, and stopping smoking was associated with lower risk. Of 158 de novo aneurysms, 23 ruptured, none under systematic surveillance."],"caution":"Prophylactic hemodynamic augmentation and induced hypervolemia are harmful.","sources":[{"title":"AHA/ASA 2023 aneurysmal SAH guideline — official summary","url":"https://professional.heart.org/en/science-news/2023-guideline-for-the-management-of-patients-with-aneurysmal-subarachnoid-hemorrhage/top-things-to-know","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"European Stroke Organisation (ESO), European Association of Neurosurgical Societies (EANS) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on aneurysmal subarachnoid haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/42095754/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendations from the archived full-text transcription (reviewed 2026-09-30); cited in topic summaries."},{"title":"Guidelines for Seizure Prophylaxis in Patients with Aneurysmal Subarachnoid Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society","url":"https://pubmed.ncbi.nlm.nih.gov/42552475/","year":2026,"type":"Guideline","checkedAt":"2026-10-17","access":"PMC full text (PMC13642444) read 2026-10-17; supplementary tables not reviewed."},{"title":"2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/37212182/","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 38011240 (Stroke 2023;54:e516) is indexed; its body was not re-read."},{"title":"ISAT (18-year) — The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial (ISAT).","url":"https://pubmed.ncbi.nlm.nih.gov/25465111/","year":2015,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results. Long-term follow-up of a randomized trial cohort."},{"title":"De novo aneurysms after aSAH in young survivors — Lifelong De Novo Aneurysm Risk After Aneurysmal Subarachnoid Hemorrhage in Young Survivors.","url":"https://pubmed.ncbi.nlm.nih.gov/42636016/","year":2026,"type":"Observational study","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Single-region (Stockholm) cohort with index events 1967–2014."}],"related":[{"label":"GCS","href":"#/encounter/gcs"},{"label":"Hunt and Hess","href":"#/tools/hunt-hess"},{"label":"WFNS","href":"#/tools/wfns"},{"label":"aSAH critical care","href":"#/evidence/sah-critical-care"}]},{"id":"cvt","title":"Cerebral venous thrombosis","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["CVST","venous sinus thrombosis","headache","pregnancy","postpartum","papilledema","venography"],"summary":"Anticoagulate on diagnosis, even with venous hemorrhage: parenteral heparin (LMWH favored; nonheparin agents if VITT is suspected), then oral anticoagulation for 3–12 months, or indefinitely with chronic major risk factors or recurrent VTE (AHA 2024); in pregnancy, LMWH only. DOACs are a reasonable alternative to warfarin after the lead-in: RE-SPECT CVT (dabigatran) had no recurrent VTE and major bleeding 1.7 vs 3.3%; ACTION-CVT (observational) found similar recurrence and less major hemorrhage (aHR 0.35). A 2026 meta-analysis (8 RCTs and 6 observational studies; 3,698 patients) found no significant difference between DOACs and VKAs in recurrent VTE (RR 0.92, 95% CI 0.55–1.53) or major bleeding (RR 0.74, 0.44–1.25). Endovascular therapy is rescue only (TO-ACT: no benefit); decompressive craniectomy is lifesaving with impending herniation.","recommendations":[{"text":"The mainstream initial treatment of cerebral venous thrombosis includes parenteral heparin followed by transition to oral vitamin K antagonists for 3 to 12 months, depending on the underlying cause, or indefinitely in the presence of chronic major risk factors or recurrent venous thromboembolism. [Editorial note: the statement's abbreviated key point refers broadly to thrombophilia; its treatment section specifies chronic major risk factors. An isolated thrombophilia result is not, by itself, a universal indication for indefinite treatment.]","cor":"Statement","loe":"Ungraded","source":"AHA CVT Statement 2024 · cvt-2024-5","id":"cvt-2024-5"},{"text":"The presence of venous hemorrhage does not constitute a contraindication for anticoagulation. Whether degree of venous recanalization should inform duration of anticoagulation remains an area of uncertainty.","cor":"Statement","loe":"Ungraded","source":"AHA CVT Statement 2024 · cvt-2024-25","id":"cvt-2024-25"},{"text":"Given the lack of controlled studies (and poorer outcomes in meta-analyses), endovascular therapies are reserved for patients with evidence of thrombus propagation, for individuals with neurological deterioration despite medical therapy, or for those with contraindications to anticoagulation.","cor":"Statement","loe":"Ungraded","source":"AHA CVT Statement 2024 · cvt-2024-8","id":"cvt-2024-8"}],"consider":["Confirm with MRI/MRV (CT/CTV is a reasonable alternative); add GRE/SWI or contrast MRV for cortical vein thrombosis.","Look for pregnancy/puerperium, estrogen, obesity, APS, myeloproliferative disease, malignancy and infection; headache with thrombocytopenia after an adenoviral vaccine suggests VITT — avoid heparin and involve hematology.","Watch vision, seizures and consciousness; escalate for deterioration or propagation despite anticoagulation."],"caution":"DOACs are contraindicated in pregnancy and breastfeeding and carry more thrombotic events in APS.","sources":[{"title":"AHA 2024 CVT diagnosis and management statement — official summary","url":"https://professional.heart.org/en/science-news/diagnosis-and-management-of-cerebral-venous-thrombosis/top-things-to-know","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"Diagnosis and Management of Cerebral Venous Thrombosis: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/38284265/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Key-point statements (ungraded) from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards."},{"title":"European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - Endorsed by the European Academy of Neurology","url":"https://pubmed.ncbi.nlm.nih.gov/31008314/","year":2017,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"TO-ACT — Effect of Endovascular Treatment With Medical Management vs Standard Care on Severe Cerebral Venous Thrombosis: The TO-ACT Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/32421159/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ACTION-CVT — Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT): A Multicenter International Study.","url":"https://pubmed.ncbi.nlm.nih.gov/35143325/","year":2022,"type":"Observational study","checkedAt":"2026-10-01","access":"PubMed bibliographic identity and primary-abstract study design checked: retrospective observational cohort, not random treatment allocation. Outcomes not reviewed here."},{"title":"CVT DOAC vs VKA meta-analysis — Comparison of DOAC Versus VKA for Cerebral Venous Thrombosis: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42910429/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. 8 RCTs and 6 observational studies; the RCT-only estimates were also imprecise (recurrent VTE RR 1.06, 0.35–3.24)."},{"title":"RE-SPECT CVT — Safety and Efficacy of Dabigatran Etexilate vs Dose-Adjusted Warfarin in Patients With Cerebral Venous Thrombosis.","url":"https://pubmed.ncbi.nlm.nih.gov/31479105/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed; bibliographic record checked."}],"related":[{"label":"Maternal stroke","href":"#/evidence/maternal-stroke"},{"label":"Antiphospholipid syndrome","href":"#/evidence/antiphospholipid-syndrome"},{"label":"Follow-up imaging","href":"#/evidence/imaging-follow-up"}]},{"id":"dizziness","title":"Acute dizziness: HINTS and when to image","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["vertigo","HINTS","HINTS plus","GRACE-3","posterior circulation","acute vestibular syndrome","skew deviation","head impulse","nystagmus","BPPV","Dix-Hallpike"],"summary":"Sort dizziness by timing and triggers (GRACE-3). In acute vestibular syndrome (continuous vertigo with nystagmus, nausea, head-motion intolerance, unsteady gait) and vascular risk, a trained examiner's HINTS beats early MRI: any central sign — normal head impulse, direction-changing nystagmus or skew deviation — was 100% sensitive and 96% specific for stroke; adding new hearing loss (HINTS plus) reached 99.2% sensitivity for central causes. Early DWI missed 12–14% of infarcts within 48 h. Central or equivocal findings: MRI/MRA. ABCD2 is not a dizziness screen (sensitivity 61%).","consider":["Head impulse: a corrective saccade suggests a peripheral lesion; a normal head impulse in continuous vertigo is a central sign.","Nystagmus: direction-changing nystagmus on eccentric gaze is central.","Test of skew (cross-cover): any vertical misalignment is central and points to the brainstem.","Hearing: new hearing loss is the \"plus\" that raises sensitivity for central causes; triggered positional episodes are not a HINTS situation."],"caution":"HINTS needs continuous vertigo with nystagmus and a trained examiner; routine CT is not the GRACE-3 way to exclude a central cause. Not every stroke causing dizziness shows nystagmus: in a prospective single-centre ED cohort of 75 patients with MRI-proven stroke causing vertigo, dizziness or imbalance, 59% had no spontaneous nystagmus but postural or gait imbalance (acute imbalance syndrome), a presentation HINTS was not designed for.","sources":[{"title":"SAEM GRACE-3 acute dizziness and vertigo — official recommendations","url":"https://www.saem.org/publications/grace/grace-3","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Official SAEM recommendations page."},{"title":"HINTS to diagnose stroke in the acute vestibular syndrome (Kattah 2009)","url":"https://pubmed.ncbi.nlm.nih.gov/19762709/","year":2009,"type":"Observational study","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"HINTS outperforms ABCD2 in acute continuous vertigo (HINTS plus)","url":"https://pubmed.ncbi.nlm.nih.gov/24127701/","year":2013,"type":"Observational study","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"GRACE-3 — Guidelines for reasonable and appropriate care in the emergency department 3: acute dizziness and vertigo in the emergency department.","url":"https://pubmed.ncbi.nlm.nih.gov/37166022/","year":2023,"type":"Guideline","checkedAt":"2026-10-03","access":"PubMed bibliographic record checked; recommendations summarized from the official SAEM page."},{"title":"Acute imbalance syndrome cohort — Acute Imbalance Syndrome vs Acute Vestibular Syndrome: Clinical and Topographical Differentiation.","url":"https://pubmed.ncbi.nlm.nih.gov/42848973/","year":2026,"type":"Observational study","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Prospective single-centre ED cohort."}],"related":[{"label":"Stroke chameleons","href":"#/evidence/stroke-chameleons"},{"label":"Basilar occlusion","href":"#/evidence/basilar-occlusion"},{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"}]},{"id":"inpatient-care","title":"Inpatient stroke: complication review","category":"Inpatient care and complications","settings":["hospital"],"keywords":["stroke unit","dysphagia","aspiration","fever","glucose","DVT","VTE","pressure injury","urinary retention","post-thrombectomy","HeadSOAR","ZODIAC","head position"],"summary":"Stroke-unit care with protocols: bedside swallow screen before any oral intake; treat fever to normothermia and look for its source; treat glucose <60 mg/dL and keep persistent hyperglycemia at 140–180 mg/dL (not 80–130); oxygen only for hypoxia, to keep SpO2 >94%; intermittent pneumatic compression for immobile patients and no elastic stockings; no routine bladder catheters or prophylactic antibiotics; no high-dose very early mobilization within 24 h (AHA 2026).","recommendations":[{"text":"In AIS patients, a bedside swallow screening prior to any oral intake is recommended to identify patients at increased aspiration risk.","cor":"1","loe":"C-EO","source":"AHA/ASA AIS 2026 · ais-2026-160 · p. 74","id":"ais-2026-160"},{"text":"In AIS patients, it is reasonable to treat persistent hyperglycemia to achieve blood glucose levels of 140-180 mg/dL with close monitoring to prevent worse functional outcomes.","cor":"2a","loe":"C-LD","source":"AHA/ASA AIS 2026 · ais-2026-82 · p. 37","id":"ais-2026-82"},{"text":"In inpatient AIS patients with hyperglycemia, IV insulin targeting blood glucose of 80-130 mg/dL is not recommended as it does not improve 3-month functional outcomes.","cor":"3: No Benefit","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-83 · p. 37","id":"ais-2026-83"},{"text":"In AIS patients with hyperthermia, targeting normothermia (including nurse-initiated fever management protocols) is recommended to improve functional outcomes and reduce mortality.","cor":"1","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-78 · p. 37","id":"ais-2026-78"},{"text":"In AIS patients with impaired mobility and no contraindications, intermittent pneumatic compression (IPC) in addition to routine care is recommended over routine care alone to reduce DVT risk.","cor":"1","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-169 · p. 76","id":"ais-2026-169"}],"consider":["After IVT: BP <180/105 for at least 24 h; antiplatelets in the first 24 h only when a strong indication outweighs the uncertain risk.","Screen nutrition within 48 h and depression with a structured tool; start enteral feeding within 7 days if the patient cannot swallow.","After EVT: neurological checks, access site, the BP plan and urgent imaging for any decline.","Awaiting thrombectomy for LVO: in ZODIAC (12 US hospitals; 92 of 182 planned, enrollment halted by the DSMB at the second interim analysis; published after the AHA 2026 literature cutoff), a 0° vs 30° head position reduced ≥2-point NIHSS worsening before EVT (1 vs 26 patients); 90-day deaths were 2 vs 10, but 90-day mRS did not differ significantly. AHA 2026's COR 3: No Benefit for routine 24-h flat positioning (ais-2026-66) addresses AIS patients overall, not LVO awaiting EVT. Head position after successful EVT (anterior LVO, eTICI ≥2b): in HeadSOAR (BMJ 2026; 67 centres in China; 1,368 patients), 72 h at 30–40° vs flat at 0–10° did not significantly improve 90-day mRS (adjusted generalized OR 1.12, 95% CI 0.97–1.29); 90-day mortality was 18.3 vs 20.3% (aRR 0.86, 0.69–1.07), and the authors could not exclude a modest benefit of elevation. ZODIAC's flat-positioning result before EVT should not be extended to the period after reperfusion, where flat positioning showed no advantage."],"caution":"Intensive targets backfire here: targeting SBP <140 for 72 h after successful anterior-LVO EVT is harmful (AHA 2026, COR 3: Harm); after successful LVO EVT, a 24-h <140 target also lowered functional independence (OPTIMAL-BP 39.4 vs 54.4%), and ESO 2025 recommends against intensive lowering below 140 in the first 24 h; IV insulin to 80–130 mg/dL adds hypoglycemia without benefit.","sources":[{"title":"AHA 2024 systemic complications of acute stroke statement — official summary","url":"https://professional.heart.org/en/science-news/addressing-systemic-complications-of-acute-stroke/top-things-to-know","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"AHA 2021 acute stroke nursing care statements — official summary","url":"https://professional.heart.org/en/science-news/2021-update-care-of-the-patient-with-acute-ischemic-stroke/top-things-to-know","year":2021,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"AHA/ASA 2026 acute ischemic stroke guideline — official summary","url":"https://professional.heart.org/en/science-news/2026-guideline-for-the-early-management-of-patients-with-acute-ischemic-stroke/top-things-to-know","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"OPTIMAL-BP randomized trial","url":"https://pubmed.ncbi.nlm.nih.gov/37668619/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22: LVO with mTICI ≥2b after EVT; SBP <140 vs 140–180 for 24 h; stopped early for safety."},{"title":"HeadSOAR — head positioning after endovascular thrombectomy (BMJ 2026)","url":"https://pubmed.ncbi.nlm.nih.gov/42624516/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; full text and registry NCT06115707 not reviewed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"2025 update to European Stroke Organisation (ESO) guideline on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/42095756/","year":2026,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (against intensive SBP lowering <140 in the first 24 h after successful thrombectomy, high certainty); other recommendations from the archived full-text transcription (reviewed 2026-09-30). Published in 2026 under a 2025-update title."},{"title":"SO2S — Effect of Routine Low-Dose Oxygen Supplementation on Death and Disability in Adults With Acute Stroke: The Stroke Oxygen Study Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/28973619/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"HeadPoST — Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/28636854/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SHINE — Intensive vs Standard Treatment of Hyperglycemia and Functional Outcome in Patients With Acute Ischemic Stroke: The SHINE Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/31334795/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"AVERT dose-response — Prespecified dose-response analysis for A Very Early Rehabilitation Trial (AVERT).","url":"https://pubmed.ncbi.nlm.nih.gov/26888985/","year":2016,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic identity and primary-abstract design checked: observational secondary dose-response analysis of AVERT, irrespective of randomized treatment assignment. This is not a randomized comparison of mobilization doses; Outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"OPTIMISTmain — Safety and efficacy of low-intensity versus standard monitoring following intravenous thrombolytic treatment in patients with acute ischaemic stroke (OPTIMISTmain): an international, pragmatic, stepped-wedge, cluster-randomised, controlled non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40412428/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked: clinically stable with NIHSS <10 within 2 h of IVT; mRS 2–6 31.7 vs 30.9% (RR 1.03, 95% CI 0.92–1.15; margin 1.15; p=0.057); authors report weak evidence of noninferiority."},{"title":"ZODIAC — Optimal Head-of-Bed Positioning Before Thrombectomy in Large Vessel Occlusion Stroke: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40465238/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PMC full text (PMC12138796) read 2026-10-31; bibliographic record checked."}],"related":[{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"},{"label":"ICH protocol","href":"#/protocols/ich"},{"label":"Follow-up imaging","href":"#/evidence/imaging-follow-up"},{"label":"Acute BP context","href":"#/evidence/acute-bp"}]},{"id":"imaging-follow-up","title":"Follow-up imaging by diagnosis","category":"Inpatient care and complications","settings":["on-call","hospital","clinic"],"keywords":["follow-up imaging","repeat CT","DSA","CTA","MRI","vasospasm","TCD","coil follow-up","MRV","recanalization"],"summary":"TIA, and by extension minor stroke: brain MRI with DWI, ideally within 24 h of onset, plus head-and-neck vessel imaging in the ED (AHA 2023 TIA statement, ungraded). ICH: repeat CT within 24 h (sooner with decline) for expansion; CTA ± venography for lobar ICH <70 y, deep or posterior fossa ICH <45 y, or 45–70 y without hypertension; DSA if CTA suggests a macrovascular cause or for primary IVH; MRI/MRA if CTA is negative; repeat DSA at 3–6 months may be reasonable after a negative first study. aSAH: CTA/CTP and TCD for vasospasm (AHA 2023, 2a; ESO 2026 makes no TCD recommendation); after adequately occluded coiling, image again at ≥12 months (ESO 2026 consensus). CVT: MRI/MRV (CT/CTV acceptable); whether recanalization should guide anticoagulation duration is uncertain.","consider":["Any neurological decline: urgent CT first (hemorrhage, swelling, hydrocephalus), then CTA if reocclusion or vasospasm is possible.","Ischemic stroke: noninvasive intracranial and vertebrobasilar imaging (CTA or MRA) identifies atherosclerosis, dissection and moyamoya (AHA 2021, 2a).","Established FMD: at least one brain-to-pelvis CTA or MRA (consensus)."],"caution":"Schedules are examples; image sooner whenever the examination changes.","sources":[{"title":"ESH/SVM 2019 first international consensus on fibromuscular dysplasia","url":"https://journals.sagepub.com/doi/pdf/10.1177/1358863X18821816","year":2019,"type":"Consensus statement","checkedAt":"2026-10-02","access":"Selected primary PDF passages read (brain-to-pelvis imaging)."},{"title":"Diagnosis and Management of Cerebral Venous Thrombosis: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/38284265/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Key-point statements (ungraded) from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards."},{"title":"European Stroke Organisation (ESO), European Association of Neurosurgical Societies (EANS) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on aneurysmal subarachnoid haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/42095754/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendations from the archived full-text transcription (reviewed 2026-09-30); cited in topic summaries."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/37212182/","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 38011240 (Stroke 2023;54:e516) is indexed; its body was not re-read."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/36655570/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Key-point statements (ungraded) from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards."}],"related":[{"label":"ICH first-hour targets","href":"#/evidence/ich-management"},{"label":"aSAH critical care","href":"#/evidence/sah-critical-care"},{"label":"CVT","href":"#/evidence/cvt"}]},{"id":"anticoagulant-labels","title":"Anticoagulants: label and interaction review","category":"Prevention and antithrombotics","settings":["on-call","hospital","clinic"],"keywords":["DOAC","apixaban","Eliquis","rivaroxaban","Xarelto","dabigatran","Pradaxa","edoxaban","Savaysa","warfarin","renal","P-gp","CYP3A4"],"summary":"Before procedures or switching, confirm the exact drug, dose, indication, last intake and current renal function against the U.S. label; in anticoagulant-associated ICH, identify the drug and last dose but do not delay reversal (AHA 2022, COR 1). AF and VTE dosing differ. Apixaban's AF dose adjustment combines age, weight and serum creatinine; edoxaban carries an upper creatinine-clearance restriction for AF; warfarin needs INR monitoring. Check P-gp/CYP3A4 interactions and feeding-tube or swallowing constraints.","consider":["Are the indication, current formulation, last dose, adherence and any planned procedure established?","Are current renal function, weight, age and hepatic status appropriate for the specific label?","Have P-gp/CYP interactions, other antithrombotics and nonprescription products been checked?","Do food, swallowing or feeding-tube requirements affect reliable administration?"],"caution":"Creatinine clearance alone does not select a dose; check the full label with a pharmacist and use the ICH protocol for urgent reversal.","sources":[{"title":"Eliquis (apixaban) U.S. prescribing information","url":"https://packageinserts.bms.com/pi/pi_eliquis.pdf","year":2026,"type":"Drug label","checkedAt":"2026-10-01","access":"Full primary label accessed, revision 08/2026; indications, adult adjustment, renal and interaction sections spot-checked, not a complete label review."},{"title":"Xarelto (rivaroxaban) U.S. prescribing information","url":"https://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/XARELTO-pi.pdf","year":2026,"type":"Drug label","checkedAt":"2026-10-01","access":"Full primary label accessed, revision 03/2026; indications, renal, interaction and administration sections spot-checked, not a complete label review."},{"title":"Pradaxa (dabigatran) capsules — U.S. label on DailyMed","url":"https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=ba74e3cd-b06f-4145-b284-5fd6b84ff3c9","year":2025,"type":"Drug label","checkedAt":"2026-10-01","access":"Full primary label accessed, revision 06/2025; indication-specific renal and interaction sections spot-checked, not a complete label review."},{"title":"Savaysa (edoxaban) — U.S. label on DailyMed","url":"https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e77d3400-56ad-11e3-949a-0800200c9a66","year":2023,"type":"Drug label","checkedAt":"2026-10-01","access":"Full primary label accessed, revision 10/2023 (DailyMed updated 07/2025); boxed warning, indications, renal and interaction sections spot-checked."},{"title":"Warfarin sodium — U.S. label on DailyMed","url":"https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=541c9a70-adaf-4ef3-94ba-ad4e70dfa057","year":2026,"type":"Drug label","checkedAt":"2026-10-01","access":"Full primary label accessed, revision 09/2026; boxed warning, indications, INR monitoring and interaction sections spot-checked, not a complete label review."}],"related":[{"label":"Creatinine clearance","href":"#/encounter/crcl"},{"label":"Reversal","href":"#/evidence/antithrombotic-reversal"},{"label":"ICH protocol","href":"#/protocols/ich"}]},{"id":"af-timing","title":"AF after ischemic stroke: anticoagulation timing","category":"Prevention and antithrombotics","settings":["on-call","hospital","clinic"],"keywords":["atrial fibrillation","DOAC","ELAN","OPTIMAS","CATALYST","restart anticoagulation","apixaban","rivaroxaban","edoxaban","dabigatran","when to start","start timing","TIMING","START"],"summary":"Early oral anticoagulation is reasonable and low risk versus a delayed start in carefully selected (e.g., milder) AF-associated ischemic stroke (AHA 2026, 2a), although its efficacy against early recurrence is not established. CATALYST (5,441 patients from 4 trials; published after the AHA 2026 evidence-review cutoff): starting within 4 days vs day 5 or later reduced 30-day recurrent ischemic stroke, sICH or unclassified stroke (2.1 vs 3.0%; OR 0.70), with identical sICH (0.4%). ELAN schedule: within 48 h for minor or moderate and day 6–7 for major imaging-defined infarcts. OPTIMAS: within 4 days was noninferior to days 7–14 (3.3% each).","recommendations":[{"text":"In carefully selected (e.g., milder severity) AIS patients with atrial fibrillation, a strategy of early oral anticoagulation post-stroke is low risk and is reasonable compared with delayed anticoagulation, although the efficacy of early anticoagulation for preventing early recurrent stroke is not established.","cor":"2a","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-154 · p. 68","id":"ais-2026-154"},{"text":"In stroke or TIA patients with AF who do not have moderate-to-severe mitral stenosis or a mechanical heart valve, a DOAC (apixaban, dabigatran, edoxaban, or rivaroxaban) is recommended over warfarin to reduce recurrent stroke risk.","cor":"1","loe":"B-R","source":"AHA/ASA Secondary Prevention 2021 · secondary-prevention-2021-82 · p. 38","id":"secondary-prevention-2021-82"}],"consider":["Size the infarct on imaging (ELAN categories), not by NIHSS alone; brain imaging before starting may be considered (AHA 2021, 2b). ELAN infarct size: minor ≤1.5 cm; moderate involves a cortical superficial branch of the MCA, ACA or PCA, a deep MCA branch or the internal border zone; major involves an entire MCA, ACA or PCA territory, two or more MCA cortical branches, cortical plus deep MCA branches, or a brainstem or cerebellar lesion >1.5 cm (ELAN, NEJM 2023).","Larger infarcts: in a prespecified OPTIMAS analysis (3,572 participants; segmented infarct volume), the effect of starting a DOAC within 4 days vs days 7–14 did not vary with infarct volume, and sICH with infarcts >25 mL was 3/238 early vs 5/239 delayed; only 187 had infarcts >50 mL. In ELAN, prior IVT or thrombectomy did not modify the early-vs-late effect. Both are secondary analyses within each trial's selected patients.","Hemorrhagic transformation: starting or continuing anticoagulation may be considered case by case (AHA 2026, 2b).","TIA with nonvalvular AF: starting anticoagulation immediately is reasonable (AHA 2021, 2a, expert opinion)."],"caution":"Trial schedules guide but do not set an individual start date for very large infarcts or significant hemorrhagic transformation.","sources":[{"title":"ELAN: imaging-based analysis of the randomized trial","url":"https://pubmed.ncbi.nlm.nih.gov/38805207/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed (post hoc imaging analysis of ELAN)."},{"title":"OPTIMAS randomized trial","url":"https://pubmed.ncbi.nlm.nih.gov/39491870/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"CATALYST individual-participant meta-analysis","url":"https://pubmed.ncbi.nlm.nih.gov/40570866/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"ELAN — Early versus Later Anticoagulation for Stroke with Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/37222476/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ELAN prior reperfusion analysis — Prior Reperfusion Strategy Does Not Modify Outcome in Early Versus Late Start of Anticoagulants in Patients With Ischemic Stroke: Prespecified Subanalysis of the Randomized Controlled ELAN Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40402090/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. 1,973 of 2,013 ELAN patients; the title says prespecified and the abstract post hoc."},{"title":"TIMING — Early Versus Delayed Non-Vitamin K Antagonist Oral Anticoagulant Therapy After Acute Ischemic Stroke in Atrial Fibrillation (TIMING): A Registry-Based Randomized Controlled Noninferiority Study.","url":"https://pubmed.ncbi.nlm.nih.gov/36065821/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"OPTIMAS infarct volume and location analysis — Early versus delayed anticoagulation in acute ischemic stroke with atrial fibrillation according to infarct volume and location: A prespecified subgroup analysis of the OPTIMAS randomized controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41906919/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; PMC full text (PMC13392158) not read. Prespecified analysis of 3,572 participants (98.6% of the trial)."},{"title":"STABLED — Catheter Ablation and Oral Anticoagulation for Secondary Stroke Prevention in Atrial Fibrillation: The STABLED Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41770549/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract and PMC full text (PMC12954600) read 2026-10-31; bibliographic record checked; the major-bleeding and hemorrhagic-stroke figures appear in both the Results text and Table 3. A JAMA Neurol 'Clarification to Table 3' (PMID 41973432, same issue; PMC13077508 has no text) could not be read and is not reconciled."}],"related":[{"label":"Renal function worksheet","href":"#/encounter/crcl"}]},{"id":"stroke-workup","title":"Stroke mechanism, ESUS and rhythm monitoring","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["etiology","TOAST","cryptogenic","ESUS","AF","telemetry","loop recorder","echocardiography"],"summary":"Complete or start the etiologic workup within 48 h of onset to guide prevention: brain CT or MRI, ECG, and CBC, coagulation, glucose, HbA1c, creatinine and lipids (AHA 2021, COR 1), plus carotid imaging for revascularization candidates (COR 1) and intracranial and vertebrobasilar imaging (2a). Cryptogenic stroke: echocardiography and prolonged rhythm monitoring are reasonable (2a) — CRYSTAL AF found AF in 12.4 vs 2.0% at 12 months with an implantable monitor. ESUS: antiplatelet, not empiric anticoagulation — NAVIGATE ESUS (rivaroxaban), RE-SPECT ESUS (dabigatran) and ARCADIA (apixaban for atrial cardiopathy) were neutral.","consider":["Classify the mechanism (TOAST); an incomplete workup leaves it undetermined and does not establish ESUS.","ESUS: TEE, cardiac CT or cardiac MRI might be reasonable to find cardioaortic sources (2b).","Who reviews the monitor and acts on AF?"],"caution":"A brief negative ECG does not exclude paroxysmal AF.","sources":[{"title":"AHA/ASA secondary prevention: diagnostic and mechanism-based approach","url":"https://professional.heart.org/en/science-news/2021-guideline-for-the-prevention-of-stroke-in-patients-with-stroke-and-transient-ischemic-attack/top-things-to-know","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin","url":"https://pubmed.ncbi.nlm.nih.gov/36082257/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 37021192 not reconciled."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"NAVIGATE ESUS — Rivaroxaban for Stroke Prevention after Embolic Stroke of Undetermined Source.","url":"https://pubmed.ncbi.nlm.nih.gov/29766772/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"RE-SPECT ESUS — Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source.","url":"https://pubmed.ncbi.nlm.nih.gov/31091372/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ARCADIA — Apixaban to Prevent Recurrence After Cryptogenic Stroke in Patients With Atrial Cardiopathy: The ARCADIA Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38324415/","year":2024,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ARCADIA hemorrhage analysis — Apixaban Versus Aspirin and Risk of Hemorrhage in the ARCADIA Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41741942/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Secondary analysis; primary safety sample censored at permanent study-drug discontinuation, with an intention-to-treat sensitivity analysis."},{"title":"Jefferson Inherited Thrombophilia Audit — Low value of inherited thrombophilia testing among patients with stroke or transient ischemic attack: A three-year retrospective study.","url":"https://pubmed.ncbi.nlm.nih.gov/37633204/","year":2023,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"sifap — Acute cerebrovascular disease in the young: the Stroke in Young Fabry Patients study.","url":"https://pubmed.ncbi.nlm.nih.gov/23306324/","year":2013,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"UKYSS — Demographics, risk factor profiles and etiologies in young ischemic and hemorrhagic stroke - the United Kingdom Young Stroke Study (UKYSS).","url":"https://pubmed.ncbi.nlm.nih.gov/42640350/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Illicit Drug Use and Stroke (meta-analysis + Mendelian randomization) — Does illicit drug use increase stroke risk? A systematic review, meta-analyses, and Mendelian randomization analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/41566428/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"2024 ACC Expert Consensus Decision Pathway on Practical Approaches for Arrhythmia Monitoring After Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/39692645/","year":2024,"type":"Consensus statement","checkedAt":"2026-10-03","access":"PubMed bibliographic record checked (no abstract); pathway details not reproduced."}],"related":[{"label":"TOAST classification","href":"#/evidence/stroke-classification"},{"label":"PFO","href":"#/evidence/pfo"},{"label":"Encounter","href":"#/encounter"}]},{"id":"stroke-classification","title":"TOAST classification and stroke mechanism","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["TOAST","stroke subtype","etiology","large artery atherosclerosis","cardioembolism","small vessel occlusion","lacunar","undetermined","lateral medullary","Wallenberg"],"summary":"TOAST sorts ischemic stroke into five subtypes (large-artery atherosclerosis, cardioembolism, small-vessel occlusion, other determined etiology and undetermined etiology), with possible or probable diagnoses by the clinician's certainty; in its original test two neurologists agreed in 19 of 20 patients. Assign the subtype after brain imaging, vessel imaging and cardiac evaluation, because the mechanism decides prevention (antiplatelet or anticoagulant, revascularization, PFO closure).","consider":["An incomplete workup leaves the mechanism undetermined; it does not establish ESUS.","DWI pattern helps: a single deep lacune suggests small-vessel disease, scattered emboli in several territories a cardiac source, and a watershed pattern large-artery disease (AHA TIA statement).","Pure lateral medullary infarction (n=130; angiography in 123): vertebral artery disease in 67% and PICA disease in 10%; presumed mechanisms included large-vessel 50%, dissection 15%, small-vessel 13% and cardioembolic 5%."],"caution":"TOAST was built to classify trial participants; it does not replace an individual mechanism review.","sources":[{"title":"TOAST: classification of subtype of acute ischemic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/7678184/","year":1993,"type":"Report","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"Pure lateral medullary infarction: clinical-radiological correlation of 130 patients","url":"https://pubmed.ncbi.nlm.nih.gov/12805095/","year":2003,"type":"Observational study","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/36655570/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Key-point statements (ungraded) from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards."}],"related":[{"label":"Stroke mechanism workup","href":"#/evidence/stroke-workup"},{"label":"Lacunar stroke","href":"#/evidence/lacunar-small-vessel"}]},{"id":"pfo","title":"PFO: attribution and closure discussion","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["patent foramen ovale","RoPE","PASCAL","atrial septal aneurysm","shunt","cryptogenic stroke"],"summary":"PFO closure with long-term antiplatelet therapy is reasonable for ages 18–60 with nonlacunar stroke of undetermined cause after a full evaluation and a PFO with high-risk anatomic features (AHA 2021, 2a); without them AHA rates the benefit uncertain (2b), but ESO 2024 recommends closure when PASCAL rates the PFO possibly or probably causal. RESPECT: recurrent ischemic stroke 0.58 vs 1.07 per 100 patient-years (HR 0.55) over a median 5.9 years; CLOSE: 0/238 vs 14/235 strokes over a mean 5.3 years. Closure adds AF (CLOSE 4.6 vs 0.9%) and venous thromboembolism (RESPECT).","consider":["Exclude competing causes first: vessel imaging, prolonged rhythm monitoring and echocardiography with a bubble study.","Use RoPE and PASCAL to judge causality: in pooled trial data (SCOPE), closure reduced stroke when PASCAL rated the PFO possible or probable (HR 0.38 and 0.10) but not unlikely (HR 1.14); AF beyond day 45 rose with closure in unlikely (+4.4%) and possible (+1.5%) categories.","Discuss procedural risk, AF and the long-term antiplatelet plan with the closure team. ESO 2024 suggests closure plus antiplatelet therapy over long-term anticoagulation alone (possible or probable PASCAL; low certainty); if closure is declined, individualize antiplatelet versus anticoagulant therapy (expert consensus)."],"caution":"Evidence over age 60 and for an incidental PFO is limited.","sources":[{"title":"AAN PFO advisory: patient and family summary","url":"https://www.aan.com/Guidelines/home/GetGuidelineContent/1008","year":2020,"type":"Guideline","checkedAt":"2026-10-01","access":"AAN patient and family summary."},{"title":"SCOPE pooled trial data: PASCAL categories and closure benefit","url":"https://pubmed.ncbi.nlm.nih.gov/34905030/","year":2021,"type":"Meta-analysis","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (individual-participant data, 6 RCTs; stroke HR and AF beyond day 45 by PASCAL category)."},{"title":"European Stroke Organisation (ESO) Guidelines on the diagnosis and management of patent foramen ovale (PFO) after stroke","url":"https://pubmed.ncbi.nlm.nih.gov/38752755/","year":2024,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22; PMC copy has no body text. The anticoagulation statements (PICO 3 conditional, low certainty; PICO 4 expert consensus if closure is refused) are from the archived full-text transcription (Table 12); other recommendations not reviewed."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"RESPECT — Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/28902590/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"CLOSE — Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/28902593/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"REDUCE — Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/28902580/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."}],"related":[{"label":"RoPE worksheet","href":"#/tools/rope"},{"label":"PASCAL worksheet","href":"#/tools/pascal"}]},{"id":"carotid","title":"Carotid stenosis: symptoms, severity and referral","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["CEA","CAS","endarterectomy","carotid stenting","NASCET","CREST-2","revascularization","timing","within 2 weeks","symptomatic stenosis","CREST-H"],"summary":"TIA or nondisabling stroke within 6 months with ipsilateral 70–99% stenosis: endarterectomy if perioperative stroke or death risk is <6% (AHA 2021, COR 1), ideally within 2 weeks (2a); 50–69%: endarterectomy depending on patient factors (COR 1); <50%: no revascularization (COR 3: No Benefit). At age ≥70 or within the first week, endarterectomy is preferred over stenting (2a). Asymptomatic: for >70% stenosis, AHA 2024 recommends shared decision-making on revascularization versus medical management (COR 1); at low perioperative risk, adding revascularization to intensive medical therapy may be reasonable (2b). ESO 2021 recommends endarterectomy for 60–99% stenosis at increased stroke risk on best medical therapy (moderate-quality evidence). Postdating both, CREST-2 (≥70%) found fewer 4-year events with stenting plus intensive medical management (2.8 vs 6.0%) but no significant benefit from endarterectomy (3.7 vs 5.3%); ACST-2 (2021) found stenting and endarterectomy similar (5-year non-procedural stroke 5.3 vs 4.5%).","recommendations":[{"text":"CEA is recommended for patients with TIA or nondisabling ischemic stroke within the past 6 months and ipsilateral severe (70-99%) carotid stenosis to reduce future stroke risk, provided the estimated perioperative morbidity and mortality is below 6%.","cor":"1","loe":"A","source":"AHA/ASA Secondary Prevention 2021 · secondary-prevention-2021-60 · p. 32","id":"secondary-prevention-2021-60"},{"text":"When carotid revascularization is indicated for TIA or nondisabling stroke, it is reasonable to perform the procedure within 2 weeks of the index event rather than delaying surgery, to increase the likelihood of a stroke-free outcome.","cor":"2a","loe":"C-LD","source":"AHA/ASA Secondary Prevention 2021 · secondary-prevention-2021-66 · p. 32","id":"secondary-prevention-2021-66"}],"consider":["How was the stenosis measured (NASCET), and does the lesion explain the event?","Large or disabling infarct, hemorrhage or near-occlusion: individualize timing with vascular surgery.","Everyone gets intensive medical therapy: antiplatelet, statin and BP control (COR 1).","Revascularizing to improve cognition: in CREST-2 (≥70% asymptomatic stenosis), neither stenting nor endarterectomy added to intensive medical management improved cognition over up to 4 years (prespecified secondary outcome; 2,165 US patients). In the CREST-H substudy (51 patients with reduced baseline cognition), revascularization did not improve 1-year cognition, and the effect did not differ by baseline hemodynamic impairment (JAMA 2026)."],"caution":"CREST-2 ran two separate trials, so it does not compare stenting directly with endarterectomy.","sources":[{"title":"ESO carotid endarterectomy and stenting guideline","url":"https://pubmed.ncbi.nlm.nih.gov/34414302/","year":2021,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (asymptomatic and symptomatic recommendations); full text not reviewed."},{"title":"2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/39429201/","year":2024,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (literature searched May–November 2023); no PMC copy. The asymptomatic carotid grades (shared decision-making >70%, COR 1; revascularization at low perioperative risk, 2b) are from the archived full-text transcription. Interpret with newer evidence (CREST-2). Indexed correction(s) 39585937, 39869715 not reconciled."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"CREST — Stenting versus endarterectomy for treatment of carotid-artery stenosis.","url":"https://pubmed.ncbi.nlm.nih.gov/20505173/","year":2010,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 2 corrections or notices; check them before applying results."},{"title":"CREST-2 — Medical Management and Revascularization for Asymptomatic Carotid Stenosis.","url":"https://pubmed.ncbi.nlm.nih.gov/41269206/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"PubMed bibliographic record checked; PMC full text (PMC13148431) read 2026-10-21."},{"title":"CREST-2 cognitive outcomes — Revascularization of Asymptomatic Carotid Artery Stenosis: Cognitive Results of the CREST-2 Randomized Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42747844/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked; prespecified secondary outcomes of both randomized trials."},{"title":"CREST-H — Revascularization in Asymptomatic Carotid Artery Stenosis With Hemodynamic Impairment and Cognitive Outcomes: The CREST-H Substudy of the CREST-2 Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42747834/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked; randomized substudy of CREST-2."},{"title":"ECST-2 — Optimised medical therapy alone versus optimised medical therapy plus revascularisation for asymptomatic or low-to-intermediate risk symptomatic carotid stenosis (ECST-2): 2-year interim results of a multicentre randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40252662/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ACST-2 — Second asymptomatic carotid surgery trial: a randomised comparison of carotid artery stenting versus carotid endarterectomy.","url":"https://pubmed.ncbi.nlm.nih.gov/34469763/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed; bibliographic record checked."}],"related":[{"label":"NASCET","href":"#/tools/nascet"},{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"}]},{"id":"sicas","title":"Symptomatic intracranial atherosclerosis","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["sICAS","intracranial stenosis","SAMMPRIS","BASIS","angioplasty","DAPT"],"summary":"Severe (70–99%) intracranial stenosis with stroke or TIA within 30 days: aspirin plus clopidogrel for up to 90 days (AHA 2021, 2a; AAN 2022, when hemorrhagic-transformation risk is low), plus high-intensity statin with LDL <70 mg/dL, long-term SBP <140 and exercise (COR 1). No angioplasty or stenting as first treatment (COR 3: Harm) — SAMMPRIS: 30-day stroke or death 14.7 vs 5.8% with stenting. BASIS (China, 2024; after AHA 2021 and AAN 2022): at ages 35–80 with TIA within 90 days or stroke 14–90 days earlier, submaximal balloon angioplasty plus medical therapy lowered a 1-year composite that included later revascularization of the qualifying artery (4.4 vs 13.5%), but 30-day stroke or death was 3.2 vs 1.6% and dissection occurred in 14.5%. AAN 2022 advises against routine angioplasty alone outside trials, and ESO 2022 against first-line angioplasty or stenting.","consider":["Confirm the stenosis is symptomatic and in the right territory; 50–69% stenosis gets medical therapy (stenting is harmful).","Write the DAPT stop date and the single agent to continue.","Recurrent events despite therapy: recheck adherence and mechanism; the usefulness of angioplasty or stenting is unknown (2b)."],"caution":"Long-term BP targets do not apply in the acute, perfusion-dependent phase.","sources":[{"title":"AAN symptomatic intracranial atherosclerosis advisory","url":"https://www.aan.com/Guidelines/home/GetGuidelineContent/1069","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"AAN practice advisory."},{"title":"BASIS randomized trial","url":"https://pubmed.ncbi.nlm.nih.gov/39235816/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract re-read 2026-10-21: population, primary result, 30-day risk and dissection rate; protocol not reviewed."},{"title":"Stroke Prevention in Symptomatic Large Artery Intracranial Atherosclerosis Practice Advisory: Report of the AAN Guideline Subcommittee","url":"https://pubmed.ncbi.nlm.nih.gov/35314513/","year":2022,"type":"Practice advisory","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (systematic review through November 2020); full advisory not reviewed. Interpret with newer evidence (BASIS 2024)."},{"title":"European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease","url":"https://pubmed.ncbi.nlm.nih.gov/36082254/","year":2022,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (endovascular therapy not recommended as first choice in high-grade symptomatic ICAD, moderate-level evidence); full recommendations not reviewed. Interpret with newer evidence (BASIS 2024)."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"CASSISS — Effect of Stenting Plus Medical Therapy vs Medical Therapy Alone on Risk of Stroke and Death in Patients With Symptomatic Intracranial Stenosis: The CASSISS Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35943472/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SAMMPRIS — Stenting versus aggressive medical therapy for intracranial arterial stenosis.","url":"https://pubmed.ncbi.nlm.nih.gov/21899409/","year":2011,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."}],"related":[{"label":"DAPT source screen","href":"#/encounter/dapt"}]},{"id":"dissection","title":"Cervical artery dissection","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["carotid dissection","vertebral dissection","neck pain","arteriopathy","antithrombotic"],"summary":"Extracranial carotid or vertebral dissection with stroke or TIA: give antithrombotic therapy for at least 3 months (AHA 2021, COR 1) — antiplatelet or anticoagulant are both reasonable (AHA 2026, 2a), but a large infarct, hemorrhagic transformation or intradural extension may favor antiplatelet therapy (AHA 2024). CADISS found no difference (stroke or death 3/126 vs 1/124); TREAT-CAD did not show aspirin noninferior to a vitamin K antagonist (composite 23 vs 15%; 7 ischemic strokes vs none). Pooled CADISS/TREAT-CAD participant data (444 patients): 90-day ischemic stroke, death or major bleeding 1.4% with anticoagulation vs 4.4% with antiplatelets (P=0.06, not significant), with fewer strokes (OR 0.14) but 2 vs 0 bleeding events. AHA 2024 suggests individualizing the choice for at least 3–6 months.","recommendations":[{"text":"In AIS patients with extracranial carotid or vertebral arterial dissection, treatment with either antiplatelet or anticoagulant therapy for at least 3 months is reasonable to prevent recurrent stroke.","cor":"2a","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-142 · p. 62","id":"ais-2026-142"}],"consider":["Confirm on CTA or MRI/MRA and separate cervical from intracranial or aortic dissection.","Recurrent events despite antithrombotics: endovascular therapy may be considered (AHA 2021, 2b).","Look for an underlying arteriopathy such as FMD when the history suggests it."],"caution":"Neither trial was powered to prove equivalence, and DOACs were not tested.","sources":[{"title":"AHA cervical artery dissection statement: overview","url":"https://professional.heart.org/en/science-news/treatment-and-outcomes-of-cervical-artery-dissection-in-adults/top-things-to-know","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/38299330/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (literature 1990–2022); full statement not reviewed. Interpret with newer evidence (2024 CADISS/TREAT-CAD participant-data meta-analysis; AHA 2026 AIS guideline)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"ESO guideline for the management of extracranial and intracranial artery dissection","url":"https://pubmed.ncbi.nlm.nih.gov/34746432/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 37021160 not reconciled."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"CADISS — Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/25684164/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"TREAT-CAD — Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/33765420/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CAD antithrombotic IPD meta-analysis — Antithrombotic Treatment for Cervical Artery Dissection: A Systematic Review and Individual Patient Data Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/38739383/","year":2024,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"PubMed bibliographic record and abstract checked 2026-10-21."},{"title":"STOP-CAD — Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection: The STOP-CAD Study.","url":"https://pubmed.ncbi.nlm.nih.gov/38335240/","year":2024,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"Ischemic protocol","href":"#/protocols/ischemic"}]},{"id":"secondary-prevention","title":"Secondary prevention and medication review","category":"Prevention and antithrombotics","settings":["hospital","clinic"],"keywords":["blood pressure","LDL","lipids","statin","diabetes","adherence","smoking","DAPT transition"],"summary":"Noncardioembolic stroke or TIA: antiplatelet rather than anticoagulant (COR 1); DAPT only short term (minor stroke [NIHSS ≤3] or high-risk TIA [ABCD2 ≥4] without IVT, started within 24 h: 21 days, AHA 2026 COR 1; severe intracranial stenosis: up to 90 days). BP <130/80 for most (AHA 2021, COR 1). Atherosclerotic stroke: statin ± ezetimibe to LDL <70 mg/dL (COR 1); no known coronary disease or major cardiac source and LDL >100: atorvastatin 80 mg (SPARCL). Diabetes: glucose-lowering drugs with proven cardiovascular benefit (AHA 2021, COR 1). Recheck lipids 4–12 weeks after a change, then every 3–12 months.","recommendations":[{"text":"Antiplatelet therapy is recommended over oral anticoagulation for patients with noncardioembolic ischemic stroke or TIA to reduce recurrent ischemic stroke and other cardiovascular events while minimizing bleeding risk.","cor":"1","loe":"A","source":"AHA/ASA Secondary Prevention 2021 · secondary-prevention-2021-144 · p. 64","id":"secondary-prevention-2021-144"},{"text":"An office BP goal of less than 130/80 mmHg is recommended for most hypertensive stroke or TIA patients to reduce recurrent stroke and vascular events.","cor":"1","loe":"B-R","source":"AHA/ASA Secondary Prevention 2021 · secondary-prevention-2021-28 · p. 20","id":"secondary-prevention-2021-28"},{"text":"For ischemic stroke or TIA patients with atherosclerotic disease (intracranial, carotid, aortic, or coronary), lipid-lowering therapy with a statin (plus ezetimibe if needed) to achieve an LDL-C goal below 70 mg/dL is recommended to reduce major cardiovascular events.","cor":"1","loe":"A","source":"AHA/ASA Secondary Prevention 2021 · secondary-prevention-2021-32 · p. 21","id":"secondary-prevention-2021-32"}],"consider":["Is the mechanism settled, and does it change the drug (AF, PFO, dissection, intracranial stenosis)? Check adherence, cost, smoking, diet and activity at every visit.","Very high risk (stroke plus another major ASCVD event, or ≥2 high-risk conditions): ACC/AHA 2026 goal LDL-C <55 mg/dL; add ezetimibe and/or a PCSK9 antibody as needed (COR 1).","Noncardioembolic stroke while taking aspirin: over a median of about 19 months, switching to another antithrombotic was not clearly better than continuing aspirin (network meta-analysis of 9 RCTs, 5,459 patients; recurrent ischemic stroke RR 0.88, 95% CI 0.76–1.03). Trials with only ≤90-day outcomes were excluded, so this does not address short-term DAPT after minor stroke or high-risk TIA.","Type 2 diabetes with minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4): in LAMP (China, open-label with blinded end points; 636 patients randomized within 24 h), 90 days of liraglutide reduced 90-day stroke recurrence (7.9 vs 13.8%; HR 0.56); its authors call the trial underpowered. It postdates AHA 2021 and does not establish an acute indication. A 2026 meta-analysis of four randomized trials of early GLP-1 receptor agonists after ischemic stroke or high-risk TIA (LAMP, GALLOP-1, GALLOP-2, TEXAIS; 1,514 patients) found only a fragile gain in 90-day mRS 0–2 (RR 1.06, 1.01–1.11) that was not significant without LAMP (RR 1.07, 0.92–1.24)."],"caution":"Avoid indefinite DAPT or antiplatelet-plus-anticoagulant combinations without a separate indication.","sources":[{"title":"AHA/ASA secondary stroke prevention guideline: overview","url":"https://professional.heart.org/en/science-news/2021-guideline-for-the-prevention-of-stroke-in-patients-with-stroke-and-transient-ischemic-attack/top-things-to-know","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"2026 multisociety dyslipidemia guideline: overview","url":"https://professional.heart.org/en/science-news/2026-guideline-on-the-management-of-dyslipidemia/top-things-to-know","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page."},{"title":"European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack","url":"https://pubmed.ncbi.nlm.nih.gov/36082250/","year":2022,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract read 2026-10-21; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"ATIS-NVAF — Optimal Antithrombotics for Ischemic Stroke and Concurrent Atrial Fibrillation and Atherosclerosis: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41051787/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CHANCE — Clopidogrel with aspirin in acute minor stroke or transient ischemic attack.","url":"https://pubmed.ncbi.nlm.nih.gov/23803136/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"POINT — Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA.","url":"https://pubmed.ncbi.nlm.nih.gov/29766750/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"THALES — Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA.","url":"https://pubmed.ncbi.nlm.nih.gov/32668111/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"INSPIRES — Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/38157499/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CHANCE-2 — Ticagrelor versus Clopidogrel in CYP2C19 Loss-of-Function Carriers with Stroke or TIA.","url":"https://pubmed.ncbi.nlm.nih.gov/34708996/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"TAPIS — Ticagrelor with aspirin dual antiplatelet therapy combined with intravenous thrombolysis in patients with ischaemic stroke in China (TAPIS): a multicentre, double-blind, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42114550/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"MATCH — Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/15276392/","year":2004,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"RESTART — Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial.","url":"https://pubmed.ncbi.nlm.nih.gov/31128924/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CMOSS — Extracranial-Intracranial Bypass and Risk of Stroke and Death in Patients With Symptomatic Artery Occlusion: The CMOSS Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37606672/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. This report concerns bypass for symptomatic artery occlusion, not intracranial stenting."},{"title":"Switching from aspirin network meta-analysis — Switching From Aspirin Monotherapy After Noncardioembolic Stroke: A Systematic Review and Network Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/41347302/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked."},{"title":"LAMP — Liraglutide in Acute Minor Ischemic Stroke or High-Risk Transient Ischemic Attack With Type 2 Diabetes: The LAMP Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41182740/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked."},{"title":"Early GLP-1RA meta-analysis — Early GLP-1 Receptor Agonist Therapy in Acute Ischemic Stroke and High-Risk Transient Ischemic Attack: A Systematic Review and Meta-analysis of Randomized Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42878597/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31 (Ann Indian Acad Neurol 2026;29(5):685-696); bibliographic record checked; full text not reviewed."},{"title":"RESTART extended follow-up — Effects of Antiplatelet Therapy After Stroke Caused by Intracerebral Hemorrhage: Extended Follow-up of the RESTART Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/34477823/","year":2021,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record and notices checked; outcomes not reviewed here. Extended follow-up of the original randomized population."}],"related":[{"label":"DAPT source screen","href":"#/encounter/dapt"},{"label":"Encounter","href":"#/encounter"}]},{"id":"recovery","title":"Recovery, rehabilitation and follow-up","category":"Recovery and rehabilitation","settings":["hospital","clinic"],"keywords":["rehabilitation","function","mood","depression","anxiety","caregiver","participation","telehealth"],"summary":"AHA/ASA AIS 2026: formal inpatient interdisciplinary assessment and rehabilitation matched to the patient (COR 1); no high-dose, very early mobilization within 24 h of stroke onset (COR 3: Harm); screen for depression with a structured inventory and treat diagnosed depression (COR 1). CSBPR 2025 (Canada) adds: begin mobilization once medically stable, ideally 24–48 h after stroke, with caution and clinical judgment (strong recommendation; moderate-quality evidence). SSRIs are not recommended for motor or functional recovery (COR 3: No Benefit): fluoxetine 20 mg daily for 6 months did not improve mRS and increased fractures (FOCUS, AFFINITY, EFFECTS), when started 2–15 days after stroke; this does not apply to treating diagnosed depression. Levodopa/carbidopa 100/25 mg three times daily for 39 days, added to task-oriented inpatient rehabilitation after acute ischemic or hemorrhagic stroke with hemiparesis, did not improve 3-month Fugl-Meyer scores, with similar serious adverse events (ESTREL RCT, Switzerland, 610 patients: −0.9 points, 95% CI −3.8 to 2.0; postdates the AIS 2026 evidence review, not graded). Reassess function, mood and goals at follow-up.","consider":["Which impairments, daily activities and participation goals need assessment or renewed therapy?","Have the patient and care partner received education, training and support?","Is follow-up feasible (transport, access, telehealth), and who reassesses progress?"],"caution":"A screening score is not a diagnosis, and this card gives no driving, work or travel clearance. Grades are from AHA/ASA AIS 2026 (acute ischemic stroke) unless labelled CSBPR 2025; the August 2026 AHA/ASA rehabilitation guideline was not reviewed.","sources":[{"title":"2026 AHA/ASA adult stroke rehabilitation and recovery guideline: overview","url":"https://professional.heart.org/en/science-news/2026-guideline-for-adult-stroke-rehabilitation-and-recovery/top-things-to-know","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Official AHA summary page; not used for this card's grades."},{"title":"FOCUS trial of fluoxetine after stroke","url":"https://pubmed.ncbi.nlm.nih.gov/30528472/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract read."},{"title":"AFFINITY trial of fluoxetine after stroke","url":"https://pubmed.ncbi.nlm.nih.gov/32702334/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract read."},{"title":"EFFECTS trial of fluoxetine after stroke","url":"https://pubmed.ncbi.nlm.nih.gov/32702335/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract read."},{"title":"2026 Guideline for Adult Stroke Rehabilitation and Recovery: A Guideline From the American Heart Association and American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/42657476/","year":2026,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed record and abstract read: published online 2026-08-27 (Stroke 2026;57(10):e514–e658); replaces the 2016 guideline; literature since 2016 searched June–October 2025, so later evidence is not reflected. No PMC copy; recommendations not reviewed or quoted. A correction was published 2026-10-26 (PMID 42932410; Stroke 2026;57(11):e700–e701); its content was not reviewed. Archive held only an access placeholder."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery and Community Participation Following Stroke. Part One: Stroke Rehabilitation Planning for Optimal Care Delivery, 7th Edition Update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41257448/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PMC full text (PMC12871428) read 2026-10-31; only the mobilization-timing recommendations (section 3) are used, with strength and evidence quality as published."},{"title":"ESTREL — Levodopa Added to Stroke Rehabilitation: The ESTREL Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40982270/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; PMC full text (PMC12455486) not read."}],"related":[{"label":"PHQ-2 worksheet","href":"#/tools/phq2"},{"label":"mRS descriptors","href":"#/tools/mrs-descriptors"},{"label":"Encounter","href":"#/encounter"}]},{"id":"maternal-stroke","title":"Pregnancy and postpartum stroke","category":"Stroke in specific populations","settings":["on-call","hospital","clinic"],"keywords":["maternal","pregnancy","postpartum","preeclampsia","eclampsia","breastfeeding"],"summary":"Pregnancy should not delay evidence-based treatment of acute stroke, and CT, CTA and noncontrast MRI are safe (AHA 2026 maternal statement), but IVT needs an individual risk–benefit review (ESO 2022 consensus). No reperfusion RCT included pregnant or postpartum patients; ESO 2022 expert consensus supports thrombectomy for LVO (preferred over IVT whenever possible) and IVT (in pregnancy by majority), not withheld if thrombectomy is unavailable; ESO found no IVT data within 10 days of delivery. Severe hypertension (systolic ≥160 or diastolic ≥110 mm Hg, confirmed within 15 minutes) is an emergency; magnesium and antihypertensives are the cornerstones for preeclampsia and eclampsia. Consider ICH, SAH, CVT, RCVS and PRES as well as ischemic stroke, especially postpartum.","consider":["Establish the pregnancy or postpartum stage, blood pressure and likely mechanism.","Involve vascular neurology and maternal-fetal medicine early; a transradial approach is preferred for endovascular procedures when possible.","Plan for infant care, breastfeeding and rehabilitation support."],"caution":"Acute stroke alone is not an indication for immediate delivery; stabilize the mother first, and the statement supplies no universal antithrombotic choice.","sources":[{"title":"Prevention and Treatment of Maternal Stroke in Pregnancy and Postpartum: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/41603019/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-22","access":"Primary abstract read; full statement not accessible. The severe-hypertension threshold, magnesium and transradial details come from the archived transcription (incomplete fragments) and were not verified against the full statement."},{"title":"European Stroke Organisation guidelines on stroke in women: Management of menopause, pregnancy and postpartum","url":"https://pubmed.ncbi.nlm.nih.gov/35647308/","year":2022,"type":"Guideline","checkedAt":"2026-10-22","access":"PMC body text read (PMC9134774; recommendation and vote tables not in the retrieved text): no RCTs of IVT or MT in pregnancy or postpartum; expert consensus, not evidence-based recommendations; no IVT data <10 days after delivery. Search to 2020; interpret with newer evidence (AHA 2026 maternal statement). Erratum 37021188 not reconciled (PMC copy has no body)."},{"title":"Finnish Subsequent-Pregnancy Cohort — Stroke Recurrence and Pregnancy Outcomes in the Subsequent Pregnancies After Maternal Ischemic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/40970275/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"},{"label":"RCVS and PRES","href":"#/evidence/rcvs-pres"},{"label":"CVT","href":"#/evidence/cvt"}]},{"id":"cancer-stroke","title":"Stroke with active cancer","category":"Stroke in specific populations","settings":["on-call","hospital","clinic"],"keywords":["malignancy","hypercoagulability","NBTE","cancer-related stroke","oncology","cancer evaluation"],"summary":"Complete the usual arterial and cardiac workup before blaming active cancer: it can coexist with conventional mechanisms or cause thrombosis directly. The 2026 AHA statement grades the certainty of cancer-related causation and highlights how uncertain treatment remains.","consider":["What clinical evidence supports cancer-related thrombosis or another cancer-associated mechanism?","Have recurrent thrombosis, bleeding, cancer treatment and patient goals been reviewed together?"],"caution":"A cancer diagnosis does not establish the mechanism or an automatic anticoagulant indication.","sources":[{"title":"AHA Scientific Statement 2026: Classification and Management of Ischemic Stroke in Patients With Active Cancer","url":"https://pubmed.ncbi.nlm.nih.gov/41623113/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."}],"related":[]},{"id":"preexisting-disability","title":"Stroke with prior disability or dementia","category":"Stroke in specific populations","settings":["on-call","hospital","clinic"],"keywords":["premorbid","prestroke mRS","dementia","disability","reperfusion","baseline function"],"summary":"Prior disability or dementia was usually excluded from reperfusion trials, and observational data suggest many treated patients can return to their own baseline despite a worse overall prognosis; AHA/ASA AIS 2026, ICA or M1 occlusion within 6 h with NIHSS ≥6 and ASPECTS ≥6: EVT is reasonable at prestroke mRS 2 (2a) and might be reasonable at mRS 3–4 (2b). Decide with the actual baseline, supports and the outcomes the patient values.","consider":["What were the patient’s actual baseline function, supports and valued activities?","What additional disability might this stroke cause, and what outcome would the patient consider worthwhile?","Are treatment risks and the limits of the evidence being discussed without relying on a baseline score alone?"],"caution":"Prior disability alone does not decide treatment, and observational benefit does not apply to every patient.","sources":[{"title":"Endovascular Treatment and Thrombolysis for Acute Ischemic Stroke in Patients With Premorbid Disability or Dementia: A Scientific Statement From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35343235/","year":2022,"type":"Scientific statement","checkedAt":"2026-10-22","access":"Primary abstract checked: proposes principles rather than COR/LOE-graded recommendations; the 2a/2b grades on this card are from AHA/ASA AIS 2026 (ais-2026-118/119)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."}],"related":[{"label":"mRS descriptors","href":"#/tools/mrs-descriptors"},{"label":"EVT selection","href":"#/evidence/evt-selection"}]},{"id":"perioperative-stroke","title":"Perioperative stroke","category":"Stroke in specific populations","settings":["on-call","hospital","clinic"],"keywords":["surgery","anesthesia","postoperative","noncardiac surgery","perioperative antithrombotics"],"summary":"After noncardiac, nonneurological surgery, any new deficit should trigger the stroke pathway with prompt imaging, preferring thrombectomy for LVO and weighing surgical-site bleeding before IVT (AHA 2021 statement). Before such surgery, include recent stroke, vascular disease and the procedure in the risk discussion and plan antithrombotic changes as a team.","consider":["Are recent stroke history, vascular disease and the proposed procedure included in the risk discussion?","Are perioperative medication changes and the responsible teams clearly documented?"],"caution":"Surgery timing after a recent stroke and perioperative medication changes need procedure-specific multidisciplinary review.","sources":[{"title":"Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/33827230/","year":2021,"type":"Scientific statement","checkedAt":"2026-10-22","access":"Primary abstract read; the thrombectomy-preference and surgical-site-bleeding points come from the archived transcription (incomplete fragments); full statement not reviewed."},{"title":"2024 AHA/ACC perioperative cardiovascular management for noncardiac surgery: official overview","url":"https://professional.heart.org/en/science-news/2024-guideline-for-perioperative-cardiovascular-management-for-noncardiac-surgery/top-things-to-know","year":2024,"type":"Guideline","checkedAt":"2026-10-01","access":"Official summary read for team-based assessment and individualized perioperative antithrombotic management; full surgery-timing and medication tables not reviewed here."}],"related":[{"label":"Ischemic protocol","href":"#/protocols/ischemic"}]},{"id":"sex-gender-stroke","title":"Sex, gender and equitable stroke care","category":"Stroke in specific populations","settings":["hospital","clinic"],"keywords":["women","menopause","sex differences","gender","equity","thrombectomy"],"summary":"Base reperfusion decisions on the individual's findings and priorities; population-level sex and gender differences in recognition, access and endovascular outcomes do not create separate eligibility rules. Much of the evidence records sex rather than gender, leaving gaps (AHA statement). Acute and secondary-prevention therapies have comparable efficacy in women and men, yet women are less likely to receive timely acute treatment; include hypertensive disorders of pregnancy, menopause and hormone therapy in risk assessment (WSO 2025 statement).","consider":["Could differences in recognition, access, baseline circumstances or support be influencing care?","Does the cited evidence actually address this patient population?"],"caution":"Population-level differences do not establish an individual treatment effect or a separate eligibility rule.","sources":[{"title":"Toward a Better Understanding of Sex- and Gender-Related Differences in Endovascular Stroke Treatment: A Scientific Statement From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35695016/","year":2022,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Addressing sex and gender differences in stroke risk and management: A scientific statement from the World Stroke Organization","url":"https://pubmed.ncbi.nlm.nih.gov/41131690/","year":2025,"type":"Scientific statement","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31 (Int J Stroke, online 2025-10-23); full text not read."},{"title":"Danish Hormonal Contraception Cohort — Stroke and myocardial infarction with contemporary hormonal contraception: real-world, nationwide, prospective cohort study.","url":"https://pubmed.ncbi.nlm.nih.gov/39938934/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Danish Progestogen-Only Contraceptive Cohort — Risk of ischemic and hemorrhagic stroke in users of progestogen-only contraceptives: A Danish registry study.","url":"https://pubmed.ncbi.nlm.nih.gov/42624314/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[]},{"id":"pediatric-stroke","title":"Stroke in neonates and children","category":"Stroke in specific populations","settings":["on-call","hospital","clinic"],"keywords":["pediatric","childhood","neonatal","perinatal","arteriopathy","child stroke"],"summary":"Suspect stroke in any child with a sudden focal deficit, including a first seizure (AHA 2026, COR 1). Image with MRI/MRA, or CT/CTA if MRI is not available within 25 minutes (2a). Alteplase may be considered from 28 days to 18 years within 4.5 h for a disabling deficit (2b). EVT by experienced neurointerventionalists can be effective for LVO at age 6 or older within 6 h, or 6–24 h with salvageable tissue (2a). EVT by neurointerventionalists with pediatric experience may be reasonable from 28 days to 6 years within 24 h with salvageable tissue (2b).","recommendations":[{"text":"In pediatric patients with sudden-onset focal neurological deficits, including first-time seizure, acute stroke is recommended to be suspected to enable timely diagnosis.","cor":"1","loe":"C-EO","source":"AHA/ASA AIS 2026 · ais-2026-25 · p. 18","id":"ais-2026-25"},{"text":"In pediatric patients aged 28 days to 18 years with confirmed AIS presenting within 4.5 hours of symptom onset with disabling deficits, IVT with alteplase may be considered as it appears safe, though efficacy is uncertain.","cor":"2b","loe":"C-LD","source":"AHA/ASA AIS 2026 · ais-2026-97 · p. 38","id":"ais-2026-97"},{"text":"In pediatric patients 6 years or older with acute neurological symptoms from ischemic stroke due to LVO within 6 hours of symptom onset, EVT performed by experienced neurointerventionalists can be effective to improve functional outcomes.","cor":"2a","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-133 · p. 60","id":"ais-2026-133"},{"text":"In pediatric patients 6 years or older with ischemic stroke due to LVO, presenting 6-24 hours from symptom onset with potentially salvageable brain tissue, EVT can be effective to improve functional outcomes.","cor":"2a","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-134 · p. 60","id":"ais-2026-134"},{"text":"In pediatric patients aged 28 days to 6 years with acute neurological symptoms (including first-time seizure) and AIS due to LVO within 24 hours of symptom onset with potentially salvageable brain tissue, EVT by neurointerventionalists with pediatric experience may be reasonable to improve functional outcomes.","cor":"2b","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-135 · p. 60","id":"ais-2026-135"}],"consider":["Call pediatric stroke expertise early and use age-appropriate imaging.","Consider age-specific mechanisms and mimics.","Follow-up should cover development, learning, family support and recurrence prevention."],"caution":"Adult pathways cannot simply be transferred to neonates or children. For intracerebral hemorrhage in children (28 days to 18 years), see the 2025 International Pediatric Stroke Organization consensus (21 acute-phase statements agreed by modified Delphi, not graded; literature to March 2022).","sources":[{"title":"AHA/ASA management of stroke in neonates and children: official overview","url":"https://professional.heart.org/en/science-news/management-of-stroke-in-neonates-and-children/top-things-to-know","year":2019,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official AHA summary page (2019 statement)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Pediatric Intracerebral Hemorrhage Management-Consensus Statement of the International Pediatric Stroke Organization-Part 1: Acute Phase and Workup","url":"https://pubmed.ncbi.nlm.nih.gov/41467366/","year":2025,"type":"Consensus statement","checkedAt":"2026-10-31","access":"Primary abstract and PMC methods read 2026-10-31 (PMC12909056): modified Delphi, statements approved at >80% agreement, ungraded; last literature search March 2022. Individual statements not summarized here."},{"title":"Pediatric Intracerebral Hemorrhage Management-Consensus Statement of the International Pediatric Stroke Organization-Part 2: Outcomes, Rehabilitation, and Transition to Adulthood","url":"https://pubmed.ncbi.nlm.nih.gov/41467378/","year":2025,"type":"Consensus statement","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; PMC full text (PMC12909026) not read."},{"title":"Save ChildS — Feasibility, Safety, and Outcome of Endovascular Recanalization in Childhood Stroke: The Save ChildS Study.","url":"https://pubmed.ncbi.nlm.nih.gov/31609380/","year":2020,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"TIPS design — Thrombolysis in acute childhood stroke: design and challenges of the thrombolysis in pediatric stroke clinical trial.","url":"https://pubmed.ncbi.nlm.nih.gov/19223687/","year":2009,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record and notices checked; outcomes not reviewed here. Trial design report; this citation does not supply completed treatment outcomes."},{"title":"Save ChildS Pro — Endovascular thrombectomy for childhood stroke (Save ChildS Pro): an international, multicentre, prospective registry study.","url":"https://pubmed.ncbi.nlm.nih.gov/39401507/","year":2024,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record and notices checked; outcomes not reviewed here. Prospective observational registry, not a randomized treatment comparison."}],"related":[]},{"id":"sickle-cell-stroke","title":"Sickle cell cerebrovascular disease","category":"Stroke in specific populations","settings":["on-call","hospital","clinic"],"keywords":["SCD","sickle cell","silent cerebral infarct","transfusion","transcranial Doppler","TCD"],"summary":"New neurological symptoms in sickle cell disease need urgent joint stroke and hematology care, including transfusion decisions, and eligible adults can receive IVT without excess sICH or other thrombolytic complications (AHA 2026, 2a). ASH guidance covers overt stroke, silent cerebral injury and prevention; disease-modifying decisions belong with the treating specialists.","consider":["Are the sickle cell genotype, prior cerebral events and preventive treatment history known?","Is the age- and disease-specific screening and follow-up plan clear?"],"caution":"An adult atherosclerotic-stroke pathway does not cover sickle cell disease.","sources":[{"title":"ASH 2020 sickle cell cerebrovascular disease guideline","url":"https://pmc.ncbi.nlm.nih.gov/articles/PMC7189278/","year":2020,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract read via live NLM PubMed record (PMID32298430); official ASH page confirms a 2023 review retained the guideline with evidence monitoring. PMC full text was challenged; detailed treatment tables not reviewed here."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."}],"related":[]},{"id":"poststroke-dysphagia","title":"Dysphagia, nutrition and oral care","category":"Inpatient care and complications","settings":["hospital","clinic"],"keywords":["swallow","aspiration","oral intake","nutrition","hydration","feeding","SLP"],"summary":"Screen swallowing at the bedside before any oral intake (AHA 2026, COR 1); if the screen fails or cannot be done, an instrumental assessment (FEES or videofluoroscopy) is reasonable (2a). Start enteral feeding within 7 days (COR 1): nasogastric tube first, and gastrostomy if unsafe swallowing is expected beyond 2–3 weeks (2a). An oral hygiene protocol may reduce pneumonia (2b).","consider":["Is the current intake plan clear to everyone, including medication routes?","Does a concerning screen or clinical change need specialist assessment?","Are hydration, oral care and reassessment in the plan?"],"caution":"A screening result is not the full swallowing diagnosis; in FOOD, early PEG increased death or poor outcome versus nasogastric feeding (P=0.05), without a difference in death alone.","sources":[{"title":"European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia","url":"https://pubmed.ncbi.nlm.nih.gov/34746431/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial","url":"https://pubmed.ncbi.nlm.nih.gov/15733717/","year":2005,"type":"Randomized trial","checkedAt":"2026-10-22","access":"Primary abstract read: PEG vs nasogastric trial (n=321): death or poor outcome +7.8% (95% CI 0.0–15.5; P=0.05); death +1.0% (P=0.9)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."}],"related":[]},{"id":"stroke-pneumonia","title":"Stroke-associated pneumonia","category":"Inpatient care and complications","settings":["hospital"],"keywords":["SAP","aspiration pneumonia","infection","dysphagia","antibiotics"],"summary":"Diagnose stroke-associated pneumonia with standardized criteria (e.g., PISCES probable or definite), not from a risk score; chest CT or CRP may add value in selected cases (ESO 2026). Prevent it with swallow screening, oral care, positioning and early mobilization within 48 h (ESO 2026), avoiding high-dose, very early mobilization within 24 h of onset (AHA/ASA AIS 2026, COR 3: Harm); do not give prophylactic antibiotics (AHA/ASA AIS 2026, COR 3: No Benefit; ESO 2026). Once SAP is diagnosed, take cultures where feasible and start empirical antibiotics promptly under local protocols for aspiration-associated pathogens (onset >7 days after stroke: hospital-acquired pneumonia protocols); give at least 5 days guided by response and stop early if SAP is refuted (ESO 2026 expert consensus).","consider":["Is pneumonia diagnosed by standardized criteria rather than a risk score or CRP alone?","Have swallowing, positioning, mobility and nutritional needs been reviewed?","Has the regimen been reviewed against cultures and local microbiology for de-escalation or stopping?"],"caution":"Most ESO recommendations rest on expert consensus because direct evidence is limited.","sources":[{"title":"ESO Guideline 2026: Stroke-Associated Pneumonia","url":"https://pubmed.ncbi.nlm.nih.gov/42095755/","year":2026,"type":"Guideline","checkedAt":"2026-10-22","access":"PMC full text read (PMC13151663); recommendation boxes and synoptic table (images) not in the retrieved text."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"PASS — The Preventive Antibiotics in Stroke Study (PASS): a pragmatic randomised open-label masked endpoint clinical trial.","url":"https://pubmed.ncbi.nlm.nih.gov/25612858/","year":2015,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[]},{"id":"stroke-unit-nursing","title":"Stroke-unit nursing and daily care","category":"Inpatient care and complications","settings":["on-call","hospital"],"keywords":["nursing","stroke unit","neurological checks","skin","mobility","discharge education"],"summary":"Care for all ages in an organized stroke unit with a trained interdisciplinary team and standardized orders (AHA 2026, COR 1). Nurse-initiated fever, glucose and swallowing protocols reduced death or dependency (QASC: 42 vs 58%). Make phase-specific monitoring and escalation explicit and carry unresolved issues into discharge planning. After IVT, in patients clinically stable with NIHSS <10 within 2 h of starting thrombolysis, a low-intensity schedule (neurological and vital-sign checks every 15 min for 2 h, every 2 h for 8 h, then every 4 h to 24 h) gave similar 90-day mRS 2–6 to standard monitoring (31.7 vs 30.9%; RR 1.03, 95% CI 0.92–1.15, noninferiority margin 1.15; OPTIMISTmain, 4,922 patients, stepped-wedge cluster RCT); the investigators call this only weak evidence of noninferiority, and it postdates the AHA 2026 evidence review.","consider":["Are phase-specific monitoring and escalation responsibilities clear?","Have functional needs, safety concerns and family teaching been incorporated into daily care?","Are unresolved inpatient issues carried forward into the discharge plan?"],"caution":"These statements do not set a universal monitoring frequency or replace response to deterioration.","sources":[{"title":"Care of the Patient With Acute Ischemic Stroke (Posthyperacute and Prehospital Discharge): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/33691469/","year":2021,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Care of the Patient With Acute Ischemic Stroke (Endovascular/Intensive Care Unit-Postinterventional Therapy): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/33691467/","year":2021,"type":"Scientific statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 42507798 not reconciled."},{"title":"Care of the Patient With Acute Ischemic Stroke (Prehospital and Acute Phase of Care): Update to the 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/33691468/","year":2021,"type":"Scientific statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"QASC — Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/21996470/","year":2011,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"HeadPoST — Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/28636854/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SHINE — Intensive vs Standard Treatment of Hyperglycemia and Functional Outcome in Patients With Acute Ischemic Stroke: The SHINE Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/31334795/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"OPTIMISTmain — Safety and efficacy of low-intensity versus standard monitoring following intravenous thrombolytic treatment in patients with acute ischaemic stroke (OPTIMISTmain): an international, pragmatic, stepped-wedge, cluster-randomised, controlled non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40412428/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked: clinically stable with NIHSS <10 within 2 h of IVT; mRS 2–6 31.7 vs 30.9% (RR 1.03, 95% CI 0.92–1.15; margin 1.15; p=0.057); authors report weak evidence of noninferiority."},{"title":"HeadSOAR — Head positioning after endovascular therapy for acute stroke due to large vessel occlusion (HeadSOAR): multicentre randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42624516/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; summarized on the inpatient-care card; full text not reviewed."}],"related":[]},{"id":"inpatient-medical-complications","title":"Systemic complications during stroke admission","category":"Inpatient care and complications","settings":["hospital"],"keywords":["cardiac complications","infection","glucose","temperature","delirium","aphasia","medical complications"],"summary":"Watch for infection (pneumonia, urinary), fever, hyperglycemia, VTE, acute kidney injury, GI bleeding, urinary retention, cardiac events and delirium, which cluster early after stroke and worsen outcomes. In ischemic stroke (AHA 2026): treat persistent hyperglycemia to 140–180 mg/dL with close monitoring (2a) but not with IV insulin to 80–130 (COR 3: No Benefit; SHINE vs a sliding-scale 80–179 target: no functional benefit, severe hypoglycemia 2.6% vs none); target normothermia in fever (COR 1); avoid routine indwelling bladder catheters (COR 3: Harm). ICH glucose and temperature targets differ (see the ICH card).","consider":["Have new systemic symptoms or laboratory changes been assessed alongside the neurological course?","Could aphasia be limiting the examination, and does fluctuating attention need broader reassessment?","Do medical, nursing and rehabilitation teams share a complication plan?"],"caution":"A bedside impression cannot exclude an acute cause of change; aphasia, delirium and neurological worsening can coexist.","sources":[{"title":"AHA Systemic Complications of Acute Stroke Scientific Statement 2024","url":"https://pubmed.ncbi.nlm.nih.gov/39633600/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"AHA poststroke cognitive impairment: official overview","url":"https://professional.heart.org/en/science-news/cognitive-impairment-after-ischemic-and-hemorrhagic-stroke/top-things-to-know","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official summary read for differential assessment, comorbid delirium, home safety, driving and work considerations; full statement not re-reviewed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"European Stroke Organisation (ESO) guidelines on glycaemia management in acute stroke","url":"https://pubmed.ncbi.nlm.nih.gov/31008333/","year":2018,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"European Stroke Organisation (ESO) guidelines for the management of temperature in patients with acute ischemic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/26148223/","year":2015,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"Hyponatremia & ICH — Severity-Stratified Hyponatremia Is Associated with Increased Mortality and Complications in Nontraumatic Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/42194925/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"INTREPID — Fever Prevention in Patients With Acute Vascular Brain Injury: The INTREPID Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39320879/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SETPOINT2 — Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation: The SETPOINT2 Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35506515/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ELSO LV venting and acute brain injury — Impact of Left Ventricular Venting on Acute Brain Injury in Patients With Cardiogenic Shock: An Extracorporeal Life Support Organization Registry Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/41104911/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"Follow-up imaging","href":"#/evidence/imaging-follow-up"},{"label":"ICH first-hour targets","href":"#/evidence/ich-management"}]},{"id":"vte-prevention","title":"VTE prevention after stroke","category":"Inpatient care and complications","settings":["hospital"],"keywords":["DVT","pulmonary embolism","IPC","immobility","heparin","thromboprophylaxis"],"summary":"Immobile after ischemic stroke: intermittent pneumatic compression unless contraindicated (AHA/ASA AIS 2026, COR 1; CLOTS 3, started within 3 days of admission: proximal DVT 8.5 vs 12.1%), and prophylactic-dose UFH or LMWH is reasonable to reduce VTE (2a), although a survival benefit is not well established (2b). Do not use elastic compression stockings (COR 3: Harm). Nonambulatory after ICH: IPC from the day of diagnosis (AHA 2022, COR 1); low-dose UFH or LMWH can be useful (2a), and starting it 24–48 h after onset may be reasonable (2b), weighing VTE prevention against hematoma expansion.","consider":["What are the current mobility, VTE and bleeding risks?","Is IPC fitted and worn as intended, with skin checks?","Before heparin prophylaxis, review renal function, recent treatment and hemorrhage risk."],"caution":"Graduated compression stockings are not equivalent to intermittent pneumatic compression.","sources":[{"title":"European Stroke Organisation (ESO) guidelines for prophylaxis for venous thromboembolism in immobile patients with acute ischaemic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/31008263/","year":2016,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial","url":"https://pubmed.ncbi.nlm.nih.gov/23727163/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-22","access":"Primary abstract read: immobile patients enrolled day 0–3 of admission; proximal DVT 8.5 vs 12.1%; skin breaks 3 vs 1%. Indexed correction notices not reconciled."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"CLOTS 1 — Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/19477503/","year":2009,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"PREVAIL — The efficacy and safety of enoxaparin versus unfractionated heparin for the prevention of venous thromboembolism after acute ischaemic stroke (PREVAIL Study): an open-label randomised comparison.","url":"https://pubmed.ncbi.nlm.nih.gov/17448820/","year":2007,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[]},{"id":"spasticity","title":"Spasticity and contracture prevention","category":"Recovery and rehabilitation","settings":["hospital","clinic"],"keywords":["tone","muscle overactivity","contracture","botulinum","pain","range of motion"],"summary":"Recognize poststroke spasticity early — pain, hygiene, positioning, mobility or care tasks affected by tone or restricted movement — and refer for rehabilitation assessment before contracture and secondary impairment set in. The AHA 2026 statement defines early treatment as within 3 months of stroke onset (a working definition); for established spasticity, botulinum toxin has the most early-treatment evidence (mainly short-term reduction in muscle overactivity; functional gains less consistent). Higher risk: severe initial sensorimotor impairment, early hyperreflexia or spasticity, hemorrhage, NIHSS ≥10, or lesions >3 cm or in the corticospinal tract, internal capsule, basal ganglia or brainstem.","consider":["What active and passive functional goals matter to the patient and caregiver?","Is timely specialist or rehabilitation assessment needed?"],"caution":"Increased tone is not the only cause of impaired movement; treatment follows a functional assessment.","sources":[{"title":"AHA Scientific Statement 2026: Early Recognition and Intervention for Poststroke Spasticity","url":"https://pubmed.ncbi.nlm.nih.gov/41608795/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-22","access":"PMC body text read (PMC13063836; Table and figures not in the retrieved text); correction 42044236 (Stroke 2026;57(5):e193) not reconciled; the 2026 AHA/ASA rehabilitation guideline was not reviewed for spasticity."}],"related":[]},{"id":"aphasia","title":"Aphasia and communication rehabilitation","category":"Recovery and rehabilitation","settings":["hospital","clinic"],"keywords":["speech","language","communication","SLT","SLP","comprehension","delirium"],"summary":"Offer speech-language therapy of at least 20 h in total (ESO 2025, recommended), ideally ≥3 h a week on ≥4 days (suggested), tailored to the communication activities that matter to the patient and to language-task difficulty, in person with digital augmentation, one-to-one or in groups (all suggested). Use tDCS alongside therapy only within high-quality trials (ESO expert consensus; benefit uncertain).","consider":["Are assessment and shared decisions adapted to language impairment?","Is the therapy plan feasible, sufficiently supported and reassessed as needs change?"],"caution":"Aphasia does not establish impaired decision-making capacity; the ≥20 h recommendation rests on low-quality evidence, and certainty differs across therapy comparisons.","sources":[{"title":"ESO Guideline 2025: Aphasia Rehabilitation","url":"https://pubmed.ncbi.nlm.nih.gov/40401776/","year":2025,"type":"Guideline","checkedAt":"2026-10-21","access":"PMC full text read (PMC12098336)."}],"related":[]},{"id":"visual-recovery","title":"Visual impairment and neglect","category":"Recovery and rehabilitation","settings":["hospital","clinic"],"keywords":["hemianopia","diplopia","visual field","neglect","eye movements","vision","perception"],"summary":"Screen every adult with stroke for visual problems — central vision, eye movements, visual fields, neglect and perception — ideally by eye-team assessment or at least with a validated tool, because many patients cannot report visual symptoms (ESO 2025, suggested). Screen early: by ESO expert consensus this is feasible within 3–4 days and most patients can be assessed within the first week (timing is not an evidence-based recommendation). Refer eye-movement disorders to specialist eye services (meanwhile, partial or total occlusion can relieve diplopia; total occlusion leaves the patient monocular), start compensatory visual scanning training for field loss as early as feasible, and individualize neglect and perceptual treatment with occupational therapy, neuropsychology and eye-care teams (ESO 2025, suggested).","consider":["Has the patient been assessed for the relevant type of visual impairment?","Do reading, mobility or daily activities require adaptations and specialist input?","Are visual findings communicated to the rehabilitation and follow-up teams?"],"caution":"Different visual syndromes need different assessments, and this card does not establish driving fitness.","sources":[{"title":"ESO Guideline 2025: Visual Impairment in Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/40401755/","year":2025,"type":"Guideline","checkedAt":"2026-10-21","access":"PMC full text read (PMC12098360)."}],"related":[{"label":"Acute retinal ischemia and CRAO","href":"#/evidence/retinal-ischemia"}]},{"id":"motor-recovery","title":"Motor recovery, walking and daily activity","category":"Recovery and rehabilitation","settings":["hospital","clinic"],"keywords":["gait","upper limb","arm recovery","balance","sit to stand","exercise","mobility"],"summary":"ESO 2025: add at least 20 h of repetitive upper-limb practice (weak, very low certainty) to improve arm capacity; offer high-intensity gait training to improve walking endurance in chronic stroke with stable cardiovascular status (strong, moderate certainty); add sit-to-stand training for balance (weak, moderate certainty). In subacute inpatient rehabilitation in Canada (12 units; mean 29 days after stroke), a structured, progressive walking protocol (at least 30 min of walking-related activity per session, progressed by heart rate and step count) improved 6-minute walk distance by 43.6 m (95% CI 12.7–76.1) more than usual care at 4 weeks, with no serious adverse events during sessions (Walk 'n Watch, stepped-wedge cluster RCT, 306 patients; postdates ESO 2025, not graded).","consider":["Which movement and participation goals are being measured over time?","Is practice linked to tasks the patient needs in daily life?","Do cardiovascular stability, endurance and access support the proposed training approach?"],"caution":"Results from chronic, stable stroke do not automatically apply during acute illness; dose needs a rehabilitation assessment. The August 2026 AHA/ASA rehabilitation guideline was not reviewed.","sources":[{"title":"ESO Guideline 2025: Motor Rehabilitation After Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/40401760/","year":2025,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract read; PMC returned no body text."},{"title":"2026 Guideline for Adult Stroke Rehabilitation and Recovery: A Guideline From the American Heart Association and American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/42657476/","year":2026,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed record and abstract read: published online 2026-08-27 (Stroke 2026;57(10):e514–e658); replaces the 2016 guideline; literature since 2016 searched June–October 2025, so later evidence is not reflected. No PMC copy; recommendations not reviewed or quoted. A correction was published 2026-10-26 (PMID 42932410; Stroke 2026;57(11):e700–e701); its content was not reviewed. Archive held only an access placeholder."},{"title":"VNS-REHAB — Vagus nerve stimulation paired with rehabilitation for upper limb motor function after ischaemic stroke (VNS-REHAB): a randomised, blinded, pivotal, device trial.","url":"https://pubmed.ncbi.nlm.nih.gov/33894832/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Walk 'n Watch — Safety and effectiveness of the Walk 'n Watch structured, progressive exercise protocol delivered by physical therapists for inpatient stroke rehabilitation in Canada: a phase 3, multisite, pragmatic, stepped-wedge, cluster-randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40683274/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."},{"title":"AVERT dose-response — Prespecified dose-response analysis for A Very Early Rehabilitation Trial (AVERT).","url":"https://pubmed.ncbi.nlm.nih.gov/26888985/","year":2016,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic identity and primary-abstract design checked: observational secondary dose-response analysis of AVERT, irrespective of randomized treatment assignment. This is not a randomized comparison of mobilization doses; Outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."}],"related":[]},{"id":"psychosocial-recovery","title":"Mood, anxiety, fatigue and psychosocial recovery","category":"Recovery and rehabilitation","settings":["hospital","clinic"],"keywords":["depression","anxiety","fatigue","stress","quality of life","psychosocial","caregiver"],"summary":"Screen for depression with a structured inventory (AHA/ASA AIS 2026, COR 1) and treat diagnosed depression (not a positive screen alone) with antidepressants and/or psychotherapy or other nonpharmacological options (COR 1). Ask about anxiety, fatigue and stress, and give patients and families education and access to interdisciplinary support. CSBPR 2025: routine prophylactic antidepressants for all survivors are not recommended (strong recommendation; moderate-quality evidence); supervised exercise, ideally at least 3 times a week, is recommended for mild (strong; high quality) or moderate (strong; moderate quality) depressive symptoms; antidepressants are not recommended for poststroke fatigue without depression or anxiety (strong; moderate quality).","consider":["Which emotional symptoms or fatigue are limiting recovery or daily life?","Is a concerning screen followed by clinical assessment and a practical care pathway?","Post-stroke fatigue (CSBPR 2025): screen for treatable contributors such as mood disorders, sleep disorders, other medical conditions and sedating medications (strong recommendation; low-quality evidence). Modafinil may be considered (conditional recommendation; low-quality evidence); CSBPR notes that no medication is approved specifically for post-stroke fatigue. Cognitive behavioral therapy or mindfulness-based stress reduction may be considered as adjuncts (strong recommendation; low-quality evidence)."],"caution":"A screening score is not a diagnosis, and fatigue or distress should not be assigned a single cause without assessment.","sources":[{"title":"Nursing's Role in Psychosocial Health Management After a Stroke Event: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/39155870/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"2026 Guideline for Adult Stroke Rehabilitation and Recovery: A Guideline From the American Heart Association and American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/42657476/","year":2026,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed record and abstract read: published online 2026-08-27 (Stroke 2026;57(10):e514–e658); replaces the 2016 guideline; literature since 2016 searched June–October 2025, so later evidence is not reflected. No PMC copy; recommendations not reviewed or quoted. A correction was published 2026-10-26 (PMID 42932410; Stroke 2026;57(11):e700–e701); its content was not reviewed. Archive held only an access placeholder."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Canadian Stroke Best Practice Recommendations Rehabilitation, Recovery, and Community Participation Following Stroke, Part Three: Optimizing Activity and Community Participation Following Stroke, 7th Edition Update, 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41258868/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PMC full text (PMC12928792) read 2026-10-31, including section 2 (sleep health and post-stroke fatigue: screening and management); only the prophylactic-antidepressant, supervised-exercise and fatigue recommendations are used, with strength and evidence quality as published."},{"title":"Suicide after stroke — Increased risk of suicide after stroke: A population-based matched cohort study.","url":"https://pubmed.ncbi.nlm.nih.gov/40913243/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"PHQ-2 worksheet","href":"#/tools/phq2"}]},{"id":"driving-work","title":"Driving, seizures and return to participation","category":"Recovery and rehabilitation","settings":["clinic"],"keywords":["driving","work","licensure","seizure","reporting","transportation","return to work"],"summary":"Discuss driving and return to work explicitly at follow-up, before the patient resumes either; seizures, cognitive impairment and medication effects can make driving unsafe. After seizures, the AAN 2025 position is that licensing should ordinarily require at least 3 seizure-free months, extended individually; seizures exclusively provoked by a factor unlikely to recur (e.g., major systemic infection with high fever) may need no interval, but a structural lesion such as stroke is an unfavorable factor that can extend it, and driving should pause during and after an antiseizure-medication taper unless another is started.","consider":["Are seizures, cognition, vision, motor function or medication effects relevant to the intended activity?","Have the applicable licensing rules and any specialist assessment requirements been checked?","What transport, workplace or rehabilitation support is needed?"],"caution":"A position statement is not state law or individual clearance; state seizure-free intervals vary (3 to 18 months) and should be followed. The August 2026 AHA/ASA rehabilitation guideline, which revises return-to-work and driving recommendations, was not reviewed.","sources":[{"title":"Seizures, Driver Licensure, and Medical Reporting Update: An AAN Position Statement","url":"https://pubmed.ncbi.nlm.nih.gov/40073306/","year":2025,"type":"Position statement","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (11 consensus positions); no PMC copy. The provoked-seizure example, stroke as an unfavorable factor and the 3–18-month state range are from the archived full-text transcription."},{"title":"AHA poststroke cognitive impairment: official overview","url":"https://professional.heart.org/en/science-news/cognitive-impairment-after-ischemic-and-hemorrhagic-stroke/top-things-to-know","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official summary read for differential assessment, comorbid delirium, home safety, driving and work considerations; full statement not re-reviewed."},{"title":"2026 Guideline for Adult Stroke Rehabilitation and Recovery: A Guideline From the American Heart Association and American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/42657476/","year":2026,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed record and abstract read: published online 2026-08-27 (Stroke 2026;57(10):e514–e658); replaces the 2016 guideline; literature since 2016 searched June–October 2025, so later evidence is not reflected. No PMC copy; recommendations not reviewed or quoted. A correction was published 2026-10-26 (PMID 42932410; Stroke 2026;57(11):e700–e701); its content was not reviewed. Archive held only an access placeholder."}],"related":[]},{"id":"poststroke-primary-care","title":"Long-term follow-up and primary care","category":"Recovery and rehabilitation","settings":["clinic"],"keywords":["falls","chronic care","caregiver","unmet needs","medication review","primary care"],"summary":"At every follow-up, reconcile risk-factor treatment and medications across clinicians, and rescreen cognition, mood, falls and unmet needs — they remain relevant beyond early recovery (AHA primary-care statement). For community-dwelling survivors over 50, within 5 years of stroke, who had left formal rehabilitation and could walk 10 m, a 6-month home-based physiotherapy/occupational therapy program (functional exercise, home-hazard reduction, community mobility coaching) cut the fall rate by a third over 12 months (FAST RCT, Australia, 370 patients; IRR 0.67, 95% CI 0.48–0.94), although the proportion who fell did not differ; it postdates the 2026 AHA/ASA rehabilitation guideline's literature search.","consider":["Have changes in function, falls, cognition or mood prompted reassessment?","Are patient and caregiver priorities linked to referrals and a named follow-up plan?"],"caution":"Prevention and rehabilitation plans need reassessment as health, function and support change.","sources":[{"title":"AHA/ASA Scientific Statement 2021: Primary Care of Adult Patients After Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/34261351/","year":2021,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"2026 Guideline for Adult Stroke Rehabilitation and Recovery: A Guideline From the American Heart Association and American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/42657476/","year":2026,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed record and abstract read: published online 2026-08-27 (Stroke 2026;57(10):e514–e658); replaces the 2016 guideline; literature since 2016 searched June–October 2025, so later evidence is not reflected. No PMC copy; recommendations not reviewed or quoted. A correction was published 2026-10-26 (PMID 42932410; Stroke 2026;57(11):e700–e701); its content was not reviewed. Archive held only an access placeholder."},{"title":"FAST — Home based, tailored intervention to reduce rate of falls after stroke (FAST): randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41876122/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; PMC full text (PMC13010266) not read."}],"related":[]},{"id":"poststroke-cognition","title":"Cognition after stroke and vascular brain injury","category":"Brain health and cognition","settings":["hospital","clinic"],"keywords":["cognitive impairment","dementia","vascular cognitive impairment","memory","executive function","delirium"],"summary":"Screen cognition after stroke against the person's baseline; vascular injury and preexisting neurodegeneration can interact, so look for associated conditions and plan safety, supports and follow-up across disciplines (AHA 2023). Impairment affects independence, employment and relationships. The VasCog-2-WSO criteria (2025 international Delphi consensus, WSO-endorsed) offer an international standard for diagnosing vascular cognitive impairment and dementia.","consider":["What has changed from the person’s cognitive and functional baseline?","Are language, mood, sensory limitations or acute illness affecting assessment?","Does the care plan address everyday safety, supports and follow-up evaluation?"],"caution":"A single screen does not identify the cause or establish permanent impairment.","sources":[{"title":"AHA Scientific Statement 2023: Cognitive Impairment After Ischemic and Hemorrhagic Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/37125534/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Vascular Contributions to Cognitive Impairment and Brain Health: Clinical Update and Mechanistic Considerations: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/42186798/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment","url":"https://pubmed.ncbi.nlm.nih.gov/34746430/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 35300261 not reconciled."},{"title":"Revised Diagnostic Criteria for Vascular Cognitive Impairment and Dementia-The VasCog-2-WSO Criteria","url":"https://pubmed.ncbi.nlm.nih.gov/40955506/","year":2025,"type":"Consensus statement","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31 (three Delphi survey rounds, 49–54 participants; WSO-endorsed); PMC full text (PMC12441927) not read."}],"related":[]},{"id":"sleep-brain-health","title":"Sleep disorders and brain health","category":"Brain health and cognition","settings":["hospital","clinic"],"keywords":["sleep apnea","OSA","insomnia","sleep fragmentation","circadian","STOP-Bang"],"summary":"Ask about sleep and insomnia, and consider evaluating ischemic stroke or TIA patients for sleep apnea (AHA 2021, 2b) with diagnostic testing rather than a questionnaire alone. Disturbed sleep is linked with worse cerebrovascular and cognitive outcomes, but treatment effects on those outcomes are not established (AHA 2024).","consider":["Are sleep-disordered breathing, insomnia or other sleep symptoms affecting recovery?","Does screening warrant diagnostic evaluation rather than an assumed diagnosis?","Are sleep symptoms and treatment feasibility included in follow-up?","Post-stroke PAP (postdating AHA 2024): a meta-analysis of 21 RCTs (1,457 patients in total) found fewer recurrent vascular events (OR 0.45) and less neurological deficit, but no gain in functional independence. The Sleep SMART trial of CPAP after ischemic stroke (registry enrollment 3,062) had not reported as of October 2026 (registry: active, not recruiting)."],"caution":"A screening questionnaire does not diagnose sleep apnea, and association does not prove that treatment prevents stroke or dementia.","sources":[{"title":"Impact of Sleep Disorders and Disturbed Sleep on Brain Health: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/38235581/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"SAVE — CPAP for Prevention of Cardiovascular Events in Obstructive Sleep Apnea.","url":"https://pubmed.ncbi.nlm.nih.gov/27571048/","year":2016,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Post-stroke PAP meta-analysis — Post-stroke sleep disordered breathing and the effect of positive airway pressure treatment: An updated systematic review and meta-analysis of randomized control trials.","url":"https://pubmed.ncbi.nlm.nih.gov/41297370/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31 (21 RCTs, 1,457 patients; recurrent vascular events OR 0.45; functional independence not improved); bibliographic record checked."}],"related":[{"label":"STOP-Bang worksheet","href":"#/tools/stop-bang"}]},{"id":"lifelong-brain-health","title":"Brain health across the life span","category":"Brain health and cognition","settings":["clinic"],"keywords":["brain health","cognitive resilience","cardiac brain health","cannabis","marijuana","environment","prevention"],"summary":"Address the vascular, sleep, mental-health and social factors relevant to the person's goals without overinterpreting observational findings; the 2026 AHA framework separates established knowledge from research questions.","consider":["Which vascular, sleep, mental-health or social factors are relevant to this person’s goals?","Does the proposed intervention have evidence for the outcome being claimed?"],"caution":"This framework is not a validated brain-health score or proof that any supplement, biomarker or lifestyle change prevents dementia.","sources":[{"title":"Brain Health Across the Life Span: A Framework for Future Studies: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/42047038/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"A Primary Care Agenda for Brain Health: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/33719523/","year":2021,"type":"Scientific statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"Use of Marijuana: Effect on Brain Health: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/35142225/","year":2022,"type":"Scientific statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"Cardiac Contributions to Brain Health: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/39387123/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 39705397 not reconciled."}],"related":[]},{"id":"antiamyloid-vascular-risk","title":"Antiamyloid therapy and cerebrovascular risk","category":"Brain health and cognition","settings":["on-call","hospital","clinic"],"keywords":["ARIA","amyloid","lecanemab","donanemab","Alzheimer","microbleeds","thrombolysis"],"summary":"Ask every suspected stroke patient about antiamyloid antibodies (lecanemab, donanemab): appropriate-use recommendations advise against thrombolysis in treated patients (donanemab: unless MRI unequivocally excludes ARIA), and the donanemab AUR says thrombectomy without thrombolysis should be considered for LVO. ARIA edema can mimic stroke and may be missed on CT/CTA, and fatal hemorrhages after IV thrombolysis have been reported.","consider":["Is current or recent antiamyloid treatment known, and when was the last infusion?","Could the presentation and imaging reflect ARIA, ischemia or another process?","Have the current drug label, imaging history and relevant specialists been consulted?"],"caution":"These are consensus recommendations, not trial evidence. If anticoagulation becomes necessary, the lecanemab AUR advises stopping infusions; standard-dose antiplatelet monotherapy is allowed, but the donanemab AUR makes no recommendation on dual antiplatelet therapy (insufficient safety data). The Encounter IVT checklist lists antiamyloid therapy as generally contraindicated. The AHA ARIA Summit proceedings (JAHA, August 2026; consensus-based, ungraded) advise three things for patients on antiamyloid therapy. With an LVO, skip bridging thrombolysis and go directly to thrombectomy. Thrombolysis should generally not be given when MRI is unavailable to exclude ARIA or shows ARIA. Thrombolytic order sets should list antiamyloid therapy as a relative contraindication. In select cases (MRI unavailable, high NIHSS, clear brainstem syndrome, more than 6–12 months of treatment), thrombolysis without MRI may be considered in consultation with neurology and radiology, although its safety is not established. For acute and subacute antithrombotics, aspirin monotherapy is reasonable; more data are needed, and caution is advised with DAPT or non-aspirin antiplatelets such as ticagrelor.","sources":[{"title":"Vascular Neurology Considerations for Antiamyloid Immunotherapy: A Science Advisory From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/39660440/","year":2024,"type":"Science advisory","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Lecanemab: Appropriate Use Recommendations","url":"https://pubmed.ncbi.nlm.nih.gov/37357276/","year":2023,"type":"Consensus statement","checkedAt":"2026-10-22","access":"PMC full text read (PMC10313141); concomitant-medication section re-read 2026-10-22 (thrombolytics, anticoagulants, standard-dose antiplatelets)."},{"title":"Donanemab: Appropriate Use Recommendations","url":"https://pubmed.ncbi.nlm.nih.gov/40155270/","year":2025,"type":"Consensus statement","checkedAt":"2026-10-22","access":"PMC full text read (PMC12180672); sections 5.2 (antiplatelet monotherapy allowed, no recommendation on dual therapy) and 5.3 (thrombolysis) re-read 2026-10-22."},{"title":"AHA ARIA Summit proceedings: antiamyloid therapy and stroke","url":"https://pubmed.ncbi.nlm.nih.gov/42622140/","year":2026,"type":"Consensus statement","checkedAt":"2026-10-31","access":"PMC full text (PMC13695822) read 2026-10-31: emergency imaging and treatment workflow, and acute and subacute antithrombotics; consensus-based, ungraded."}],"related":[]},{"id":"in-hospital-stroke","title":"In-hospital stroke recognition and response","category":"Systems and transitions of care","settings":["on-call","hospital"],"keywords":["code stroke","inpatient stroke","rapid response","hospital systems","stroke alert"],"summary":"Train all staff to activate the in-hospital stroke alert and give responders immediate neurological expertise (AHA 2022 statement); use an organized protocol for emergent evaluation of acute deficits at any age (AHA 2026, COR 1). Hand over time last known well, the examination, imaging and recent procedures, and track delays for quality review.","consider":["Can staff immediately activate the stroke response from this location?","Are timing, examination, imaging and relevant recent procedures communicated to the response team?","Are transfer barriers and delays captured for review?"],"caution":"Being in a monitored setting does not ensure timely recognition. In US GWTG-Stroke registry data for 2016–2023, in-hospital strokes (3.8% of ischemic stroke admissions) waited longer from recognition to CT (median 51 vs 18 min), were more severe, and had higher in-hospital mortality (adjusted OR 2.27) than community-onset strokes.","sources":[{"title":"Identifying Best Practices to Improve Evaluation and Management of In-Hospital Stroke: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/35137601/","year":2022,"type":"Scientific statement","checkedAt":"2026-10-21","access":"Primary abstract re-read: five core elements of an ungraded statement."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"GWTG-Stroke in-hospital stroke 2016–2023 — In-Hospital Stroke Quality and Outcomes in the Mechanical Thrombectomy Era: Get With The Guidelines-Stroke, 2016 to 2023.","url":"https://pubmed.ncbi.nlm.nih.gov/42145105/","year":2026,"type":"Observational study","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. US registry; the abstract lists no stroke-severity adjustment for mortality."}],"related":[{"label":"Encounter","href":"#/encounter"}]},{"id":"rural-telestroke","title":"Rural care, telestroke and transfer networks","category":"Systems and transitions of care","settings":["on-call","hospital"],"keywords":["rural","telestroke","telehealth","transfer","mobile stroke unit","destination","virtual network"],"summary":"Without in-house stroke expertise, use telestroke for IVT decisions (AHA 2026, COR 1) and teleradiology for rapid image review (COR 1); EMS should go to the closest appropriate stroke-capable hospital (COR 1), although for suspected LVO direct transport to a locally accessible thrombectomy center is reasonable (2a). Where there is neither a well-coordinated stroke system nor a local hospital proficient in thrombolysis and secondary transfer, direct transport to the closest thrombectomy-capable center may be reasonable if it does not disqualify the patient from IVT (2b). In a well-coordinated stroke system with a local stroke center proficient in thrombolysis and secondary transfer, bypassing it for a distant thrombectomy-capable center (e.g., 45–60 min away) does not improve 3-month outcome (COR 3: No Benefit). Agree transfer protocols that minimize door-in-door-out time (COR 1).","consider":["What imaging, specialist and treatment capabilities are available at the referring and receiving sites?","Are clinical information, images and the transfer plan shared through a reliable process?","Is responsibility clear if connection, transport or destination capacity changes?","Bringing the team to the patient: at 13 nonurban stroke centers in Bavaria, a flying neurointerventional team cut median decision-to-puncture time by 89 min versus interhospital transfer and was associated with better 12-month mRS (adjusted common OR 2.03, 1.09–3.84) in a 12-month secondary analysis of a study that alternated the two systems by week (pseudo-randomized; n=146)."],"caution":"Technology and center labels do not establish current local capability.","sources":[{"title":"Identifying Best Practices for Improving the Evaluation and Management of Stroke in Rural Lower-Resourced Settings: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/39665145/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Creating Virtual Stroke Networks: Current and Future Role of Artificial Intelligence, Mobile Imaging Applications, and Telehealth in Triage and Treatment of Acute Ischemic Stroke: A Scientific Statement From the American Heart Association: The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists","url":"https://pubmed.ncbi.nlm.nih.gov/41342129/","year":2025,"type":"Scientific statement","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed. Correction 41871197 (2026) not read."},{"title":"Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities From the Prehospital Stroke System of Care Consensus Conference: A Consensus Statement From the American Academy of Neurology, American Heart Association/American Stroke Association, American Society of Neuroradiology, National Association of EMS Physicians, National Association of State EMS Officials, Society of NeuroInterventional Surgery, and Society of Vascular and Interventional Neurology: Endorsed by the Neurocritical Care Society","url":"https://pubmed.ncbi.nlm.nih.gov/33691507/","year":2021,"type":"Consensus statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 34181455 not reconciled."},{"title":"Targeted Nursing Interventions for Improving Stroke Care and Outcomes in the Rural Setting: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/41164866/","year":2025,"type":"Scientific statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management","url":"https://pubmed.ncbi.nlm.nih.gov/35300251/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"Telestroke care in resource-limited settings: A World Stroke Organization scientific statement","url":"https://pubmed.ncbi.nlm.nih.gov/42630091/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31: systematic literature review combined with a structured survey and consensus process (WSO Telestroke Committee); recommendations not reviewed."},{"title":"INTERACT4 — Intensive Ambulance-Delivered Blood-Pressure Reduction in Hyperacute Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/38752650/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"BEST-MSU — Prospective, Multicenter, Controlled Trial of Mobile Stroke Units.","url":"https://pubmed.ncbi.nlm.nih.gov/34496173/","year":2021,"type":"Observational study","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. PubMed lists 1 correction or notice; check it before applying results."},{"title":"RACECAT — Effect of Direct Transportation to Thrombectomy-Capable Center vs Local Stroke Center on Neurological Outcomes in Patients With Suspected Large-Vessel Occlusion Stroke in Nonurban Areas: The RACECAT Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35510397/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. PubMed lists 1 correction or notice; check it before applying results."},{"title":"GWTG-Stroke door-in-door-out — Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/37581671/","year":2023,"type":"Observational study","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: US registry-based retrospective study; bibliographic record checked."},{"title":"Target Stroke Phase III — Association of Component Strategies of the Target Stroke Phase 3 Nationwide Quality Improvement Program With Accelerated Door-to-Puncture and Door-In-Door-Out Times for Ischemic Stroke Endovascular Thrombectomy in the United States.","url":"https://pubmed.ncbi.nlm.nih.gov/41111412/","year":2025,"type":"Observational study","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: retrospective observational cohort from the GWTG-Stroke registry; bibliographic record checked."},{"title":"AI LVO-detection accuracy meta-analysis — Diagnostic Test Accuracy of Artificial Intelligence in Large Vessel Occlusion: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42028301/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: systematic review and diagnostic-accuracy meta-analysis of 11 studies; bibliographic record checked."},{"title":"Flying Intervention Team, 12-month outcome — One-year functional outcome of the Flying Intervention Team versus patient interhospital transfer in acute ischaemic stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/41947562/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (PMC13058261 not read); bibliographic record checked. Secondary analysis of a pseudo-randomized study that alternated the two systems by week."}],"related":[]},{"id":"transitions-care","title":"Transitions, discharge communication and continuity","category":"Systems and transitions of care","settings":["hospital","clinic"],"keywords":["discharge","handoff","pending results","care transitions","care partner","person-centered"],"summary":"Before discharge, confirm that the patient's priorities, medication plan, open questions and the named follow-up owner reach the next setting, and that patient and care partner have usable information and a way to get help (AHA transitions statement). Match information to the person's health literacy, language and cognition, for example with teach-back; supporting studies are heterogeneous and often underpowered (AHA 2026 health literacy statement).","consider":["Are the patient’s priorities and support needs reflected in the next setting of care?","Are medication plans, outstanding questions and responsibility for follow-up clearly communicated?","Have the patient and care partner received usable information and a way to seek help?"],"caution":"A completed discharge document does not establish a successful transition.","sources":[{"title":"Exploring the Inclusion of Person-Centered Care Domains in Stroke Transitions of Care Interventions: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/38557155/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Health Literacy and Communication in Stroke Prevention, Management, and Recovery: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/42877955/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31 (ungraded scientific statement); full text not read."}],"related":[]},{"id":"rehab-access","title":"Rehabilitation access and recovery barriers","category":"Systems and transitions of care","settings":["hospital","clinic"],"keywords":["insurance","authorization","transport","social determinants","health equity","care access"],"summary":"Match the rehabilitation plan to documented functional needs and check coverage, travel and caregiving barriers early; name who will resolve barriers and reassess if access is delayed (AHA statements).","consider":["Do coverage, travel, caregiving or other circumstances limit the proposed rehabilitation plan?","Are the recommended setting and services linked to documented functional needs?"],"caution":"Placement availability is not the same as clinical suitability.","sources":[{"title":"Improving Access to Stroke Rehabilitation and Recovery: A Policy Statement From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/40740119/","year":2025,"type":"Policy statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Social and Environmental Determinants of Stroke Functional Outcome and Strategies to Reduce Inequities: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/42109096/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."}],"related":[]},{"id":"stroke-program-quality","title":"Stroke programs, standards and quality improvement","category":"Systems and transitions of care","settings":["hospital","clinic"],"keywords":["certification","performance measures","quality improvement","staffing","program development","rehabilitation standards"],"summary":"Match staffing and expertise to the services the program promises, and measure processes and outcomes with named responsibility; certification alone does not establish capability (AHA program guidance). In a cluster RCT at 77 hospitals in China (21,603 patients with acute ischemic stroke), an AI-assisted clinical decision support system improved adherence to performance measures and lowered 3-month new vascular events (2.9 vs 3.9%; adjusted HR 0.74, 95% CI 0.58–0.93), without a difference in disability or mortality (GOLDEN BRIDGE II).","consider":["Do staffing, expertise and operating arrangements match the services the program promises?","Are processes and outcomes measured with clear responsibility for improvement?","Are acute and postacute teams using shared expectations for coordinated care?"],"caution":"Certification does not establish identical capability across sites.","sources":[{"title":"Ideal Foundational Requirements for Stroke Program Development and Growth: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/36748462/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"American Heart Association Standards for Postacute Stroke Rehabilitation Care","url":"https://pubmed.ncbi.nlm.nih.gov/40408522/","year":2025,"type":"Clinical policy","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Clinical Performance Measures for Stroke Rehabilitation: Performance Measures From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34348470/","year":2021,"type":"Performance measures","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2024 AHA/ASA Performance and Quality Measures for Spontaneous Intracerebral Hemorrhage: A Report From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/38695183/","year":2024,"type":"Performance measures","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"Society of Vascular and Interventional Neurology (SVIN) Stroke Interventional Laboratory Consensus (SILC) Criteria for Training Standards and Maintenance of Certification in Neurointervention","url":"https://pubmed.ncbi.nlm.nih.gov/41573319/","year":2025,"type":"Consensus statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. This is a neurointerventional training and certification white paper, not a procedural treatment protocol."},{"title":"GWTG-Stroke door-in-door-out — Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/37581671/","year":2023,"type":"Observational study","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: US registry-based retrospective study; bibliographic record checked."},{"title":"Target Stroke Phase III — Association of Component Strategies of the Target Stroke Phase 3 Nationwide Quality Improvement Program With Accelerated Door-to-Puncture and Door-In-Door-Out Times for Ischemic Stroke Endovascular Thrombectomy in the United States.","url":"https://pubmed.ncbi.nlm.nih.gov/41111412/","year":2025,"type":"Observational study","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: retrospective observational cohort from the GWTG-Stroke registry; bibliographic record checked."},{"title":"AI LVO-detection accuracy meta-analysis — Diagnostic Test Accuracy of Artificial Intelligence in Large Vessel Occlusion: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42028301/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: systematic review and diagnostic-accuracy meta-analysis of 11 studies; bibliographic record checked."},{"title":"GOLDEN BRIDGE II — Effect of a clinical decision support system on stroke care quality and outcomes in patients with acute ischaemic stroke (GOLDEN BRIDGE II): cluster randomised clinical trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41862204/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; PMC full text (PMC13003563) not read."}],"related":[]},{"id":"extended-window-ivt","title":"Wake-up and extended-window thrombolysis","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["wake up","unknown onset","DWI FLAIR","perfusion mismatch","EXTEND","WAKE-UP","late window","TRACE-III","TIMELESS","OPTION","TNK-PLUS","HOPE","EXPECTS","tenecteplase","alteplase","ETERNAL-LVO"],"summary":"Unknown onset within 4.5 h of symptom recognition with DWI–FLAIR mismatch and a DWI lesion <1/3 of the MCA territory: IVT can be beneficial (AHA 2026, 2a; WAKE-UP: mRS 0–1 53.3 vs 41.8%). Perfusion mismatch at 4.5–9 h, or within 9 h of the sleep midpoint, in patients ineligible for EVT: IVT can be beneficial (2a; EXTEND: 35.4 vs 29.5%, sICH 6.2 vs 0.9%). LVO at 4.5–24 h with salvageable tissue and no EVT access: IVT may be beneficial (2b; TRACE-III tenecteplase 33.0 vs 24.2%, sICH 3.0 vs 0.8%). With EVT planned, late tenecteplase added nothing (TIMELESS; TNK-PLUS; basilar: ATTENTION LATE).","recommendations":[{"text":"In AIS patients with unknown onset time who are within 4.5 hours of symptom recognition and have a DWI lesion smaller than one-third of MCA territory with no marked FLAIR signal change, IVT within 4.5 hours of symptom recognition can be beneficial to improve functional outcomes.","cor":"2a","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-100 · p. 44","id":"ais-2026-100"},{"text":"For AIS patients ineligible for EVT who have salvageable penumbra on automated perfusion imaging, IVT can be beneficial within 4.5–9 hours of last known well or within 9 hours of the midpoint of sleep for wake-up stroke.","cor":"2a","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-101 · p. 44","id":"ais-2026-101"},{"text":"In AIS patients with LVO and salvageable ischemic penumbra, presenting 4.5-24 hours from symptom onset or last known well, who cannot receive EVT, IVT directed by clinicians with expertise in thrombolytic stroke care may be beneficial to improve functional outcomes.","cor":"2b","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-102 · p. 44","id":"ais-2026-102"}],"consider":["Perfusion mismatch at 4.5–24 h without planned EVT (China): OPTION (non-LVO, tenecteplase; mRS 0–1 43.6 vs 34.2%, sICH 2.8 vs 0%) and HOPE (with or without LVO, alteplase; 40 vs 26%, sICH 3.8 vs 0.5%) were positive; both postdate the AHA 2026 evidence review (to March 2025) and are not graded there. Posterior circulation at 4.5–24 h, mostly mild, no EVT: EXPECTS (alteplase) functional independence 89.6 vs 72.6%.","ESO Annual Stroke Evidence Update (February 2026; the authors' interpretation, not a guideline recommendation): late-window (4.5–24 h) tenecteplase 'may be considered in carefully selected patients' with perfusion or MRI mismatch and limited established infarction; it notes that these trials enrolled highly selected patients, mostly with advanced imaging and often confirmed LVO.","Pin down last known well, symptom discovery and the imaging route (MRI mismatch vs automated perfusion). Wake-up stroke selected by non-contrast CT alone: tenecteplase did not improve mRS (TWIST, aOR 1.18; 95% CI 0.88–1.58); ESO 2023 recommends against it (strong recommendation, low-quality evidence).","ETERNAL-LVO (Australia; EVT-eligible hemispheric LVO with CT-perfusion mismatch within 24 h of onset, so the early window was included; controls had standard care, which could include IV alteplase; 79% had EVT; stopped early, n=242; postdates the AHA 2026 literature cutoff): tenecteplase did not improve mRS 0–1 or return to baseline (37 vs 43%; aRR 0.90, 0.66–1.21); sICH 4 vs 1%."],"caution":"Benefit beyond 9 h comes from imaging-selected trials in China (TRACE-III, OPTION, HOPE, EXPECTS); the 2a grades rest on WAKE-UP and EXTEND. Late IVT costs more sICH: in a 2026 meta-analysis of 18 RCTs beyond 4.5 h (11 perfusion- or MRI-selected, 7 allowing NCCT/CTA selection), sICH 3.2 vs 1.4% without higher 90-day mortality (13.7 vs 13.0%); in trial-level meta-regression, benefit was smaller where more patients had EVT.","sources":[{"title":"European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/33817340/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"WAKE-UP: MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset","url":"https://pubmed.ncbi.nlm.nih.gov/29766770/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary publication record checked."},{"title":"TRACE-III: Tenecteplase for Ischemic Stroke at 4.5 to 24 Hours without Thrombectomy","url":"https://pubmed.ncbi.nlm.nih.gov/38884324/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"TIMELESS: Tenecteplase for Stroke at 4.5 to 24 Hours with Perfusion-Imaging Selection","url":"https://pubmed.ncbi.nlm.nih.gov/38329148/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"OPTION: Tenecteplase for Acute Non-Large Vessel Occlusion 4.5 to 24 Hours After Ischemic Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/41642827/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"TNK-PLUS: Intravenous Tenecteplase Prior to Endovascular Treatment for Ischemic Stroke at 4.5 to 24 Hours","url":"https://pubmed.ncbi.nlm.nih.gov/42099212/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"HOPE: alteplase at 4.5–24 h with perfusion selection","url":"https://pubmed.ncbi.nlm.nih.gov/40773205/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"EXPECTS: alteplase for posterior circulation stroke at 4.5–24 h","url":"https://pubmed.ncbi.nlm.nih.gov/40174223/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"TWIST: tenecteplase in CT-selected wake-up stroke","url":"https://pubmed.ncbi.nlm.nih.gov/36549308/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"ESO expedited recommendation on tenecteplase (2023)","url":"https://pubmed.ncbi.nlm.nih.gov/37021186/","year":2023,"type":"Guideline","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed; full recommendation tables not reviewed."},{"title":"TRACE-5: tenecteplase for basilar occlusion within 24 h","url":"https://pubmed.ncbi.nlm.nih.gov/41655588/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"ATTENTION LATE: tenecteplase before EVT for late basilar occlusion","url":"https://pubmed.ncbi.nlm.nih.gov/42776543/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"ESO annual stroke evidence update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41706824/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PMC full text (PMC12915583) read 2026-10-31. ESO Guideline Board evidence review; its practice implications are the authors' interpretation, not guideline recommendations."},{"title":"EXTEND — Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/31067369/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"EPITHET — Effects of alteplase beyond 3 h after stroke in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET): a placebo-controlled randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/18296121/","year":2008,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ECASS4-EXTEND — Extending the time window for intravenous thrombolysis in acute ischemic stroke using magnetic resonance imaging-based patient selection.","url":"https://pubmed.ncbi.nlm.nih.gov/30947642/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CHABLIS-T II — Tenecteplase Thrombolysis for Stroke up to 24 Hours After Onset With Perfusion Imaging Selection: The CHABLIS-T II Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39744861/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"OPTION rationale and design — A multicenter, prospective, randomized, open-label, blinded endpoint trial of intravenous thrombolysis with tenecteplase for acute non-large vessel occlusion in extended time window (OPTION): Rationale and design.","url":"https://pubmed.ncbi.nlm.nih.gov/41169527/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record and notices checked; outcomes not reviewed here. Trial design report; this citation does not supply completed treatment outcomes."},{"title":"ETERNAL-LVO — Efficacy of Tenecteplase in Large Vessel Occlusion Stroke Within 24 Hours of Symptom Onset: The ETERNAL-LVO Randomized Controlled Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40927857/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Control arm (no IVT or alteplase), EVT eligibility and basilar exclusion from the ClinicalTrials.gov registry record NCT04454788."},{"title":"Extended-window IVT meta-analysis (18 RCTs) — Exploring Between-Study Heterogeneity in Extended-Window IV Thrombolysis for Acute Ischemic Stroke: A Meta-Analysis of 18 Randomized Controlled Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42475651/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."},{"title":"Late-window IVT meta-analysis (14 RCTs) — Intravenous Thrombolysis Beyond the Conventional Time Window for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42560675/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (PMC13448797 not read); bibliographic record checked."}],"related":[{"label":"Reperfusion overview","href":"#/evidence/acute-reperfusion"},{"label":"CT perfusion","href":"#/evidence/ct-perfusion"},{"label":"Ischemic stroke protocol","href":"#/protocols/ischemic"}]},{"id":"minor-stroke-antiplatelets","title":"Minor stroke, TIA and short-course antiplatelets","category":"Acute ischemic stroke","settings":["on-call","hospital","clinic"],"keywords":["minor stroke","nondisabling","DAPT","aspirin","clopidogrel","ticagrelor","CHANCE","POINT","THALES","INSPIRES","ARAMIS","TEMPO-2","TAPIS"],"summary":"Noncardioembolic minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4) within 24 h without IVT: aspirin plus clopidogrel with a loading dose for 21 days, then one agent (AHA 2026, COR 1). CHANCE: stroke 8.2 vs 11.7%; POINT: major ischemic events 5.0 vs 6.5% with major hemorrhage 0.9 vs 0.4%. Lower-grade options: ticagrelor plus aspirin for 30 days (NIHSS ≤5, or TIA with ABCD2 ≥6 or symptomatic stenosis ≥50%; COR 2b; THALES 5.5 vs 6.6%, severe bleeding 0.5 vs 0.1%); presumed atherosclerotic cause at 24–72 h (or NIHSS 4–5 within 24 h): clopidogrel plus aspirin for 21 days (COR 2a; INSPIRES 7.3 vs 9.2%); known CYP2C19 loss-of-function carriers: ticagrelor plus aspirin for 21 days, then ticagrelor, rather than clopidogrel-aspirin (COR 2b; CHANCE-2 6.0 vs 7.6%).","recommendations":[{"text":"In patients with minor noncardioembolic AIS (NIHSS 3 or less) or high-risk TIA (ABCD2 4 or greater) who did not receive IVT, DAPT (aspirin plus clopidogrel with loading dose) is recommended to be initiated within 24 hours of symptom onset and continued for 21 days, followed by single antiplatelet therapy, to reduce the 90-day risk of recurrent ischemic stroke.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-147 · p. 62","id":"ais-2026-147"},{"text":"In patients with recent (under 24 hours) minor noncardioembolic AIS (NIHSS 5 or less) or high-risk TIA (ABCD2 6 or greater, or symptomatic intracranial/extracranial stenosis 50% or greater) who did not receive IVT, DAPT with ticagrelor (including loading dose) plus aspirin for 30 days may be considered to reduce 30-day recurrent stroke risk.","cor":"2b","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-148 · p. 62","id":"ais-2026-148"},{"text":"In patients with minor noncardioembolic AIS (NIHSS 5 or less) or high-risk TIA (ABCD2 4 or greater) within 24-72 hours of onset (or NIHSS 4-5 within 24 hours) who did not receive IVT and have presumed atherosclerotic cause (50% or greater intracranial or extracranial stenosis or acute infarctions of presumed large artery origin), DAPT (clopidogrel plus aspirin) for 21 days followed by SAPT is reasonable to reduce 90-day recurrent stroke risk.","cor":"2a","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-149 · p. 62","id":"ais-2026-149"}],"consider":["Disabling deficit? Assess for IVT/EVT first. Non-disabling: DAPT was noninferior to alteplase (ARAMIS), and alteplase showed no benefit in PRISMS (stopped early).","Write the stop date (day 21 or 30) and the single agent to continue.","After IVT, two Chinese RCTs postdating AHA 2026 disagree: TAPIS (NIHSS 4–10; aspirin plus ticagrelor within 6 h of onset) improved mRS 0–1 (68.7 vs 62.0%; sICH 0.9 vs 0.7%, wide CI); EAST (NIHSS 0–5; clopidogrel plus aspirin within 6 h after IVT) did not (89.7 vs 89.6%). AHA 2026 rates the risk of antiplatelets in the first 24 h after IVT as uncertain (COR 2b, B-NR)."],"caution":"Do not extend DAPT beyond 21–30 days without a separate indication; bleeding rose with DAPT in POINT, THALES and INSPIRES.","sources":[{"title":"European Stroke Organisation expedited recommendation for the use of short-term dual antiplatelet therapy early after minor stroke and high-risk TIA","url":"https://pubmed.ncbi.nlm.nih.gov/34414300/","year":2021,"type":"Guideline","checkedAt":"2026-10-17","access":"PMC full text (PMC8370083) read: recommendations 1–2 with GRADE strength and quality."},{"title":"EAST: clopidogrel plus aspirin after IVT for minor stroke","url":"https://pubmed.ncbi.nlm.nih.gov/40973702/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"CHANCE — Clopidogrel with aspirin in acute minor stroke or transient ischemic attack.","url":"https://pubmed.ncbi.nlm.nih.gov/23803136/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"POINT — Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA.","url":"https://pubmed.ncbi.nlm.nih.gov/29766750/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"THALES — Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA.","url":"https://pubmed.ncbi.nlm.nih.gov/32668111/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"INSPIRES — Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/38157499/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CHANCE-2 — Ticagrelor versus Clopidogrel in CYP2C19 Loss-of-Function Carriers with Stroke or TIA.","url":"https://pubmed.ncbi.nlm.nih.gov/34708996/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"TAPIS — Ticagrelor with aspirin dual antiplatelet therapy combined with intravenous thrombolysis in patients with ischaemic stroke in China (TAPIS): a multicentre, double-blind, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42114550/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"TEMPO-2 — Tenecteplase versus standard of care for minor ischaemic stroke with proven occlusion (TEMPO-2): a randomised, open label, phase 3 superiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38768626/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ARAMIS — Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke: The ARAMIS Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37367978/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"PRISMS — Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits.","url":"https://pubmed.ncbi.nlm.nih.gov/29998337/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."}],"related":[{"label":"DAPT calculator","href":"#/encounter/dapt"},{"label":"TIA evaluation","href":"#/evidence/tia-evaluation"},{"label":"Reperfusion overview","href":"#/evidence/acute-reperfusion"}]},{"id":"thrombolytic-choice","title":"Thrombolytic agent and evidence selection","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["tenecteplase","TNK","TNKase","alteplase","tPA","reteplase","prourokinase","AcT","ATTEST-2","TRACE-2","ORIGINAL","EXTEND-IA TNK","bolus"],"summary":"Within 4.5 h use tenecteplase 0.25 mg/kg (max 25 mg) as a single bolus or alteplase 0.9 mg/kg (max 90 mg) (AHA 2026, COR 1); for LVO within 4.5 h, ESO 2023 recommends tenecteplase 0.25 mg/kg over alteplase (strong, moderate-quality evidence). Tenecteplase was noninferior in AcT, ATTEST-2 (OR 1.07), TRACE-2 and ORIGINAL, and doubled early reperfusion before EVT in EXTEND-IA TNK (22 vs 10%). Do not use tenecteplase 0.4 mg/kg (COR 3: No Benefit, LOE A). Reteplase or mutant prourokinase may be considered when EVT is not planned (2b).","recommendations":[{"text":"In adult AIS patients presenting within 4.5 hours of symptom onset or last known well who are eligible for IVT, tenecteplase 0.25 mg/kg (max 25 mg) or alteplase 0.9 mg/kg (max 90 mg) is recommended to improve functional outcomes.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-98 · p. 42","id":"ais-2026-98"},{"text":"In adult AIS patients presenting within 4.5 hours of symptom onset or last known well who are eligible for IVT, tenecteplase at a dose of 0.4 mg/kg is not recommended.","cor":"3: No Benefit","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-99 · p. 42","id":"ais-2026-99"}],"consider":["Use the agent and dose source your protocol specifies; dose by weight with the calculator.","Angioedema occurred in 1% with either agent (ATTEST-2): be ready to manage the airway and bleeding.","Not recommended: desmoteplase, urokinase, mutant prourokinase plus low-dose alteplase and adjunctive sonothrombolysis (COR 3: No Benefit); streptokinase is COR 3: Harm (higher early mortality)."],"caution":"US labels cover alteplase and (since February 2025) tenecteplase within 3 h of onset, while AHA 2026 (COR 1) supports either agent to 4.5 h; the tenecteplase label uses five weight bands (15–25 mg), above 0.25 mg/kg below 100 kg (0.33 mg/kg at 45 kg), reaching 0.4 mg/kg (rated COR 3: No Benefit) at 37.5 kg or less. A positive trial does not establish local approval or availability of a newer thrombolytic.","sources":[{"title":"European Stroke Organisation (ESO) expedited recommendation on tenecteplase for acute ischaemic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/37021186/","year":2023,"type":"Guideline","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed; full recommendation tables not reviewed."},{"title":"RAISE: Reteplase versus Alteplase for Acute Ischemic Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/38884332/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked; no approval or availability inferred."},{"title":"Food and Drug Administration Approval of Tenecteplase: What This Means for the Field of Acute Stroke Treatment (editorial reproducing the US label dosing table)","url":"https://pubmed.ncbi.nlm.nih.gov/41573708/","year":2025,"type":"Report","checkedAt":"2026-10-21","access":"PMC full text (PMC12697625): label approval date, 3-h window and weight-band table; the FDA label was not reachable."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"AcT — Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35779553/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"TRACE-2 — Tenecteplase versus alteplase in acute ischaemic cerebrovascular events (TRACE-2): a phase 3, multicentre, open-label, randomised controlled, non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/36774935/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ORIGINAL — Tenecteplase vs Alteplase for Patients With Acute Ischemic Stroke: The ORIGINAL Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39264623/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"TNK vs alteplase · RWE — Real-world efficacy and safety of Tenecteplase versus Alteplase in acute ischemic stroke: a propensity score-matched analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42206304/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. Outcome interpretation unresolved, so no summary is shown."},{"title":"TASTE — Tenecteplase versus alteplase for thrombolysis in patients selected by use of perfusion imaging within 4·5 h of onset of ischaemic stroke (TASTE): a multicentre, randomised, controlled, phase 3 non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38880118/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"T-FLAVOR — Standard-Dose Tenecteplase vs Low-Dose Alteplase for Acute Ischemic Stroke From Large-Vessel Occlusion: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42223935/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ATTEST-2 — Tenecteplase versus alteplase for acute stroke within 4·5 h of onset: a randomised, parallel group, open-label trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39424558/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"EXTEND-IA TNK — Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/29694815/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed; bibliographic record checked."}],"related":[{"label":"Tenecteplase dose","href":"#/encounter/tnk"},{"label":"Alteplase dose","href":"#/encounter/alteplase"},{"label":"Post-IVT complications","href":"#/evidence/post-ivt-complications"}]},{"id":"evt-selection","title":"Thrombectomy selection and bridging thrombolysis","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["thrombectomy","EVT","LVO","early window","late window","DAWN","DEFUSE3","HERMES","bridging","SWIFT DIRECT","MR CLEAN-NO IV","DIRECT-MT","BRIDGE-TNK","drip and ship","MILD-MT","LATE-MT","mild stroke","beyond 24 hours"],"summary":"Anterior LVO (ICA or M1), NIHSS ≥6, prestroke mRS 0–1: EVT within 6 h if ASPECTS 3–10, and at 6–24 h if ASPECTS ≥6, or ASPECTS 3–5 with age <80 and no significant mass effect (AHA 2026, COR 1). HERMES (5 RCTs, ≤12 h): mRS shift cOR 2.49; DAWN (6–24 h, clinical–core mismatch): mRS 0–2 49 vs 13%; DEFUSE 3 (6–16 h, perfusion mismatch): 45 vs 17%. Give IVT first when eligible and do not delay EVT; BRIDGE-TNK (China, ≤4.5 h) favored tenecteplase first (mRS 0–2 52.9 vs 44.1%). Outside these criteria, two open-label, perfusion-selected Chinese RCTs postdating AHA 2026 (not graded) found benefit with harms: MILD-MT (NIHSS <6, ≤24 h; mRS 0–1 69.4 vs 50.0%; serious procedural complications 13.2%) and LATE-MT (24–72 h; mRS shift cOR 1.74; sICH 4.8 vs 0%; 90-day mortality 6.0 vs 1.8%).","recommendations":[{"text":"In AIS patients with anterior circulation proximal LVO (ICA or M1), presenting within 6 hours of symptom onset, with NIHSS 6 or greater, prestroke mRS 0-1, and ASPECTS 3-10, EVT (endovascular thrombectomy) is recommended to improve functional outcomes and reduce mortality.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-114 · p. 53","id":"ais-2026-114"},{"text":"In AIS patients with anterior circulation proximal LVO (ICA or M1) presenting 6-24 hours from symptom onset, with NIHSS 6 or greater, prestroke mRS 0-1, and ASPECTS 6 or greater, EVT is recommended to improve functional outcomes and reduce mortality.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-115 · p. 53","id":"ais-2026-115"},{"text":"In AIS patients with anterior circulation proximal LVO (ICA or M1) presenting within 6 hours, NIHSS 6 or greater, ASPECTS 6 or greater, and prestroke mRS of 2, EVT is reasonable to improve functional outcomes and reduce accumulated disability.","cor":"2a","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-118 · p. 53","id":"ais-2026-118"},{"text":"In AIS patients with anterior circulation proximal LVO (ICA or M1) presenting within 6 hours, NIHSS 6 or greater, ASPECTS 6 or greater, and prestroke mRS of 3-4, EVT might be reasonable to improve functional outcomes and reduce accumulated disability.","cor":"2b","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-119 · p. 53","id":"ais-2026-119"}],"consider":["Prestroke mRS 2 (2a) or 3–4 (2b): graded only for ICA/M1 within 6 h with NIHSS ≥6 and ASPECTS ≥6.","Direct to angiography may be considered (2b each): transfers without repeat imaging unless the exam changed or transfer was delayed; EMS arrivals with a positive LVO scale, imaged by flat-panel CT. DIRECT ANGIO (France, 2026; postdates AHA 2026; direct arrivals ≤85 y within 5 h selected by neurologist exam, not a prehospital scale) stopped early for safety: more sICH (15 vs 0%), no evidence of functional benefit (small and imprecise).","ASPECTS ≥6 at 6–24 h keeps COR 1: in July 2026 the writing group declined a request from DAWN/DEFUSE investigators to downgrade it to 2b, while noting an unresolved observational mortality signal favoring perfusion selection (NO-SELECT trial ongoing).","MILD-MT and LATE-MT (NEJM 2026; postdate AHA 2026; no grade) selection: MILD-MT ICA/M1/M2, NIHSS <6 at randomization, core ≤50 mL and mismatch ≥50 mL, ≤24 h (registry also: age 18–80, prestroke mRS 0, ASPECTS ≥6); sICH 3 patients per arm. LATE-MT (registry) ICA–M2, NIHSS ≥6, prestroke mRS ≥2 excluded, CTP core <50 mL with mismatch ratio ≥1.8 and volume ≥15 mL, 24–72 h (median 38.5 h). Single-country and open-label; decide case by case with the neurointerventional team."],"caution":"Only DIRECT-MT and DEVT (both China) found EVT alone noninferior; SWIFT DIRECT, MR CLEAN-NO IV, SKIP, DIRECT-SAFE and the IRIS meta-analysis did not. Give IVT whenever eligible.","sources":[{"title":"European Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischaemic StrokeEndorsed by Stroke Alliance for Europe (SAFE)","url":"https://pubmed.ncbi.nlm.nih.gov/31165090/","year":2019,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"European Stroke Organisation - European Society for Minimally Invasive Neurological Therapy expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischaemic stroke and anterior circulation large vessel occlusion","url":"https://pubmed.ncbi.nlm.nih.gov/35300256/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed. Indexed correction(s) 37021163 not reconciled."},{"title":"AHA/ASA writing group response: EVT imaging selection in the 6–24 h window","url":"https://pubmed.ncbi.nlm.nih.gov/42535264/","year":2026,"type":"Report","checkedAt":"2026-10-21","access":"PMC full text (PMC13491549) read: request to downgrade recommendation 4.7.2 #2 declined; July 2026 print edition adds supporting text."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Canadian Stroke Best Practice Recommendations: Endovascular Thrombectomy for Acute Ischemic Stroke, Interim Update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41340372/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed abstract only. The update addresses posterior circulation stroke, large core and MeVO, and supersedes the EVT recommendations in the 2022 CSBPR acute stroke management module; recommendation wording and evidence levels were not read (publisher and strokebestpractices.ca not reached), so nothing is quoted on the cards."},{"title":"DAWN — Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct.","url":"https://pubmed.ncbi.nlm.nih.gov/29129157/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"DEFUSE-3 — Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging.","url":"https://pubmed.ncbi.nlm.nih.gov/29364767/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"DIRECT ANGIO — Safety and efficacy of direct versus conventional transfer to angiography suite in patients with severe acute stroke treated with thrombectomy (DIRECT ANGIO) in France: a multicentre, open-label, blinded-endpoint, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41864232/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"MILD-MT — Trial of Endovascular Therapy for Mild Stroke with Large-Vessel Occlusion.","url":"https://pubmed.ncbi.nlm.nih.gov/42929671/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card; NEJM full text not reviewed."},{"title":"LATE-MT — Mechanical Thrombectomy 24 to 72 Hours after Large-Vessel Ischemic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/42929656/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card; NEJM full text not reviewed."},{"title":"BRIDGE-TNK — Intravenous Tenecteplase before Thrombectomy in Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/40396577/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"MR CLEAN-LATE — Endovascular treatment versus no endovascular treatment after 6-24 h in patients with ischaemic stroke and collateral flow on CT angiography (MR CLEAN-LATE) in the Netherlands: a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37003289/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"MR CLEAN — A randomized trial of intraarterial treatment for acute ischemic stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25517348/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ESCAPE — Randomized assessment of rapid endovascular treatment of ischemic stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25671798/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"EXTEND-IA — Endovascular therapy for ischemic stroke with perfusion-imaging selection.","url":"https://pubmed.ncbi.nlm.nih.gov/25671797/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SWIFT PRIME — Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25882376/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"REVASCAT — Thrombectomy within 8 hours after symptom onset in ischemic stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/25882510/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"HERMES — Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.","url":"https://pubmed.ncbi.nlm.nih.gov/26898852/","year":2016,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"IRIS IPD meta-analysis — Value of intravenous thrombolysis in endovascular treatment for large-vessel anterior circulation stroke: individual participant data meta-analysis of six randomised trials.","url":"https://pubmed.ncbi.nlm.nih.gov/37640037/","year":2023,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"IRIS time-dependency analysis — Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke: A Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/38324409/","year":2024,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"DIRECT-MT — Endovascular Thrombectomy with or without Intravenous Alteplase in Acute Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/32374959/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"SKIP — Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/33464334/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. PubMed lists 1 correction or notice; check it before applying results."},{"title":"DEVT — Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke: The DEVT Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/33464335/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"MR CLEAN-NO IV — A Randomized Trial of Intravenous Alteplase before Endovascular Treatment for Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/34758251/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"SWIFT DIRECT — Thrombectomy alone versus intravenous alteplase plus thrombectomy in patients with stroke: an open-label, blinded-outcome, randomised non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35810756/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"DIRECT-SAFE — Endovascular thrombectomy versus standard bridging thrombolytic with endovascular thrombectomy within 4·5 h of stroke onset: an open-label, blinded-endpoint, randomised non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35810757/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"TNK-PLUS — Intravenous Tenecteplase Prior to Endovascular Treatment for Ischemic Stroke at 4.5 to 24 Hours: The TNK-PLUS Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42099212/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"ATTENTION LATE — Tenecteplase Before Thrombectomy at 4.5 to 24 Hours for Basilar Artery Occlusion: The ATTENTION LATE Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42776543/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."}],"related":[{"label":"DAWN screen","href":"#/encounter/dawn"},{"label":"DEFUSE 3 screen","href":"#/encounter/defuse3"},{"label":"CT perfusion","href":"#/evidence/ct-perfusion"},{"label":"Large core","href":"#/evidence/large-core-evt"},{"label":"Basilar occlusion","href":"#/evidence/basilar-occlusion"},{"label":"MeVO","href":"#/evidence/medium-distal-evt"}]},{"id":"large-core-evt","title":"Large-core infarction and thrombectomy","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["large core","ASPECTS","SELECT2","ANGEL-ASPECT","RESCUE-Japan LIMIT","TENSION","LASTE","TESLA"],"summary":"Large cores still benefit (AHA 2026): in anterior LVO (ICA or M1) with NIHSS ≥6 and prestroke mRS 0–1, EVT is COR 1 for ASPECTS 3–5 within 6 h (no age criterion) and at 6–24 h (age <80, no significant mass effect), and reasonable (2a) for ASPECTS 0–2 within 6 h (age <80, no significant mass effect). SELECT2: generalized OR 1.51 (mRS 0–2 20 vs 7%); ANGEL-ASPECT: GOR 1.37; RESCUE-Japan LIMIT: mRS 0–3 31.0 vs 12.7%; TENSION: cOR 2.58 with lower mortality; LASTE (ASPECTS ≤5 within 6.5 h): mortality 36.1 vs 55.5%; TESLA (NCCT ASPECTS 2–5, ≤24 h) missed its 90-day primary endpoint (posterior probability 0.96; 0.975 required), though at 1 year the utility-weighted mRS favored EVT (difference 1.18; 95% CI 0.42–1.93; reported by SVIN 2025). Expect more hemorrhage (ANGEL-ASPECT sICH 6.1 vs 2.7%).","recommendations":[{"text":"In AIS patients with anterior circulation proximal LVO (ICA or M1), presenting within 6 hours of symptom onset, with NIHSS 6 or greater, prestroke mRS 0-1, and ASPECTS 3-10, EVT (endovascular thrombectomy) is recommended to improve functional outcomes and reduce mortality.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-114 · p. 53","id":"ais-2026-114"},{"text":"In selected patients with AIS from anterior circulation proximal LVO (ICA or M1), presenting 6-24 hours from symptom onset, age under 80, NIHSS 6 or greater, prestroke mRS 0-1, ASPECTS 3-5, and without significant mass effect on imaging, EVT is recommended to improve functional outcomes and reduce mortality.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-116 · p. 53","id":"ais-2026-116"},{"text":"In selected AIS patients with anterior circulation proximal LVO (ICA or M1) presenting within 6 hours, age under 80, NIHSS 6 or greater, prestroke mRS 0-1, ASPECTS 0-2, and without significant mass effect, EVT is reasonable to improve functional outcomes and reduce mortality.","cor":"2a","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-117 · p. 53","id":"ais-2026-117"}],"consider":["Measure the core consistently (NCCT/MRI ASPECTS or CTP core) and confirm age, baseline mRS and mass effect.","Set expectations: the benefit is mostly less disability, not independence (LASTE median mRS 4 vs 6).","SVIN 2025: ASPECTS 0–5 within 6 h (age 18–80, mRS 0–1) is Class I (LASTE); ASPECTS 0–2 at 6–24 h — benefit uncertain (2b).","ATLAS (Lancet 2026; postdates AHA 2026 and SVIN 2025), IPD of 6 RCTs (n=1886): better mRS (aGenOR 1.63) and lower mortality (31.1 vs 37.3%) up to 24 h, consistent across ASPECTS and core strata; evidence is limited for core ≥150 mL beyond 6 h."],"caution":"Trial age limits: ANGEL-ASPECT ≤80; SELECT2 and TESLA ≤85; none in RESCUE-Japan LIMIT or TENSION; LASTE had no upper limit but required ASPECTS 4–5 at age ≥80 (registry: 3–5), so it gives no evidence for ASPECTS 0–2 at that age. All but TENSION (mRS ≤2) required prestroke mRS 0–1.","sources":[{"title":"Endovascular Therapy in Patients With Acute Ischemic Stroke With Large Infarct: A Guideline From the Society of Vascular and Interventional Neurology","url":"https://pubmed.ncbi.nlm.nih.gov/41573174/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PMC full text (PMC12671639) re-read: 0–6 h Class I table and trial age/mRS limits; on 2026-10-31 also the TESLA 1-year utility-weighted mRS result and the Table 2 SELECT2 1-year mortality (45.3 vs 52.2%). The 6–24 h table did not render, so its 2b wording is from the archived transcription."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Canadian Stroke Best Practice Recommendations: Endovascular Thrombectomy for Acute Ischemic Stroke, Interim Update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41340372/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed abstract only. The update addresses posterior circulation stroke, large core and MeVO, and supersedes the EVT recommendations in the 2022 CSBPR acute stroke management module; recommendation wording and evidence levels were not read (publisher and strokebestpractices.ca not reached), so nothing is quoted on the cards."},{"title":"SELECT2 — Trial of Endovascular Thrombectomy for Large Ischemic Strokes.","url":"https://pubmed.ncbi.nlm.nih.gov/36762865/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card. PubMed lists 1 correction or notice; check it before applying results."},{"title":"SELECT2 1-year — Endovascular thrombectomy plus medical care versus medical care alone for large ischaemic stroke: 1-year outcomes of the SELECT2 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38346442/","year":2024,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; 1-year follow-up of the original randomized population."},{"title":"ANGEL-ASPECT — Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct.","url":"https://pubmed.ncbi.nlm.nih.gov/36762852/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ANGEL-ASPECT 1-year — Endovascular Therapy Versus Medical Management for Large Ischemic Infarct: 1-Year Outcomes of the ANGEL-ASPECT Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40854041/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; prespecified 1-year analysis of the original randomized population (complete-case, 425 of 455)."},{"title":"RESCUE-Japan LIMIT — Endovascular Therapy for Acute Stroke with a Large Ischemic Region.","url":"https://pubmed.ncbi.nlm.nih.gov/35138767/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"TENSION — Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37837989/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"LASTE — Trial of Thrombectomy for Stroke with a Large Infarct of Unrestricted Size.","url":"https://pubmed.ncbi.nlm.nih.gov/38718358/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ATLAS — Endovascular thrombectomy for patients with large-core ischaemic stroke presenting up to 24 h after onset (ATLAS): a systematic review and individual patient data meta-analysis with central imaging adjudication.","url":"https://pubmed.ncbi.nlm.nih.gov/42107392/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"TESLA — Thrombectomy for Stroke With Large Infarct on Noncontrast CT: The TESLA Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39374319/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"TESLA 1-year — One-Year Outcomes After Endovascular Treatment for Large Acute Ischemic Stroke: The TESLA Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42545711/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed bibliographic record checked (JAMA research letter; no abstract; PMC13434966 body empty; publisher site unreachable); results not reviewed here. Long-term follow-up of the original randomized population; the 1-year benefit on the card is sourced to the SVIN 2025 large-core guideline."},{"title":"TENSION antithrombotic analysis — Large Core Stroke Thrombectomy Is Safe and Effective Regardless of Prior Antithrombotic or Thrombolytic Treatment: A Secondary Analysis of the Randomized TENSION Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42261979/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. Secondary analysis; prior antithrombotic treatment was not the randomized intervention."},{"title":"LASTE ASPECTS 0-2 — Endovascular Thrombectomy in Patients With Largest Baseline Infarcts (ASPECTS 0-2): An Ancillary Analysis of the LASTE Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41979451/","year":2026,"type":"Report","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. Ancillary analysis of the randomized trial population."},{"title":"ANGEL-ASPECT HMCAS analysis — Effects of Computed Tomography Hyperdense Middle Cerebral Artery Sign on the Efficacy of Endovascular Therapy in Acute Ischemic Stroke With Large Infarcts: A Subgroup Analysis of the ANGEL-ASPECT Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41914357/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. Subgroup analysis; the imaging sign was not a randomized exposure."}],"related":[{"label":"ASPECTS","href":"#/encounter/aspects"},{"label":"CT perfusion","href":"#/evidence/ct-perfusion"},{"label":"Malignant infarction","href":"#/evidence/malignant-edema"}]},{"id":"basilar-occlusion","title":"Basilar artery occlusion","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["basilar","posterior circulation","BAO","LVO","ATTENTION","BAOCHE","BASICS","TRACE-5","ATTENTION LATE","pc-ASPECTS"],"summary":"Basilar occlusion with NIHSS ≥10, PC-ASPECTS ≥6 and baseline mRS 0–1: EVT within 24 h (AHA 2026, COR 1). ATTENTION (≤12 h): mRS 0–3 46 vs 23%, mortality 37 vs 55%; BAOCHE (6–24 h): 46 vs 24%. NIHSS 6–9: benefit not established (2b; ESO suggests best medical treatment for NIHSS <10). Give IVT if eligible (ESO suggests IVT plus EVT over direct EVT); TRACE-5 tenecteplase within 24 h improved mRS 0–1 or return to baseline (38 vs 29%), but ATTENTION LATE found no gain from tenecteplase before EVT at 4.5–24 h (30 vs 30%).","recommendations":[{"text":"In AIS patients with basilar artery occlusion, baseline mRS 0-1, NIHSS 10 or greater, and PC-ASPECTS 6 or greater (mild ischemic damage), EVT within 24 hours of symptom onset is recommended to achieve better functional outcome and reduce mortality.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-122 · p. 56","id":"ais-2026-122"},{"text":"In AIS patients with basilar artery occlusion, baseline mRS 0-1, NIHSS 6-9, and PC-ASPECTS 6 or greater, the effectiveness of EVT within 24 hours for improving functional outcomes and reducing mortality is not well established.","cor":"2b","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-123 · p. 57","id":"ais-2026-123"}],"consider":["A low NIHSS can understate posterior-circulation disability; recheck for fluctuation.","Very extensive bilateral or brainstem infarction: ESO consensus suggests no reperfusion; with PC-ASPECTS 0–6, weigh age, frailty and prestroke disability.","First pass: aspiration is suggested over a stent retriever (ESO, weak). With suspected intracranial atherosclerosis and severe basilar stenosis, ESO consensus (written before ANGEL-REBOOT) suggests rescue angioplasty or stenting after failed EVT; AHA 2026 rates rescue angioplasty or stenting after failed EVT as uncertain (2b)."],"caution":"Most trial patients were Chinese with severe deficits; evidence for mild BAO is weak.","sources":[{"title":"European Stroke Organisation and European Society for Minimally Invasive Neurological Therapy guideline on acute management of basilar artery occlusion","url":"https://pubmed.ncbi.nlm.nih.gov/38752743/","year":2024,"type":"Guideline","checkedAt":"2026-10-21","access":"PMC full text (PMC11569583) synoptic table read; certainty symbols did not render."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Canadian Stroke Best Practice Recommendations: Endovascular Thrombectomy for Acute Ischemic Stroke, Interim Update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41340372/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed abstract only. The update addresses posterior circulation stroke, large core and MeVO, and supersedes the EVT recommendations in the 2022 CSBPR acute stroke management module; recommendation wording and evidence levels were not read (publisher and strokebestpractices.ca not reached), so nothing is quoted on the cards."},{"title":"ATTENTION — Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion.","url":"https://pubmed.ncbi.nlm.nih.gov/36239644/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"BAOCHE — Trial of Thrombectomy 6 to 24 Hours after Stroke Due to Basilar-Artery Occlusion.","url":"https://pubmed.ncbi.nlm.nih.gov/36239645/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"BASICS — Endovascular Therapy for Stroke Due to Basilar-Artery Occlusion.","url":"https://pubmed.ncbi.nlm.nih.gov/34010530/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"VERITAS — Endovascular therapy for acute vertebrobasilar occlusion (VERITAS): a systematic review and individual patient data meta-analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/39674187/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"TRACE-5 — Tenecteplase versus standard medical treatment for basilar artery occlusion within 24 h (TRACE-5): a multicentre, prospective, randomised, open-label, blinded-endpoint, superiority, phase 3 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41655588/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ATTENTION LATE — Tenecteplase Before Thrombectomy at 4.5 to 24 Hours for Basilar Artery Occlusion: The ATTENTION LATE Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42776543/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ATTENTION 1-year secondary analysis — Endovascular vs Medical Management of Acute Basilar Artery Occlusion: A Secondary Analysis of a Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39186280/","year":2024,"type":"Report","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. Secondary follow-up analysis, not a new randomized trial. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ATTENTION 3-year follow-up — Endovascular vs Medical Treatment of Basilar Artery Occlusion: 3-Year Outcomes of the ATTENTION Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41460644/","year":2026,"type":"Report","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. Long-term follow-up of the original randomized population."}],"related":[{"label":"PC-ASPECTS","href":"#/encounter/pc-aspects"},{"label":"Acute dizziness","href":"#/evidence/dizziness"},{"label":"EVT technique and rescue","href":"#/evidence/neurointerventional-care"}]},{"id":"medium-distal-evt","title":"Medium and distal vessel occlusion","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["MeVO","DMVO","distal","M2","M3","dominant M2","ACA","PCA","DISTAL","ESCAPE-MeVO","DISCOUNT","ORIENTAL-MeVO"],"summary":"Routine EVT for medium or distal occlusion is not supported — AHA 2026 rates nondominant or codominant M2, distal MCA, ACA and PCA occlusion COR 3: No Benefit — but EVT is reasonable for a disabling dominant proximal M2 occlusion within 6 h with NIHSS ≥6, ASPECTS ≥6 and prestroke mRS 0–1 (AHA 2026, 2a). DISTAL (n=543) and ESCAPE-MeVO (n=530; mortality 13.3 vs 8.4%) showed no functional benefit, and DISCOUNT (n=244) stopped for futility and excess sICH (11 vs 3% among those treated). ORIENTAL-MeVO (China, NIHSS ≥6, ≤24 h) is the only positive trial (mRS 0–2 58.6 vs 46.6%; sICH 4.7 vs 2.2%). SVIN 2026 says EVT may be considered (2b) for distal, codominant or nondominant M2 with a disabling deficit and NIHSS ≥6, and rates disabling proximal and/or dominant M2 2a.","recommendations":[{"text":"In AIS patients with occlusion of the dominant proximal M2 division of the MCA presenting within 6 hours, prestroke mRS 0-1, NIHSS 6 or greater, and ASPECTS 6 or greater, EVT is reasonable to improve functional outcomes, though benefits are uncertain.","cor":"2a","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-120 · p. 53","id":"ais-2026-120"},{"text":"In AIS patients with occlusion of the proximal nondominant or codominant M2 segment, distal MCA, anterior cerebral artery, or posterior cerebral artery, EVT is not recommended as it does not improve functional outcomes.","cor":"3: No Benefit","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-121 · p. 54","id":"ais-2026-121"},{"text":"EVT is reasonable for patients with disabling stroke due to proximal and/or dominant M2 occlusions, particularly when associated with moderate-to-severe deficits and imaging evidence of salvageable brain tissue.","cor":"2a","loe":"B-NR","source":"SVIN MeVO 2026 · svin-mevo-dvo-evt-2026-r1","id":"svin-mevo-dvo-evt-2026-r1"},{"text":"EVT may be considered in distal, codominant, or nondominant M2 occlusions who present with disabling deficits and an NIHSS score ≥6.","cor":"2b","loe":"B-R","source":"SVIN MeVO 2026 · svin-mevo-dvo-evt-2026-r2","id":"svin-mevo-dvo-evt-2026-r2"}],"consider":["Confirm the segment (dominant vs codominant/nondominant M2, M3, ACA, PCA), a disabling deficit and IVT eligibility; give IVT if eligible.","SVIN 2026: routine EVT is not recommended for distal ACA (A2/A3) or isolated PCA occlusion (COR 3: No Benefit, B-NR) and is not standard for M3/M4 (COR 3: No Benefit, B-R); it may be considered case by case for ACA occlusion with disabling deficits, large territory at risk, favorable imaging and good baseline function (2b, B-NR), and in selected patients with P1–P3 occlusion who present early, have severe deficits or cannot receive IVT (2b, B-R).","Review ORIENTAL-MeVO's population limits with the intervention team.","Secondary analyses (2026; hypothesis-generating): in DISTAL, EVT was associated with a worse 90-day mRS when admission NIHSS was ≤4 (cOR 0.47; 95% CI 0.25–0.89) but not above 4 (cOR 1.05; 95% CI 0.75–1.47); in ESCAPE-MeVO (309 of 530 with baseline perfusion imaging), perfusion mismatch volume or ratio did not modify the EVT effect."],"caution":"The AHA 2026 grading predates ORIENTAL-MeVO and DISCOUNT; one positive Chinese trial does not establish benefit for every M2 or distal lesion.","sources":[{"title":"Endovascular Thrombectomy in Medium and Distal Vessel Occlusions: A Focused Guideline From the Society of Vascular and Interventional Neurology Guidelines and Practice Standards Committee","url":"https://pubmed.ncbi.nlm.nih.gov/42404835/","year":2026,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary full text (PMC13331429) checked for the quoted recommendations."},{"title":"DISTAL: Endovascular Treatment for Stroke Due to Occlusion of Medium or Distal Vessels","url":"https://pubmed.ncbi.nlm.nih.gov/39908430/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"ESCAPE-MeVO: Endovascular Treatment of Stroke Due to Medium-Vessel Occlusion","url":"https://pubmed.ncbi.nlm.nih.gov/39908448/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"ORIENTAL-MeVO: Endovascular Treatment of Medium-Vessel-Occlusion Strokes","url":"https://pubmed.ncbi.nlm.nih.gov/42127389/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Canadian Stroke Best Practice Recommendations: Endovascular Thrombectomy for Acute Ischemic Stroke, Interim Update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41340372/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PubMed abstract only. The update addresses posterior circulation stroke, large core and MeVO, and supersedes the EVT recommendations in the 2022 CSBPR acute stroke management module; recommendation wording and evidence levels were not read (publisher and strokebestpractices.ca not reached), so nothing is quoted on the cards."},{"title":"DISCOUNT — Mechanical Thrombectomy in Ischemic Stroke With a Medium or Distal Arterial Occlusion: The DISCOUNT Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42485024/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ORIENTAL-MeVO ACAo Registry — Endovascular Thrombectomy Versus Standard Medical Management in Acute Anterior Cerebral Artery Occlusion Stroke: The ORIENTAL-MeVO Registry Study.","url":"https://pubmed.ncbi.nlm.nih.gov/42017224/","year":2026,"type":"Observational study","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22; bibliographic record checked. Retrospective propensity-weighted registry analysis, not the randomized ORIENTAL-MeVO trial."},{"title":"DISTAL 12-month follow-up — Endovascular treatment for medium or distal vessel occlusion stroke (DISTAL): 12-month outcomes of a multicentre, open-label, randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42105785/","year":2026,"type":"Report","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked. Long-term follow-up of the original randomized population."},{"title":"DISTAL secondary analysis — Differential Effect of Endovascular Treatment in Medium or Distal Vessel Occlusion: A Distal Secondary Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42961033/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; secondary analysis of the randomized population, not a new trial."},{"title":"ESCAPE-MeVO perfusion post hoc — Thrombectomy for Acute Stroke Due to Medium Vessel Occlusion Across Perfusion Mismatch Profiles: A Post Hoc Analysis of the ESCAPE-MeVO Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42867860/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; exploratory post hoc analysis limited to 309 of 530 patients with baseline perfusion imaging."}],"related":[{"label":"DISCOUNT","href":"#/evidence/discount"},{"label":"ESCAPE-MeVO","href":"#/evidence/escape-mevo"}]},{"id":"retinal-ischemia","title":"Acute retinal ischemia and CRAO","category":"Acute ischemic stroke","settings":["on-call","hospital","clinic"],"keywords":["CRAO","retinal artery","monocular vision","amaurosis","retinal stroke","ophthalmology","THEIA","TenCRAOS","nonarteritic","alteplase","tenecteplase"],"summary":"Treat acute central retinal artery occlusion as an ischemic stroke emergency — immediate ED stroke evaluation, urgent ophthalmology, arteritis screening and vascular risk-factor treatment (AHA 2021 statement) — although IVT within 4.5 h for non-arteritic CRAO is of uncertain usefulness (AHA 2026, COR 2b). The grade applies to non-arteritic CRAO with disabling visual loss in an otherwise IVT-eligible adult within 4.5 h of last known well (AHA 2026, COR 2b, LOE C-LD): THEIA (alteplase vs aspirin) and TenCRAOS (tenecteplase vs aspirin) showed no significant visual benefit, and TenCRAOS had one fatal intracranial hemorrhage.","consider":["Confirm the ophthalmic diagnosis and onset; coordinate stroke and ophthalmology assessment.","Both trials studied nonarteritic CRAO; suspected arteritis needs its own pathway.","THEIA measured visual acuity and TenCRAOS a vision-recovery threshold; weigh safety alongside benefit.","ESO 2025 suggests IVT within 4.5 h for CRAO (weak wording; very low-quality nonrandomized evidence through 2023, before THEIA and TenCRAOS). The ESO Annual Stroke Evidence Update (February 2026; the authors' interpretation, not a guideline recommendation) states that THEIA and TenCRAOS do not support routine IVT for acute CRAO and encourages trial enrolment."],"caution":"Small neutral trials do not prove equivalence, and the 2021 AHA statement predates them. A 2025 individual-participant meta-analysis of nonrandomized studies (searched to June 2023; nonarteritic CRAO with severe vision loss; published after the AHA 2026 literature cutoff) associated IVT within 4.5 h with more recovery from severe vision loss than conservative care (28.8 vs 11.1%); its authors call for powered RCTs, and THEIA and TenCRAOS did not show benefit.","sources":[{"title":"Management of Central Retinal Artery Occlusion: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/33677974/","year":2021,"type":"Scientific statement","checkedAt":"2026-10-22","access":"Primary abstract read; ED-triage and arteritis-screening details from the archived transcription; full statement not reviewed. Indexed correction(s) 34029154 not reconciled."},{"title":"THEIA: Intravenous alteplase versus oral aspirin for acute central retinal artery occlusion within 4.5 hours of severe vision loss","url":"https://pubmed.ncbi.nlm.nih.gov/41109232/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"TenCRAOS: A Randomized Trial of Tenecteplase in Acute Central Retinal Artery Occlusion","url":"https://pubmed.ncbi.nlm.nih.gov/41604638/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked (population, comparison, outcomes and safety)."},{"title":"ESO guideline on visual impairment in stroke (2025)","url":"https://pubmed.ncbi.nlm.nih.gov/40401755/","year":2025,"type":"Guideline","checkedAt":"2026-10-17","access":"PMC full text (PMC12098360) read for PICO 9 and its evidence table."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"ESO annual stroke evidence update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41706824/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PMC full text (PMC12915583) read 2026-10-31. ESO Guideline Board evidence review; its practice implications are the authors' interpretation, not guideline recommendations."},{"title":"CRAO thrombolysis IPD meta-analysis — Early Thrombolysis and Outcomes in Central Retinal Artery Occlusion: An Individual Participant Data Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/40832714/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Nonrandomized studies searched to June 2023."}],"related":[]},{"id":"neurointerventional-care","title":"EVT technique, anesthesia and rescue questions","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["anesthesia","aspiration","stent retriever","tandem lesion","rescue stenting","angioplasty","intra arterial thrombolysis","adjuncts","EDESTROKE"],"summary":"Aim for eTICI 2b–3 as early as possible with a stent retriever, aspiration or both (AHA 2026, COR 1); general anesthesia or procedural sedation are both acceptable (COR 1). Tandem lesions: treating both may be reasonable (2b). Intra-arterial thrombolytic after mTICI ≥2b may be reasonable (2b); preprocedural tirofiban is not useful (COR 3: No Benefit). Rescue angioplasty or stenting after failed EVT remains uncertain (2b); in ANGEL-REBOOT (China; eTICI 0–2a or >70% residual stenosis after EVT, tirofiban in 96%) it did not improve 90-day mRS (cOR 0.86) and raised sICH (5 vs 1%); a later 1-year report (2025, after the AHA 2026 literature window) found a better mRS distribution (generalized OR 1.34), less same-artery recurrence (4 vs 13%) and similar mortality (15 vs 17%).","consider":["Document final eTICI, complications, access site and the BP plan for the receiving team. Tandem stenting or rescue stenting commits the patient to antiplatelets — weigh hemorrhage risk.","Avoid SBP drops during the procedure (prior ESO advice; the ESO 2025 BP update notes no study defines a safe drop).","Extubation timing after successful EVT under general anesthesia (EDESTROKE, JAMA Neurol 2026; single center in Spain; n=174, anterior-circulation LVO): early (<6 h) vs delayed (6–12 h) extubation did not improve 90-day mRS 0–2 (47.7 vs 45.9%; RR 1.04, 95% CI 0.76–1.43); pneumonia 21.8 vs 29.9% (RR 0.73, 95% CI 0.44–1.22) and reintubation 4.6 vs 2.3% were imprecise.","IA lytic after successful EVT: ANGEL-TNK, PEARL and CHOICE-2 improved mRS 0–1 (CHOICE-2 57.5 vs 42.5%), but 90-day mortality was higher with IA alteplase in CHOICE-2 (12.1 vs 6.4%, P=.03) and PEARL (17.1 vs 11.3%, not significant); POST-UK, POST-TNK and, in the posterior circulation, ATTENTION-IA and IAT-TOP were neutral. ANGEL-TNK and PEARL (2025) appeared after the AHA 2026 literature window (through March 2025), CHOICE-2 and IAT-TOP after the guideline itself."],"caution":"Technique choices depend on operator expertise and devices; this card is not a procedural protocol.","sources":[{"title":"European Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischaemic StrokeEndorsed by Stroke Alliance for Europe (SAFE)","url":"https://pubmed.ncbi.nlm.nih.gov/31165090/","year":2019,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"ANGEL-REBOOT 1-year outcomes: bailout intracranial angioplasty or stenting after thrombectomy","url":"https://pubmed.ncbi.nlm.nih.gov/41122847/","year":2025,"type":"Report","checkedAt":"2026-10-22","access":"Primary abstract read via PubMed on 2026-10-22. Long-term follow-up of the original randomized population (326 of 348 completed 1 year)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"2025 update to European Stroke Organisation (ESO) guideline on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/42095756/","year":2026,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (against intensive SBP lowering <140 in the first 24 h after successful thrombectomy, high certainty); other recommendations from the archived full-text transcription (reviewed 2026-09-30). Published in 2026 under a 2025-update title."},{"title":"CHOICE — Effect of Intra-arterial Alteplase vs Placebo Following Successful Thrombectomy on Functional Outcomes in Patients With Large Vessel Occlusion Acute Ischemic Stroke: The CHOICE Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35143603/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"CHOICE-2 — Adjunctive Intra-Arterial Alteplase After Successful Thrombectomy for Acute Ischemic Stroke: The CHOICE-2 Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42096239/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"ANGEL-REBOOT — Bailout intracranial angioplasty or stenting following thrombectomy for acute large vessel occlusion in China (ANGEL-REBOOT): a multicentre, open-label, blinded-endpoint, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38914085/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"PROTECT-MT — Balloon guide catheters for endovascular thrombectomy in patients with acute ischaemic stroke due to large-vessel occlusion in China (PROTECT-MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39579782/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"PEARL — Intra-Arterial Alteplase After Successful Endovascular Reperfusion in Acute Stroke: The PEARL Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42262770/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"ANGEL-TNK — Intra-arterial Tenecteplase for Acute Stroke After Successful Endovascular Therapy: The ANGEL-TNK Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40616323/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"IAT-TOP — Intra-arterial Alteplase Thrombolysis After Successful Thrombectomy for AIS in the Posterior Circulation: The IAT-TOP Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42026933/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"DATE (IA tenecteplase dose-escalation) — Intra-Arterial Tenecteplase After Successful Reperfusion in Large Vessel Occlusion Stroke: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40616333/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"IA Thrombolysis Dose Network Meta-analysis — Dose-Specific Intra-Arterial Thrombolysis After Endovascular Thrombectomy for Large-Vessel Occlusion Stroke: A Network Meta-Analysis of Randomized Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42088338/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: network meta-analysis of 7 randomized trials (2126 patients), hypothesis-generating per its authors; bibliographic record checked."},{"title":"ASTER — Effect of Endovascular Contact Aspiration vs Stent Retriever on Revascularization in Patients With Acute Ischemic Stroke and Large Vessel Occlusion: The ASTER Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/28763550/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"COMPASS (thrombectomy) — Aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion (COMPASS): a multicentre, randomised, open label, blinded outcome, non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/30860055/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"ASTER2 — Effect of Thrombectomy With Combined Contact Aspiration and Stent Retriever vs Stent Retriever Alone on Revascularization in Patients With Acute Ischemic Stroke and Large Vessel Occlusion: The ASTER2 Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/34581737/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"VECTOR — Safety and efficacy of stent retrievers plus contact aspiration in patients with acute ischaemic anterior circulation stroke and positive susceptibility vessel sign in France (VECTOR): a randomised, single-blind trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38876748/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"SIESTA — Effect of Conscious Sedation vs General Anesthesia on Early Neurological Improvement Among Patients With Ischemic Stroke Undergoing Endovascular Thrombectomy: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/27785516/","year":2016,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"GOLIATH — Effect of General Anesthesia and Conscious Sedation During Endovascular Therapy on Infarct Growth and Clinical Outcomes in Acute Ischemic Stroke: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/29340574/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"AnStroke — General Anesthesia Versus Conscious Sedation for Endovascular Treatment of Acute Ischemic Stroke: The AnStroke Trial (Anesthesia During Stroke).","url":"https://pubmed.ncbi.nlm.nih.gov/28522637/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CANVAS II — General Anesthesia vs Conscious Sedation for Endovascular Treatment in Patients With Posterior Circulation Acute Ischemic Stroke: An Exploratory Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/36156704/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"GA vs non-GA Bayesian meta-analysis — General Anesthesia Versus Non-GA in Endovascular Therapy for Acute Ischemic Stroke: A Systematic Review and Bayesian Meta-Analysis of RCTs.","url":"https://pubmed.ncbi.nlm.nih.gov/42462185/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"EDESTROKE — Early vs Delayed Extubation After Thrombectomy for Acute Ischemic Stroke: The EDESTROKE Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41910960/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; single-center trial; full text (PMC13036632) not reviewed."},{"title":"CERES-TANDEM — Emergent Carotid Stenting for Acute Anterior Circulation Ischemic Stroke With Tandem Lesions: The Multicenter CERES-TANDEM Study.","url":"https://pubmed.ncbi.nlm.nih.gov/41453121/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"IRIS tandem-lesion carotid-stenting analysis — Acute Carotid Stenting for Tandem Lesions in Patients Randomized to Endovascular Treatment With or Without Thrombolysis: Results From the IRIS Individual Participant Data Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/41104449/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"POST-TNK — Intra-Arterial Tenecteplase Following Endovascular Reperfusion for Large Vessel Occlusion Acute Ischemic Stroke: The POST-TNK Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39804681/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"POST-UK — Intra-Arterial Urokinase After Endovascular Reperfusion for Acute Ischemic Stroke: The POST-UK Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39804674/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"ATTENTION-IA — Intra-arterial tenecteplase after successful endovascular recanalisation in patients with acute posterior circulation arterial occlusion (ATTENTION-IA): multicentre randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39809509/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."}],"related":[{"label":"Post-EVT reference","href":"#/protocols/ischemic/post-evt"}]},{"id":"malignant-edema","title":"Malignant infarction: hemicraniectomy and cerebellar decompression","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["malignant infarction","edema","hemicraniectomy","decompressive craniectomy","DESTINY","DECIMAL","HAMLET","cerebellar infarct","suboccipital","hydrocephalus","osmotherapy"],"summary":"Age ≤60 with unilateral MCA infarction deteriorating within 48 h despite medical therapy: decompressive craniectomy (AHA 2026, COR 1) — pooled DECIMAL/DESTINY/HAMLET: survival 78 vs 29% and mRS ≤3 43 vs 21% (NNT 2 and 4). Over 60: may be considered to reduce mortality (2b); DESTINY II (61–82 y) doubled survival with mRS 0–4 (38 vs 18%), but no one reached mRS 0–2. Cerebellar infarction: ventriculostomy for obstructive hydrocephalus; suboccipital decompression for brainstem compression or volume ≥35 mL (COR 1).","recommendations":[{"text":"In patients 60 years of age or younger with unilateral MCA infarctions who deteriorate neurologically within 48 hours from brain swelling despite medical therapy, decompressive craniectomy with dural expansion is recommended to reduce mortality and improve functional outcome.","cor":"1","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-189 · p. 82","id":"ais-2026-189"},{"text":"In patients over 60 years of age with unilateral MCA infarctions who deteriorate neurologically within 48 hours from brain swelling despite medical therapy, decompressive craniectomy with dural expansion may be considered to reduce mortality.","cor":"2b","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-190 · p. 82","id":"ais-2026-190"},{"text":"In patients with cerebellar infarction and obstructive hydrocephalus, ventriculostomy is recommended to improve neurological function and decrease mortality. Concomitant or subsequent decompressive craniectomy may or may not be necessary based on infarction size, neurological condition, degree of brainstem compression, and effectiveness of medical management.","cor":"1","loe":"C-LD","source":"AHA/ASA AIS 2026 · ais-2026-192 · p. 84","id":"ais-2026-192"},{"text":"In patients with cerebellar infarction causing neurological deterioration from brainstem compression or infarct volumes 35 mL or greater, decompressive suboccipital craniectomy with dural expansion is recommended to improve outcomes and decrease mortality.","cor":"1","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-193 · p. 84","id":"ais-2026-193"}],"consider":["Discuss goals early and transfer large MCA or cerebellar infarcts to a neurosurgical center before they swell.","Falling consciousness from swelling is a reasonable trigger for surgery (2a); use osmotherapy only as a bridge.","Avoid hypothermia, barbiturates and corticosteroids for swelling (COR 3: Harm); IV glibenclamide did not help at ages 18–70 (COR 3: No Benefit)."],"caution":"Surgery saves lives, but most older survivors need help with daily care; decide with the outcomes the patient would accept.","sources":[{"title":"European Stroke Organisation (ESO) guidelines on the management of space-occupying brain infarction","url":"https://pubmed.ncbi.nlm.nih.gov/34414308/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"NCS acute treatment of cerebral edema guideline","url":"https://pubmed.ncbi.nlm.nih.gov/32227294/","year":2020,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract and source scope checked; full recommendation text not reviewed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"CHARM — Intravenous glibenclamide for cerebral oedema after large hemispheric stroke (CHARM): a phase 3, double-blind, placebo-controlled, randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39577921/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"DECIMAL — Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial).","url":"https://pubmed.ncbi.nlm.nih.gov/17690311/","year":2007,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"DESTINY — Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/17690310/","year":2007,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"HAMLET — Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/19269254/","year":2009,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"DESTINY II — Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/24645942/","year":2014,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"DECIMAL/DESTINY/HAMLET — Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials.","url":"https://pubmed.ncbi.nlm.nih.gov/17303527/","year":2007,"type":"Meta-analysis","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed; bibliographic record checked."}],"related":[{"label":"Prognosis","href":"#/evidence/neuroprognostication"},{"label":"Goals of care","href":"#/evidence/goals-of-care"}]},{"id":"acute-bp","title":"Acute blood pressure targets by pathway","category":"Acute ischemic stroke","settings":["on-call","hospital"],"keywords":["blood pressure","post EVT","post IVT","hypertension","permissive hypertension","ENCHANTED","OPTIMAL-BP","HOPE","INTERACT4","prehospital"],"summary":"Before IVT <185/110 (AHA 2026, COR 1); EVT without IVT: ≤185/110 before the procedure (AHA 2026, 2a); after IVT <180/105 for at least 24 h (COR 1); during and for 24 h after EVT ≤180/105 (AHA 2026, 2a; ESO 2025 update: <180/105), but do not target SBP <140 for 72 h after successful (mTICI 2b–3) anterior-LVO EVT (COR 3: Harm). The ESO 2025 update also advises against SBP <140 in the first 24 h after successful EVT (high certainty): ENCHANTED2/MT (<120) worsened mRS (OR 1.37), OPTIMAL-BP (<140) lowered mRS 0–2 from 54.4 to 39.4%, and Cochrane 2026 (9 RCTs after IVT or EVT; intensive targets <160, mostly <140, vs mostly <180) found probably higher mortality (RR 1.19, 95% CI 1.08–1.32). HOPE (2026, post-guideline; open-label, stopped early, hypothesis-generating) favored reperfusion-guided targets but does not override COR 3: Harm. No reperfusion and <220/120: starting treatment in the first 48–72 h does not help; ≥220/120: benefit uncertain (AHA 2026, 2b; ESO 2025 expert consensus: if lowered, reduce SBP by <15% over 24 h). No routine prehospital lowering (AHA 2026, COR 3: No Benefit; ESO 2025, moderate certainty; INTERACT4 ischemic stroke cOR 1.30).","recommendations":[{"text":"AIS patients with elevated BP who are otherwise eligible for IVT are recommended to have SBP lowered below 185 mmHg and DBP below 110 mmHg before initiating IVT therapy to reduce hemorrhagic complications.","cor":"1","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-72 · p. 35","id":"ais-2026-72"},{"text":"After IVT treatment, BP is recommended to be maintained below 180/105 mmHg for at least the first 24 hours.","cor":"1","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-74 · p. 35","id":"ais-2026-74"},{"text":"In patients who undergo EVT, it is reasonable to maintain BP at or below 180/105 mmHg during and for 24 hours after the procedure.","cor":"2a","loe":"B-NR","source":"AHA/ASA AIS 2026 · ais-2026-76 · p. 35","id":"ais-2026-76"},{"text":"In AIS patients with anterior circulation LVO who have been successfully recanalized by EVT (mTICI 2b, 2c, or 3) without other indications for specific BP targets, intensive SBP reduction to below 140 mmHg for the first 72 hours is harmful and not recommended.","cor":"3: Harm","loe":"A","source":"AHA/ASA AIS 2026 · ais-2026-77 · p. 35","id":"ais-2026-77"},{"text":"In patients with mild to moderate severity AIS treated with IVT, intensive SBP reduction (target below 140 mmHg compared with below 180 mmHg) is not recommended as it does not improve functional outcome.","cor":"3: No Benefit","loe":"B-R","source":"AHA/ASA AIS 2026 · ais-2026-75 · p. 35","id":"ais-2026-75"}],"consider":["After alteplase, SBP 130–140 did not improve 90-day function versus <180, though any ICH was less frequent (14.8 vs 18.7%) (ENCHANTED; AHA 2026 COR 3: No Benefit, graded for mild-to-moderate stroke); in its prespecified severe-stroke subgroup (LVO, EVT, large-artery disease or NIHSS >10), intensive lowering raised mortality (OR 1.52; hypothesis-generating).","Treat hypertension early when a comorbid condition requires it (e.g., ACS, heart failure, aortic dissection, post-IVT sICH, preeclampsia; AHA 2026 COR 1); correct hypotension and hypovolemia. For neurological deterioration without IVT or EVT, ESO 2025 discourages routine vasopressors to raise BP (low certainty).","Hold home oral antihypertensives while swallowing is unsafe; ESO advises against routinely continuing them in the acute phase."],"caution":"One number does not fit every pathway; ICH and long-term targets are on their own cards.","sources":[{"title":"2025 update to European Stroke Organisation (ESO) guideline on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/42095756/","year":2026,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; recommendation boxes and the >220/120 expert consensus not read at primary scope."},{"title":"The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/38804130/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"ENCHANTED (BP arm): intensive vs guideline BP lowering with alteplase","url":"https://pubmed.ncbi.nlm.nih.gov/30739745/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"Comparative effects of intensive-blood pressure versus standard-blood pressure-lowering treatment in patients with severe ischemic stroke in the ENCHANTED trial","url":"https://pubmed.ncbi.nlm.nih.gov/33031175/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-22","access":"Primary abstract read: prespecified subgroup of the ENCHANTED BP arm (1,311 severe ischemic strokes: LVO, EVT, large-artery disease or NIHSS >10); mortality OR 1.52 (1.09–2.13), clinician-reported ICH OR 0.63."},{"title":"Cochrane review: BP management in reperfused ischemic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/42445947/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed (9 RCTs; search to March 2025)."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"HOPE (reperfusion-guided BP) — Personalized Blood Pressure Targeting After Endovascular Therapy for Acute Ischemic Stroke: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42258192/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"INTERACT3 — The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37245517/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"ENCHANTED2/MT — Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/36341753/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"INTERACT2 — Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/23713578/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ATACH-2 — Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/27276234/","year":2016,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"OPTIMAL-BP — Intensive vs Conventional Blood Pressure Lowering After Endovascular Thrombectomy in Acute Ischemic Stroke: The OPTIMAL-BP Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37668619/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"INTERACT4 — Intensive Ambulance-Delivered Blood-Pressure Reduction in Hyperacute Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/38752650/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"CATIS — Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial.","url":"https://pubmed.ncbi.nlm.nih.gov/24240777/","year":2014,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CATIS-2 — Early versus delayed antihypertensive treatment in patients with acute ischaemic stroke: multicentre, open label, randomised, controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37813418/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ENOS — Efficacy of nitric oxide, with or without continuing antihypertensive treatment, for management of high blood pressure in acute stroke (ENOS): a partial-factorial randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/25465108/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."},{"title":"COSSACS — Effects of antihypertensive treatment after acute stroke in the Continue or Stop Post-Stroke Antihypertensives Collaborative Study (COSSACS): a prospective, randomised, open, blinded-endpoint trial.","url":"https://pubmed.ncbi.nlm.nih.gov/20621562/","year":2010,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SCAST — The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial.","url":"https://pubmed.ncbi.nlm.nih.gov/21316752/","year":2011,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CHASE — Controlling Hypertension After Severe Cerebrovascular Event (CHASE): A randomized, multicenter, controlled study.","url":"https://pubmed.ncbi.nlm.nih.gov/32525464/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Early AHT in AIS meta-analysis — Early antihypertensive therapy in acute ischemic stroke: A Meta-analysis of randomized controlled trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42546365/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"BP-TARGET — Safety and efficacy of intensive blood pressure lowering after successful endovascular therapy in acute ischaemic stroke (BP-TARGET): a multicentre, open-label, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/33647246/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"BEST-II — Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke: The BEST-II Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37668620/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"IDENTIFY — Early intensive blood pressure management after endovascular treatment in ischaemic stroke (IDENTIFY): a multicentre, open-label, blinded-endpoint, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40538518/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"OPTIMAL-BP 1-year — Intensive Versus Conventional Blood Pressure Lowering After Successful Endovascular Thrombectomy: OPTIMAL-BP 1-Year Outcomes.","url":"https://pubmed.ncbi.nlm.nih.gov/42212393/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; 1-year follow-up extension of the original randomized population (294 of 306 completed); summarized on the OPTIMAL-BP card."},{"title":"INTERACT1-4 pooled — Effects of blood pressure lowering in relation to time in acute intracerebral haemorrhage: a pooled analysis of the four INTERACT trials.","url":"https://pubmed.ncbi.nlm.nih.gov/40541207/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; individual-patient pooled analysis of four randomized trials, not a new trial. INTERACT3 (7,036 of 11,312 patients) tested a care bundle, and the time-from-onset effect comes from the CT substudy (2,921 patients)."},{"title":"Deep vs lobar ICH BP meta-analysis — Functional Outcomes After Intensive Blood Pressure Reduction in Deep and Lobar Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/41962119/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked. Study-level stepwise meta-analysis (ATACH-2 individual data; INTERACT2 and INTERACT3 published pooled results); poor outcome was mRS 4–6 in ATACH-2 and INTERACT3 and 3–6 in INTERACT2, and INTERACT3 tested a care bundle."},{"title":"BP lowering by hematoma location (INTERACT1–4 and ATACH-2 IPD) — Effects of Blood Pressure Lowering by Hematoma Location in Acute Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/42848972/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; bibliographic record checked; individual-patient pooled analysis of five randomized trials, not a new trial; full text not reviewed."}],"related":[{"label":"Ischemic BP protocol","href":"#/protocols/ischemic/bp"},{"label":"ICH protocol","href":"#/protocols/ich"},{"label":"ICH first-hour targets","href":"#/evidence/ich-management"}]},{"id":"antithrombotic-reversal","title":"Antithrombotic-associated ICH: reversal","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital"],"keywords":["reversal","PCC","4F-PCC","andexanet","Andexxa","idarucizumab","vitamin K","protamine","platelets","DDAVP","desmopressin","apixaban","rivaroxaban","warfarin","dabigatran"],"summary":"Anticoagulant-associated ICH: stop the anticoagulant and reverse it as soon as ICH is diagnosed (AHA 2022, COR 1); antiplatelet-associated ICH: no platelet transfusion unless neurosurgery is planned (NCS/SCCM 2026, conditional; AHA 2022 COR 3: Harm for aspirin). Factor Xa inhibitor: 4F-PCC rather than andexanet (NCS/SCCM 2026, conditional); andexanet (Andexxa) was withdrawn from the US market effective 22 December 2025. Warfarin with INR ≥2.0: 4F-PCC over FFP, then IV vitamin K (COR 1). Dabigatran: idarucizumab (2a). Unfractionated heparin: protamine (2a); LMWH: protamine may partially reverse (2b). On aspirin and going to neurosurgery: platelet transfusion (conditional). No recommendation on desmopressin or on reversal in small ICH.","recommendations":[{"text":"Immediate discontinuation of anticoagulation and rapid reversal are recommended as soon as possible after diagnosis of anticoagulant-associated spontaneous ICH to improve survival.","cor":"1","loe":"C-LD","source":"AHA/ASA ICH 2022 · ich-2022-26 · p. 19","id":"ich-2022-26"},{"text":"We suggest using 4-factor prothrombin complex concentrate rather than andexanet alfa in patients with factor Xa inhibitor-associated spontaneous ICH.","cor":"Conditional","loe":"Moderate","source":"NCS/SCCM 2026 · Rec 1-1","id":"ncs-reversal-2026-1-1"},{"text":"We suggest against administering platelet transfusions to patients with spontaneous intraparenchymal hemorrhage taking antiplatelet agents who do not require neurosurgical intervention.","cor":"Conditional","loe":"Low","source":"NCS/SCCM 2026 · Rec 2-1","id":"ncs-reversal-2026-2-1"},{"text":"We suggest administering platelet transfusions to patients with spontaneous intraparenchymal hemorrhage who were on aspirin therapy who require neurosurgical intervention.","cor":"Conditional","loe":"Very low","source":"NCS/SCCM 2026 · Rec 2-2","id":"ncs-reversal-2026-2-2"},{"text":"4-factor PCC is recommended over FFP for patients with VKA-associated spontaneous ICH and INR ≥ 2.0 to achieve rapid INR correction and limit hemorrhage expansion.","cor":"1","loe":"B-R","source":"AHA/ASA ICH 2022 · ich-2022-27 · p. 19","id":"ich-2022-27"},{"text":"Idarucizumab is reasonable for patients with dabigatran-associated spontaneous ICH to reverse the anticoagulant effect.","cor":"2a","loe":"B-NR","source":"AHA/ASA ICH 2022 · ich-2022-31 · p. 19","id":"ich-2022-31"}],"consider":["Record drug, dose, last intake and renal function; activated charcoal may help if a DOAC was taken within the previous few hours (2b).","Dabigatran without idarucizumab: PCC/aPCC or renal replacement therapy may be considered (2b).","Traumatic ICH: viscoelastic-assay-guided treatment if available (NCS/SCCM 2026)."],"caution":"ANNEXA-I's better hemostasis came with more thrombotic events and no functional gain; take doses from the ICH protocol.","sources":[{"title":"Treatment of Antithrombotic-Associated Intracranial Hemorrhage in Adults: A Focused Guideline Update from the Neurocritical Care Society and the Society of Critical Care Medicine","url":"https://pubmed.ncbi.nlm.nih.gov/42786382/","year":2026,"type":"Guideline","checkedAt":"2026-10-17","access":"Abstract rechecked 2026-10-17: direction and population of the recommendations it summarizes. GRADE strength and certainty were transcribed from the full text on 2026-09-30 and not re-verified (no PMC copy)."},{"title":"AABB news: AstraZeneca withdraws factor Xa reversal agent (Andexxa) from the U.S. market","url":"https://www.aabb.org/news-resources/news/article/2025/12/23/astrazeneca-withdraws-factor-xa-reversal-agent-from-u.s.-market","year":2025,"type":"Report","checkedAt":"2026-10-03","access":"News report dated 2025-12-23; withdrawal effective 2025-12-22, consistent with the archived 2026-09-26 safety review."},{"title":"European Stroke Organisation Guideline on Reversal of Oral Anticoagulants in Acute Intracerebral Haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/31903428/","year":2019,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine","url":"https://pubmed.ncbi.nlm.nih.gov/26714677/","year":2016,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"ANNEXA-I — Andexanet for Factor Xa Inhibitor-Associated Acute Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/38749032/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ANNEXA-4 — Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors.","url":"https://pubmed.ncbi.nlm.nih.gov/30730782/","year":2019,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Andexanet vs 4F-PCC meta-analysis — Efficacy and Safety of Andexanet Alfa Versus Four Factor Prothrombin Complex Concentrate for Emergent Reversal of Factor Xa Inhibitor Associated Intracranial Hemorrhage: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/39379749/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"ICH reversal protocol","href":"#/protocols/ich/reversal"},{"label":"Anticoagulant labels","href":"#/evidence/anticoagulant-labels"},{"label":"ANNEXA-I","href":"#/evidence/annexa-i"}]},{"id":"caa-ich-recurrence","title":"CAA, lobar hemorrhage and recurrence risk","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital","clinic"],"keywords":["CAA","amyloid angiopathy","lobar ICH","cortical superficial siderosis","convexity SAH","TFNE","CAA-ri","anticoagulation after ICH"],"summary":"In patients aged 50 or older, suspect CAA with lobar ICH, convexity SAH or transient focal episodes; MRI with blood-sensitive sequences looks for lobar microbleeds and cortical superficial siderosis (ICAA/WSO 2025). Recurrence risk rises with lobar location, older age, more lobar microbleeds, disseminated superficial siderosis, poor BP control, Asian or Black race and APOE ε2/ε4 (AHA 2022, 2a). Restarting antiplatelets may be reasonable (2b; RESTART: recurrent ICH 4 vs 9%, not significant). In AF after ICH, PRESTIGE-AF found fewer ischemic strokes but more recurrent ICH with DOACs; a 2025 meta-analysis of six RCTs (798 patients, including PRESTIGE-AF; postdates AHA 2022) found the same trade-off (ischemic stroke RR 0.20; recurrent ICH RR 3.14; all-cause mortality not different) — individualize; if anticoagulation is restarted, starting 7–8 weeks after ICH may be considered after weighing individual factors (AHA 2022, 2b); left atrial appendage closure may be considered if anticoagulation is not possible (2b).","consider":["Transient focal episodes may be CAA rather than TIA — avoid reflex antithrombotics.","Long-term BP <130/80 is reasonable after ICH (AHA 2022, 2a). RECAP-ICH (individual-participant meta-analysis of 4 trials; 2,944 ICH survivors, 75% Asian; postdates AHA 2022): BP-lowering treatment vs placebo or standard care (mean SBP difference 11.2 mm Hg) reduced recurrent stroke (6.5 vs 10.4%; HR 0.62), driven by fewer recurrent ICH (2.2 vs 5.6%; HR 0.39), without excess serious adverse events.","Ask about antiamyloid therapy; CAA changes those decisions.","ENRICH-AF (edoxaban vs no anticoagulation, antiplatelet monotherapy allowed, in AF after intracranial hemorrhage; 948 enrolled; completed July 2026; no peer-reviewed report as of October 2026): after a safety review of the first 699 patients, its DSMB advised halting enrollment of patients with lobar ICH (174) or isolated convexity SAH (34), subtypes typically caused by CAA and now excluded in the registry criteria, and stopping study drug in that subgroup (WSO 2025). A 2025 meta-analysis attributes this to excess recurrent intracranial bleeding; WSO 2025 notes that the data behind the recommendation were unpublished, and that an earlier individual-patient meta-analysis of four trials (412 patients) found no treatment interaction with lobar ICH or convexity SAH."],"caution":"Recurrence estimates are population averages, not an individual prognosis.","sources":[{"title":"Diagnosis and management of cerebral amyloid angiopathy: a scientific statement from the International CAA Association and the World Stroke Organization","url":"https://pubmed.ncbi.nlm.nih.gov/40721902/","year":2025,"type":"Scientific statement","checkedAt":"2026-10-22","access":"Primary abstract read; recommendations 1 (suspect CAA at age ≥50) and 4 (blood-sensitive MRI) from the archived transcription; full statement not reviewed."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"Ischemic stroke prevention in patients with atrial fibrillation and a recent ischemic stroke, TIA, or intracranial hemorrhage: A World Stroke Organization (WSO) scientific statement","url":"https://pubmed.ncbi.nlm.nih.gov/39719823/","year":2025,"type":"Scientific statement","checkedAt":"2026-10-31","access":"PMC full text (PMC11951358) read 2026-10-31. It grades the strength of evidence for each statement (for example B2, C1) instead of making clinical recommendations; the AF prevention card uses its device-detected AF (statement 11) and breakthrough-stroke (statements 16–19) evidence statements. The CAA and ICH recurrence card uses its ENRICH-AF DSMB paragraph, the 412-patient meta-analysis paragraph and statements 23–25."},{"title":"ENRICH-AF — Anticoagulation in patients with cerebral amyloid angiopathy.","url":"https://pubmed.ncbi.nlm.nih.gov/37839419/","year":2023,"type":"Report","checkedAt":"2026-10-31","access":"PubMed bibliographic record re-checked 2026-10-31 (Lancet 2023;402:1418-1419, letter, no abstract); letter not read and not summarized (outcome interpretation unresolved, so no summary is shown). Main trial: ClinicalTrials.gov registry record NCT03950076 read 2026-10-31: randomized open-label (PROBE) design; edoxaban vs non-anticoagulant therapy, meaning no antithrombotic or antiplatelet monotherapy, after intracranial hemorrhage with AF and CHA₂DS₂-VASc ≥2; status completed, 948 enrolled, primary completion 2026-07-22, no posted results. Lobar ICH and isolated convexity SAH were enrolled until the DSMB stopped their enrollment and are now excluded; the DSMB also advised stopping study drug in that subgroup (WSO 2025 statement, PMC11951358, read 2026-10-31). News coverage reports an ESC Congress 2026 presentation, but no peer-reviewed report was found in PubMed as of 2026-10-31: presented only; do not summarize or apply its outcomes until published."},{"title":"Anticoagulation after ICH in AF meta-analysis — Safety and efficacy of oral anticoagulation in patients with intracranial hemorrhage and atrial fibrillation: a systematic review and meta-analysis of randomized controlled clinical trials.","url":"https://pubmed.ncbi.nlm.nih.gov/41446322/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract and PMC full text (PMC12722659) read 2026-10-31; bibliographic record checked. Six RCTs including PRESTIGE-AF; the recurrent-ICH result lost significance without PRESTIGE-AF; STATICH data came from a conference presentation. Source of the ENRICH-AF lobar ICH/convexity SAH safety withdrawal. The ENRICH-AF withdrawal statement is in its discussion (a secondary source)."},{"title":"Edinburgh CT criteria — The Edinburgh CT and genetic diagnostic criteria for lobar intracerebral haemorrhage associated with cerebral amyloid angiopathy: model development and diagnostic test accuracy study.","url":"https://pubmed.ncbi.nlm.nih.gov/29331631/","year":2018,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Edinburgh criteria & ICH recurrence (IPD) — Association between the Edinburgh CT and genetic diagnostic criteria for cerebral amyloid angiopathy-associated lobar intracerebral haemorrhage and recurrent intracerebral haemorrhage: an individual patient data meta-analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/40975099/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"RECAP-ICH — Intensive blood pressure lowering after spontaneous intracerebral haemorrhage for secondary stroke prevention (RECAP-ICH): a systematic review and individual participant data meta-analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42586098/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (2,944 participants; recurrent stroke HR 0.62, recurrent ICH HR 0.39); bibliographic record checked; full text not read. Individual-participant meta-analysis of 4 trials of BP-lowering treatment vs placebo or standard care, not a test of the <130/80 target. Included trials are not named in the abstract; overlap with TRIDENT not confirmed."}],"related":[{"label":"PRESTIGE-AF","href":"#/evidence/prestige-af"},{"label":"RESTART","href":"#/evidence/restart"}]},{"id":"unruptured-aneurysms","title":"Unruptured intracranial aneurysm review","category":"Hemorrhage and neurocritical care","settings":["hospital","clinic"],"keywords":["aneurysm","UIA","PHASES","ELAPSS","UIATS","rupture risk","coiling","clipping","flow diversion"],"summary":"Weigh rupture risk (size, location, growth, morphology, prior SAH; PHASES, ELAPSS and UIATS support the discussion) against treatment risk and patient preference in a multidisciplinary team; for symptomatic aneurysms (cranial nerve deficit, mass effect or thromboembolism), ESO consensus suggests repair. Stop smoking and treat hypertension. All ESO recommendations rest on very low-certainty evidence.","consider":["Review aneurysm size, location, morphology, growth and prior hemorrhage alongside patient factors.","Clarify the purpose and interval of surveillance with the treating team.","Discuss treatment alternatives, smoking/BP review and preferences in a multidisciplinary setting.","ADPKD (KDIGO 2025, per an ERA Working Group commentary): screening for unruptured aneurysms is selective, centered on a family history of aneurysm, SAH or unexplained sudden death; contrast-free time-of-flight MR angiography is the preferred test, and high-risk people with a negative first screen may be rescreened every 5–10 years (practice points)."],"caution":"Scores support discussion; they do not choose a procedure or capture every relevant feature.","sources":[{"title":"European Stroke Organisation (ESO) guidelines on management of unruptured intracranial aneurysms","url":"https://pubmed.ncbi.nlm.nih.gov/36082246/","year":2022,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract read; the symptomatic-aneurysm expert consensus is from the archived transcription; full recommendation tables not reviewed."},{"title":"KDIGO 2025 Clinical Practice Guideline for ADPKD: a commentary on intracranial aneurysms and other vascular manifestations from the ERA Working Group Genes & Kidney","url":"https://pubmed.ncbi.nlm.nih.gov/42065712/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract and PMC full text (PMC13719708) read 2026-10-31; its recommendation boxes are images absent from the text, and the KDIGO 2025 guideline itself (PMID 39848759) was not read, so the card avoids the graded wording of recommendation 6.1.2 and labels the imaging and rescreening items as practice points."},{"title":"PHASES — Development of the PHASES score for prediction of risk of rupture of intracranial aneurysms: a pooled analysis of six prospective cohort studies.","url":"https://pubmed.ncbi.nlm.nih.gov/24290159/","year":2014,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"PHASES","href":"#/tools/phases"}]},{"id":"poststroke-seizures","title":"Seizures after stroke: treatment versus prophylaxis","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital","clinic"],"keywords":["seizure","EEG","levetiracetam","phenytoin","prophylaxis","epilepsy","ASM withdrawal"],"summary":"Treat clinical or EEG-confirmed seizures. Do not give prophylactic antiseizure drugs after ischemic stroke or ICH without seizures (AHA 2026; AHA 2022: no benefit). After aSAH, AHA 2023 allows prophylaxis only with high-risk features (2b) and lists phenytoin as harmful (3: Harm); NCS 2026 suggests ASM or no ASM (conditional, low certainty) and allows either agent and duration; its expert guidance prefers levetiracetam, stopped by 3 days unless seizures or EEG features suggest ongoing risk. Continuous EEG (at least 24 h) is reasonable for unexplained or fluctuating mental status after ICH (AHA 2022, 2a).","recommendations":[{"text":"In adult AIS patients, prophylactic antiseizure medication is not recommended as it does not prevent seizures or improve functional outcome.","cor":"3: No Benefit","loe":"C-LD","source":"AHA/ASA AIS 2026 · ais-2026-195 · p. 84","id":"ais-2026-195"},{"text":"Prophylactic antiseizure medication is not beneficial for patients with spontaneous ICH who have no evidence of seizures with regard to functional outcomes, long-term seizure control, or mortality.","cor":"3: No Benefit","loe":"B-NR","source":"AHA/ASA ICH 2022 · ich-2022-73 · p. 34","id":"ich-2022-73"}],"consider":["After an unprovoked poststroke seizure, choose the antiseizure drug by patient factors (AHA 2026, COR 1).","Document the indication and a review date for any antiseizure drug continued at discharge.","High seizure risk (SeLECT ≥5 after ischemic stroke or CAVE ≥2 after ICH) is not an indication for prophylaxis outside trials: in a phase 2a trial (125 patients, underpowered), eslicarbazepine 800 mg/day for 30 days, started within 96–120 h, did not significantly reduce first unprovoked seizure, death or discontinuation at 6 months (28 vs 37%; OR 0.66, 95% CI 0.31–1.40); all 5 deaths were in the drug arm (judged unrelated).","aSAH with a seizure at onset: treat for no more than 7 days; longer courses do not reduce later seizures."],"caution":"Permissive prophylaxis recommendations do not justify indefinite treatment.","sources":[{"title":"Guidelines for Seizure Prophylaxis in Patients Hospitalized with Nontraumatic Intracerebral Hemorrhage: A Clinical Practice Guideline for Health Care Professionals from the Neurocritical Care Society","url":"https://pubmed.ncbi.nlm.nih.gov/39707127/","year":2024,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Guidelines for Seizure Prophylaxis in Patients with Aneurysmal Subarachnoid Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society","url":"https://pubmed.ncbi.nlm.nih.gov/42552475/","year":2026,"type":"Guideline","checkedAt":"2026-10-17","access":"PMC full text (PMC13642444) read 2026-10-17; supplementary tables not reviewed."},{"title":"Antiseizure Medication Withdrawal in Seizure-Free Patients: Practice Advisory Update Summary: Report of the AAN Guideline Subcommittee","url":"https://pubmed.ncbi.nlm.nih.gov/34873018/","year":2021,"type":"Practice advisory","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"European Stroke Organisation guidelines for the management of post-stroke seizures and epilepsy","url":"https://pubmed.ncbi.nlm.nih.gov/31008306/","year":2017,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/37212182/","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 38011240 (Stroke 2023;54:e516) is indexed; its body was not re-read."},{"title":"PEACH — Safety and efficacy of prophylactic levetiracetam for prevention of epileptic seizures in the acute phase of intracerebral haemorrhage (PEACH): a randomised, double-blind, placebo-controlled, phase 3 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35963261/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"PEACH EEG analysis — Dynamics of early electroencephalographic patterns and epileptic seizures in acute intracerebral hemorrhage: A prospective controlled study.","url":"https://pubmed.ncbi.nlm.nih.gov/41250972/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record and notices checked; outcomes not reviewed here. Secondary EEG-pattern analysis of trial participants."},{"title":"Eslicarbazepine antiepileptogenesis (BIA-2093-213) — Safety and efficacy of eslicarbazepine acetate for seizure prevention in patients with stroke at high risk of developing post-stroke epilepsy: a proof-of-concept, phase 2a, randomised, double-blind, placebo-controlled antiepileptogenesis trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41722592/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Phase 2a; its authors call it underpowered."}],"related":[]},{"id":"functional-seizures","title":"Functional seizures and diagnostic communication","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital","clinic"],"keywords":["functional seizure","PNES","dissociative seizure","video EEG","nonepileptic"],"summary":"Make a positive diagnosis from the event history, witness accounts and, when feasible, video-EEG of a typical event; explain it respectfully, screen for coexisting epilepsy and psychiatric conditions, and arrange continuity (AAN 2025). Do not prescribe ASMs or benzodiazepines for functional seizures without another indication, taper ASMs that lack one, and refer appropriate patients for psychological treatment (AAN 2025).","consider":["Review event history, witness information and typical-event recording or video-EEG when feasible.","Explain the diagnostic rationale and arrange continuity rather than relying on a label alone.","Do not prescribe ASMs or benzodiazepines for functional seizures alone; taper ASMs that lack another indication."],"caution":"Functional seizures and epilepsy can coexist; a normal routine EEG or one bedside sign does not make the diagnosis.","sources":[{"title":"Management of Functional Seizures Practice Guideline Executive Summary: Report of the AAN Guidelines Subcommittee","url":"https://pubmed.ncbi.nlm.nih.gov/41370742/","year":2025,"type":"Guideline","checkedAt":"2026-10-17","access":"Primary abstract (executive summary) checked 2026-10-17; full recommendation tables not reviewed."}],"related":[]},{"id":"neuroprognostication","title":"Stroke prognosis: timing, confounders and uncertainty","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital","clinic"],"keywords":["prognosis","ICH score","NIHSS","withdrawal of life support","swallow","tracheostomy","recovery"],"summary":"Do not settle prognosis early — aside from the most clinically devastated patients, defer ICH neuroprognostication for at least the first 48–72 h of ICU admission (NCS 2023 good-practice statement) — but discuss goals before deterioration in large hemispheric infarction (NCS 2026, strong) and honor documented prior wishes. After ICH, full care with new DNAR or withdrawal deferred until at least the second full hospital day is reasonable unless prior wishes say otherwise (AHA 2022, 2a). Severity scores such as the ICH score frame discussion but must not be the sole basis to limit treatment (COR 3), and a DNAR order alone should not limit other care. Clear confounders such as sedation and medical instability first (NCS).","recommendations":[{"text":"A baseline severity score alone is not recommended as the sole basis for forecasting individual prognosis or deciding to limit life-sustaining treatment in patients with spontaneous ICH.","cor":"3: No Benefit","loe":"B-NR","source":"AHA/ASA ICH 2022 · ich-2022-94 · p. 44","id":"ich-2022-94"}],"consider":["Identify sedation, medical instability and other confounders before discussing prognosis.","Explain the outcome being estimated, the time horizon and the range of uncertainty.","Revisit recovery over time and incorporate what outcomes the patient would value.","After ICH, the original ICH score or the max-ICH score alone is not a reliable predictor of poor function at ≥3 months, nor the original score of 30-day mortality (NCS 2023; weak, low or very low certainty)."],"caution":"Premature withdrawal can distort both individual care and the evidence used to estimate prognosis.","sources":[{"title":"Guidelines for Neuroprognostication in Critically ill Adults with Acute Ischemic Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/41942818/","year":2026,"type":"Guideline","checkedAt":"2026-10-22","access":"PMC full text (PMC13249629) read 2026-10-22, including the premature-prognostication and large-hemispheric-infarction goals-of-care recommendations; evidence tables not reviewed."},{"title":"Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/37923968/","year":2023,"type":"Guideline","checkedAt":"2026-10-17","access":"PMC full text (PMC10959839) read 2026-10-17; evidence tables not reviewed."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."}],"related":[{"label":"ICH severity score","href":"#/encounter/ich-score"},{"label":"Goals of care","href":"#/evidence/goals-of-care"}]},{"id":"goals-of-care","title":"Consent, goals of care and palliative support","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital","clinic"],"keywords":["consent","capacity","surrogate","palliative","goals of care","end of life","shared decision"],"summary":"Offer palliative support alongside restorative stroke care. With large cerebral or cerebellar infarcts at risk of swelling, discuss options and likely outcomes early (AHA 2026, COR 1). Clarify capacity and the appropriate surrogate; after ICH, a surrogate–physician shared decision-making model is reasonable for patients who cannot fully participate (AHA 2022 ICH, 2a).","consider":["Clarify capacity, the appropriate surrogate and known preferences.","Explain the decision, alternatives and uncertainty in language suited to the situation.","Identify symptom burden, psychosocial needs and when specialist support would help."],"caution":"Palliative care is not withdrawal of treatment; emergency consent rules depend on the setting.","sources":[{"title":"Palliative and End-of-Life Care in Stroke: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/39676661/","year":2024,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Consent Issues in the Management of Acute Ischemic Stroke: AAN Position Statement","url":"https://pubmed.ncbi.nlm.nih.gov/35312627/","year":2022,"type":"Position statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"Clinical Guidance in Neuropalliative Care: An AAN Position Statement","url":"https://pubmed.ncbi.nlm.nih.gov/35256519/","year":2022,"type":"Position statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."}],"related":[{"label":"Neuroprognostication","href":"#/evidence/neuroprognostication"}]},{"id":"brain-death","title":"BD/DNC: determination and communication resources","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital"],"keywords":["brain death","BD DNC","apnea test","ancillary testing","cerebral circulatory arrest","DSA"],"summary":"Use the institutional BD/DNC process and the 2023 multisociety guideline for prerequisites, confounders, examination, apnea testing and ancillary-test indications; the 2025 AAN statement covers communication, objections, pregnancy and public trust.","consider":["Use the complete institutional process for prerequisites, confounders and examiner qualifications.","Consult the guideline for neurologic examination, apnea testing and valid ancillary-test indications.","Plan clear communication and address accommodations or objections through the relevant process."],"caution":"This is a source navigator, not a determination checklist.","sources":[{"title":"2023 Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline","url":"https://pubmed.ncbi.nlm.nih.gov/37821233/","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract and source scope checked; full recommendation text not reviewed."},{"title":"Brain Death/Death by Neurologic Criteria Guidance on Communication, Objections, Pregnancy, and Public Trust: An AAN Position Statement","url":"https://pubmed.ncbi.nlm.nih.gov/41187308/","year":2025,"type":"Clinical policy","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Technical Performance and Interpretation of Digital Subtraction Angiography to Determine Cerebral Circulatory Arrest in Patients Being Evaluated for Brain Death/Death by Neurological Criteria: A Brief Practice Update From the Society of Vascular and Interventional Neurology (SVIN)","url":"https://pubmed.ncbi.nlm.nih.gov/41816515/","year":2025,"type":"Practice update","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Concerns DSA for cerebral circulatory arrest in brain-death evaluation, not collateral grading (the archive ID is historical)."}],"related":[]},{"id":"moyamoya","title":"Moyamoya disease and syndrome","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["moyamoya","RNF213","bypass","hemodynamic impairment","collaterals"],"summary":"Moyamoya with ischemic stroke or TIA: direct or indirect extracranial–intracranial bypass can be beneficial to prevent recurrent ischemia (AHA 2021, 2a); refer to an experienced center. Distinguish ischemic from hemorrhagic presentations and moyamoya disease from secondary moyamoya syndrome, and review perfusion studies and the antithrombotic rationale.","consider":["Confirm the vascular pattern and whether a secondary moyamoya syndrome is plausible.","Ischemic presentation with hemodynamic impairment (adults and children): ESO 2023 suggests direct or combined rather than indirect bypass, 6–12 weeks after the last event; it recommends direct bypass for adults with hemorrhagic presentation (low-quality evidence); long-term antiplatelet therapy for non-hemorrhagic moyamoya is expert consensus.","Clarify surveillance imaging and perioperative planning."],"caution":"Do not manage moyamoya as ordinary atherosclerotic stenosis.","sources":[{"title":"European Stroke Organisation (ESO) Guidelines on Moyamoya angiopathy Endorsed by Vascular European Reference Network (VASCERN)","url":"https://pubmed.ncbi.nlm.nih.gov/37021176/","year":2023,"type":"Guideline","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (bypass by presentation, technique and timing; antiplatelet consensus); full recommendation tables not reviewed."},{"title":"Adult Moyamoya Disease and Syndrome: Current Perspectives and Future Directions: A Scientific Statement From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/37609846/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-21","access":"Primary abstract read 2026-10-21; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."}],"related":[]},{"id":"cns-vasculitis","title":"Suspected primary CNS vasculitis","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["PACNS","CNS vasculitis","angiitis","RCVS","CSF","biopsy","vessel wall MRI"],"summary":"Do not diagnose PACNS from imaging alone: no single MRI pattern or routine CSF abnormality establishes it. Exclude RCVS, infection and other mimics, and confirm with expert multidisciplinary review, including tissue diagnosis when needed, before prolonged immunotherapy (ESO 2023).","consider":["Review alternative vascular, infectious, inflammatory and noninflammatory explanations.","Discuss the roles and limitations of vascular imaging, CSF studies and tissue diagnosis.","Clarify what evidence supports the diagnosis before committing to prolonged immunotherapy."],"caution":"Evidence is sparse, and vessel imaging alone cannot separate PACNS from mimics such as RCVS.","sources":[{"title":"European Stroke Organisation (ESO) guidelines on Primary Angiitis of the Central Nervous System (PACNS)","url":"https://pubmed.ncbi.nlm.nih.gov/37903069/","year":2023,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."}],"related":[{"label":"RCVS and PRES","href":"#/evidence/rcvs-pres"}]},{"id":"rcvs-pres","title":"RCVS and PRES","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["RCVS","reversible cerebral vasoconstriction","RCVS2","thunderclap","convexity SAH","PRES","posterior reversible encephalopathy","eclampsia","postpartum"],"summary":"Recurrent thunderclap headaches with segmental cerebral vasoconstriction suggest RCVS; over half of cases are postpartum or follow adrenergic or serotonergic drugs. Vasoconstriction peaks 2–3 weeks after onset and resolves within 3 months, and stroke can follow initially normal imaging. RCVS2 (thunderclap headache, carotid involvement, vasoconstrictive trigger, sex, SAH; range −2 to +10): ≥5 was 99% specific and 90% sensitive for RCVS; ≤2 was 100% specific (85% sensitive) for excluding it; performance was similar against PACNS in a separate validation cohort. PRES (bilateral subcortical vasogenic edema) follows BP fluctuation, renal failure, cytotoxic drugs, autoimmune disease or eclampsia, and usually resolves.","consider":["Exclude aneurysmal SAH first and remove vasoactive triggers; avoid empirical glucocorticoids when RCVS is likely (in 162 patients they independently predicted worsening and poor outcome; observational).","Repeat vessel imaging if early imaging is normal but suspicion persists.","Nimodipine may ease thunderclap headache within 48 h but has no proven effect on stroke or hemorrhage.","PRES: treat the driver (BP, drug, eclampsia) and watch for hemorrhage or posterior-fossa edema with hydrocephalus."],"caution":"Evidence is observational; RCVS2 was derived from 30 RCVS patients at one center.","sources":[{"title":"RCVS2 score and diagnostic approach for RCVS","url":"https://pubmed.ncbi.nlm.nih.gov/30635475/","year":2019,"type":"Observational study","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."},{"title":"Reversible cerebral vasoconstriction syndrome (review)","url":"https://pubmed.ncbi.nlm.nih.gov/22995694/","year":2012,"type":"Report","checkedAt":"2026-10-03","access":"Abstract verified via PubMed."},{"title":"PRES: clinical and radiological manifestations and pathophysiology (review)","url":"https://pubmed.ncbi.nlm.nih.gov/26184985/","year":2015,"type":"Report","checkedAt":"2026-10-03","access":"Abstract verified via PubMed."},{"title":"Glucocorticoid-associated worsening in RCVS","url":"https://pubmed.ncbi.nlm.nih.gov/27940651/","year":2017,"type":"Observational study","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed; retrospective cohort."}],"related":[{"label":"Sudden severe headache","href":"#/evidence/thunderclap-sah-evaluation"},{"label":"CNS vasculitis","href":"#/evidence/cns-vasculitis"},{"label":"Maternal stroke","href":"#/evidence/maternal-stroke"}]},{"id":"spinal-cord-infarction","title":"Spinal cord infarction","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital"],"keywords":["spinal cord infarction","spinal stroke","owl eyes","anterior spinal artery","myelopathy","aortic surgery"],"summary":"Suspect spinal cord infarction with sudden severe myelopathy reaching its nadir within 12 h (77% of 133 Mayo patients; 76% had vascular risk factors). The first spine MRI was normal in 24%, so repeat it with DWI and axial T2: owl-eye (65%) or pencil-like (40%) T2 signal, and DWI restriction in 67% of those imaged. Supportive findings: adjacent arterial dissection or occlusion (20%) and vertebral body infarction (9%); CSF was mildly inflammatory in only 8%.","consider":["Recent aortic surgery or repair, hypotension or vertebral dissection?","Selective pain and temperature loss (39%) and a stuttering course (23%) occur; do not label transverse myelitis too early.","Apply the proposed definite, probable and possible criteria, and exclude cord compression."],"caution":"The criteria come from one center, and acute treatments lack randomized evidence.","sources":[{"title":"Spontaneous spinal cord infarction: characteristics and proposed diagnostic criteria","url":"https://pubmed.ncbi.nlm.nih.gov/30264146/","year":2019,"type":"Observational study","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"related":[{"label":"Cervical artery dissection","href":"#/evidence/dissection"}]},{"id":"inherited-arteriopathy","title":"Inherited small-vessel disease and CADASIL","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["CADASIL","NOTCH3","CARASIL","HTRA1","COL4A1","Fabry","genetic stroke","young stroke"],"summary":"Suspect CADASIL or another inherited small-vessel disease when age, family history, clinical pattern and MRI phenotype fit; confirm molecularly with genetic counseling, and treat vascular risk factors while separating established care from unproven disease-modifying treatment (AHA 2023).","consider":["Review the age, family history, clinical pattern and imaging phenotype together.","Consider genetic counseling and the implications of testing for the patient and relatives.","Address modifiable vascular factors while distinguishing established care from unproven disease-modifying treatment.","A tocotrienol-rich vitamin E complex did not slow CADASIL: in a 51-patient double-blind, placebo-controlled RCT in genetically confirmed CADASIL (T3CAD, 2026), treatment failure (stroke, disability progression or cognitive decline) over 24 months was 68.0 vs 61.5%, meeting predefined futility criteria."],"caution":"A suggestive MRI pattern is not a molecular diagnosis.","sources":[{"title":"Management of Inherited CNS Small Vessel Diseases: The CADASIL Example: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/37602377/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"T3CAD — Tocotrienol-rich vitamin E complex in CADASIL (T3CAD): a randomised, double-blind, placebo-controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42005919/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked."}],"related":[]},{"id":"lacunar-small-vessel","title":"Lacunar stroke and covert small-vessel disease","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["lacunar","small vessel","white matter hyperintensity","covert infarct","leukoaraiosis","SPS3"],"summary":"Symptomatic lacunar stroke: start antiplatelets as soon as possible (ESO 2024 expert consensus; its text adds that short-term DAPT per CHANCE/POINT may be reasonable), then long-term single antiplatelet, BP control and lipid lowering per current guidelines (ESO 2024); covert small-vessel disease found only on imaging is not an indication for antiplatelet drugs (ESO 2021). In SPS3, SBP <130 vs 130–149 did not significantly reduce all stroke but reduced ICH (HR 0.37). Address cognition and gait when relevant.","consider":["Is there a corresponding clinical stroke syndrome or only an incidental imaging finding?","Review BP, lifestyle and competing stroke mechanisms rather than assuming every small lesion is lacunar.","Address cognition, gait and functional consequences when clinically relevant."],"caution":"Do not start an antiplatelet solely for incidental white-matter changes.","sources":[{"title":"European stroke organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/38380638/","year":2024,"type":"Guideline","checkedAt":"2026-10-22","access":"PMC full text (PMC10916806) read 2026-10-22 for acute antiplatelet timing: PICO 2 expert consensus (12 of 12) and the CHANCE/POINT DAPT discussion; long-term prevention from the abstract."},{"title":"ESO Guideline on covert cerebral small vessel disease","url":"https://pubmed.ncbi.nlm.nih.gov/34414301/","year":2021,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"SPS3 — Effects of clopidogrel added to aspirin in patients with recent lacunar stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/22931315/","year":2012,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SSI antiplatelet network meta-analysis — Efficacy and safety of antiplatelet therapy for secondary prevention of small subcortical infarction: A systematic review and network meta-analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/40215388/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"Minor stroke DAPT","href":"#/evidence/minor-stroke-antiplatelets"}]},{"id":"cardiac-sources","title":"LV thrombus, LV dysfunction and other cardiac sources","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["LV thrombus","LV dysfunction","cardiomyopathy","echo","cardiac MRI","prosthetic valve","TAVR","LVAD","ECMO","cardioembolic"],"summary":"LV thrombus with stroke: warfarin for at least 3 months (AHA 2021, COR 1); DOAC safety for a new LV thrombus is uncertain (2b). The 2022 AHA LV-thrombus statement considers a DOAC a reasonable alternative to warfarin (ungraded); an RCT meta-analysis (7 trials) found similar thrombus resolution and bleeding. LV dysfunction without thrombus (sinus rhythm): anticoagulant vs antiplatelet is uncertain (AHA 2021, 2b); a 2026 AHA scientific statement (ungraded; LVEF ≤40% or wall-motion abnormality; meta-analysis of secondary trial analyses) reports anticoagulation may be associated with less recurrent stroke and net benefit vs antiplatelet therapy, so individualize with cardiology. Mechanical valves: warfarin — dabigatran (RE-ALIGN) and apixaban (PROACT Xa) caused more thromboembolism. Mechanical assist device: warfarin plus aspirin can be beneficial (AHA 2021, 2a); ARIES-HM3 (2023; first-time HeartMate 3 recipients, excluding those needing antiplatelets for other conditions) later found VKA plus placebo noninferior to VKA plus aspirin for 12-month survival free of hemocompatibility events, with less nonsurgical bleeding and no more strokes; it did not test stopping aspirin after a stroke.","consider":["Clarify the suspected source and whether the cardiac imaging adequately addresses it.","Review valve/device status, rhythm, ventricular function and the antithrombotic indication with cardiology.","Consider bleeding risk and concurrent antiplatelet exposure when discussing therapy."],"caution":"Prosthetic valves and circulatory support devices need their own specialist pathways.","sources":[{"title":"Management of Patients at Risk for and With Left Ventricular Thrombus: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/36106537/","year":2022,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Primary abstract checked; full recommendation tables not reviewed."},{"title":"Management of Patients at Risk of Ischemic Stroke With Left Ventricular Systolic Dysfunction in the Absence of Intracardiac Thrombus: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/42389837/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (LV dysfunction defined as LVEF ≤40% or wall-motion abnormality; narrative summary and meta-analysis of secondary analyses of RCTs); no PMC copy, full statement not reviewed."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"INVICTUS — Rivaroxaban in Rheumatic Heart Disease-Associated Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/36036525/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"RE-ALIGN — Dabigatran versus warfarin in patients with mechanical heart valves.","url":"https://pubmed.ncbi.nlm.nih.gov/23991661/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"PROACT Xa — Apixaban or Warfarin in Patients with an On-X Mechanical Aortic Valve.","url":"https://pubmed.ncbi.nlm.nih.gov/38320162/","year":2023,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"BHF PROTECT-TAVI — Routine Cerebral Embolic Protection during Transcatheter Aortic-Valve Implantation.","url":"https://pubmed.ncbi.nlm.nih.gov/40162661/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"PROTECTED TAVR — Cerebral Embolic Protection during Transcatheter Aortic-Valve Replacement.","url":"https://pubmed.ncbi.nlm.nih.gov/36121045/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Warfarin resumption after ICH with a mechanical valve (meta-analysis) — Resumption of Warfarin After Intracranial Hemorrhage in Patients With Mechanical Heart Valves: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/41823243/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"DOACs vs warfarin for LV thrombus (RCT meta-analysis) — Direct oral anticoagulants or warfarin in left ventricular thrombus: an updated systematic review and meta-analysis of randomized trials.","url":"https://pubmed.ncbi.nlm.nih.gov/41359218/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"RIVAWAR — Rivaroxaban vs Warfarin in Acute Left Ventricular Thrombus Following Myocardial Infarction: RIVAWAR, An Open-Label RCT.","url":"https://pubmed.ncbi.nlm.nih.gov/40706143/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ARIES-HM3 — Aspirin and Hemocompatibility Events With a Left Ventricular Assist Device in Advanced Heart Failure: The ARIES-HM3 Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37950897/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-22","access":"PubMed bibliographic record, abstract and ClinicalTrials.gov record NCT04069156 re-read 2026-10-22: first durable HeartMate 3 implant; investigator-mandated antiplatelet therapy excluded; PMC copy has no body text."},{"title":"ELSO LV venting and acute brain injury — Impact of Left Ventricular Venting on Acute Brain Injury in Patients With Cardiogenic Shock: An Extracorporeal Life Support Organization Registry Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/41104911/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"BHF PROTECT-TAVI cognitive analysis — Impact of Cerebral Embolic Protection on Cognitive Function After Transcatheter Aortic Valve Implantation: Data From the BHF PROTECT-TAVI Randomized Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40884786/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record and notices checked; outcomes not reviewed here. Secondary cognitive-outcome analysis, not a new randomized trial."}],"related":[]},{"id":"endocarditis","title":"Stroke with suspected infective endocarditis","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital"],"keywords":["endocarditis","septic embolus","infective aneurysm","mycotic aneurysm","vegetation","prosthetic valve"],"summary":"Suspected endocarditis with stroke: do not give IV thrombolysis (ESC 2023, class III; thrombectomy may be considered, IIb) and involve cardiology, infectious diseases and cardiac surgery early. Recurrent emboli with persistent vegetations despite antibiotics: early surgery is reasonable if there is no ICH or extensive brain injury (AHA 2021, 2a); with a major ischemic stroke or ICH, delaying valve surgery for at least 4 weeks may be considered if hemodynamically stable (AHA 2021, 2b). ESC 2023 differs after ischemic stroke: do not delay indicated surgery if the patient is not comatose and CT/MRI excludes hemorrhage (class I). After ICH both favor waiting: ESC suggests delaying more than 1 month if feasible, with frequent clinical and imaging reassessment (IIa).","consider":["Assess whether the presentation warrants an endocarditis evaluation and multidisciplinary team involvement.","Clarify the neurologic complication and any hemorrhage or infective aneurysm concern.","Coordinate antimicrobial, valve/device and surgical timing decisions with neurology, cardiology and infectious diseases."],"caution":"Do not apply a routine cardioembolic-stroke pathway without checking the endocarditis-specific guidance.","sources":[{"title":"2023 ESC endocarditis guideline — selected sections","url":"https://academic.oup.com/eurheartj/article/44/39/3948/7243107","year":2023,"type":"Guideline","checkedAt":"2026-10-22","access":"Publisher text not reachable and PubMed (37622656) has no abstract; the thrombolysis (class III), thrombectomy (IIb) and post-stroke surgical-timing (Table 17: class I, IIa) recommendations are from the archived transcription, re-read 2026-10-22. Corrections 37738322, 38086544 and 39824219 not reconciled."},{"title":"Infective Endocarditis: Diagnosis, Antibiotic Therapy, and Management: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/42708190/","year":2026,"type":"Scientific statement","checkedAt":"2026-10-31","access":"Abstract read 2026-10-31 (updates the 2015 AHA statement); full text not read, so its neurologic-complication, thrombolysis/thrombectomy and surgical-timing content and any recommendation grading were not reviewed; correction 42862916 (Oct 2026) not reconciled."},{"title":"2023 ESC Guidelines for the management of endocarditis","url":"https://pubmed.ncbi.nlm.nih.gov/37622656/","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 37738322, 38086544, 39824219 not reconciled."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"IE baseline antithrombotic therapy and ICH — Baseline Antithrombotic Therapy and Intracranial Hemorrhage Risk in Infective Endocarditis: A Multicenter Prospective Cohort Study.","url":"https://pubmed.ncbi.nlm.nih.gov/41643743/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Thrombectomy for IE-related LVO (meta-analysis) — Efficacy and Safety of Mechanical Thrombectomy for Patients with Infective Endocarditis-Related Large Vessel Occlusion: a Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/40830541/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"COOPER — Characteristics and Outcomes of Operated Versus Nonoperated Patients With Infective Endocarditis and Cerebral Complications: the COOPER Study.","url":"https://pubmed.ncbi.nlm.nih.gov/41864422/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"IE-associated vs AF-associated stroke imaging phenotype — Clinical and Imaging Characteristics of Infective Endocarditis-Associated Versus Atrial Fibrillation-Associated Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/41168944/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[]},{"id":"primary-prevention","title":"First-stroke prevention and metabolic health","category":"Prevention and antithrombotics","settings":["clinic","hospital"],"keywords":["primary prevention","diabetes","GLP-1","obesity","smoking","exercise","diet","Life Essential 8","STAREE","VESALIUS-CV"],"summary":"Prevention without prior stroke: control BP, lipids and glucose, stop tobacco, and address activity, diet, weight and sleep (AHA/ASA 2024), including sex-specific risk factors.","consider":["Review BP, lipids, glycemia, tobacco exposure, activity, diet, weight and sleep in context. Clarify sex-specific and other risk factors that affect the prevention discussion.","Assess medication indications, access and adherence using the relevant disease-specific guidance.","Age ≥70 without cardiovascular disease, diabetes or dementia: in STAREE (Australia, 9,971 adults, median 5.9 years), atorvastatin 40 mg vs placebo lowered major cardiovascular events (CV death, nonfatal MI or stroke, or coronary revascularization; 10.9 vs 15.5 per 1,000 person-years; HR 0.70) but did not extend disability-free survival (HR 0.94). Musculoskeletal, hepatobiliary and diabetes-related adverse events were more common. It postdates AHA/ASA 2024.","Atherosclerosis or diabetes without prior MI or stroke and LDL ≥90 mg/dL: evolocumab vs placebo lowered CHD death, MI or ischemic stroke (VESALIUS-CV, 12,257 patients; 5-year estimate 6.2 vs 8.0%; HR 0.75). Patients with prior stroke were excluded. It postdates AHA/ASA 2024."],"caution":"Evidence for a metabolic drug in one population does not establish an indication in every stroke-risk group.","sources":[{"title":"2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/39429201/","year":2024,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract checked; full recommendation tables not reviewed. Indexed correction(s) 39585937, 39869715 not reconciled."},{"title":"VESALIUS-CV — Evolocumab in Patients without a Previous Myocardial Infarction or Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/41211925/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31: adults with atherosclerosis or diabetes, no prior MI or stroke, LDL ≥90 mg/dL; evolocumab vs placebo lowered 3-point MACE (CHD death, MI or ischemic stroke; 5-year estimate 6.2 vs 8.0%; HR 0.75); bibliographic record checked."},{"title":"SOUL — Oral Semaglutide and Cardiovascular Outcomes in High-Risk Type 2 Diabetes.","url":"https://pubmed.ncbi.nlm.nih.gov/40162642/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"SURPASS-CVOT — Cardiovascular Outcomes with Tirzepatide versus Dulaglutide in Type 2 Diabetes.","url":"https://pubmed.ncbi.nlm.nih.gov/41406444/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"STAREE — Atorvastatin, Cardiovascular Events, and Disability-free Survival in Older Adults.","url":"https://pubmed.ncbi.nlm.nih.gov/42670961/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; bibliographic record checked."},{"title":"Danish Hormonal Contraception Cohort — Stroke and myocardial infarction with contemporary hormonal contraception: real-world, nationwide, prospective cohort study.","url":"https://pubmed.ncbi.nlm.nih.gov/39938934/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Danish Progestogen-Only Contraceptive Cohort — Risk of ischemic and hemorrhagic stroke in users of progestogen-only contraceptives: A Danish registry study.","url":"https://pubmed.ncbi.nlm.nih.gov/42624314/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[]},{"id":"af-prevention","title":"AF stroke prevention beyond start timing","category":"Prevention and antithrombotics","settings":["hospital","clinic"],"keywords":["atrial fibrillation","subclinical AF","device detected","AHRE","LAAO","Watchman","rheumatic","mitral stenosis","mechanical valve","ALONE-AF","OCEAN"],"summary":"After ischemic stroke or TIA with AF, anticoagulate regardless of AF pattern (paroxysmal, persistent or permanent); use a DOAC over warfarin unless there is moderate-to-severe mitral stenosis or a mechanical valve (AHA 2021, COR 1). Do not routinely add an antiplatelet without active coronary disease or a recent stent (AHA 2026, harm). Device-detected subclinical AF: apixaban reduced stroke and embolism but increased major bleeding (ARTESiA), while edoxaban did not help (NOAH-AFNET 6). ACC/AHA 2023 (device-detected atrial high-rate episodes without a previous AF diagnosis, within shared decision-making; literature search May–November 2022, before NOAH-AFNET 6 and ARTESiA): anticoagulation is reasonable for episodes ≥24 h with CHA₂DS₂-VASc ≥2 (2a, B-NR), may be reasonable for 5 min–24 h with CHA₂DS₂-VASc ≥3 (2b, B-NR), and should not be given for episodes <5 min without another indication (3: No Benefit, B-NR). History of stroke or TIA (remote events per WSO 2025), in prespecified subgroups postdating the ACC/AHA 2023 and AHA 2021 guidelines: in ARTESiA (346 patients, 8.6%; 2025), stroke or systemic embolism was 1.20 vs 3.14% per year with apixaban vs aspirin (HR 0.40; 95% CI 0.17–0.95) and major bleeding 2.26 vs 1.16% per year (HR 1.94; 95% CI 0.77–4.87); NOAH-AFNET 6's subgroup (253 patients; edoxaban vs placebo) was inconclusive. Data are lacking for device-detected AF lasting <24 h and not confirmed on 12-lead ECG that is found after a recent stroke or TIA (WSO 2025, evidence statement, not a recommendation). Nonreversible contraindication to long-term anticoagulation (CHA₂DS₂-VASc ≥2): percutaneous left atrial appendage closure is reasonable (ACC/AHA 2023, 2a; AHA 2021 stroke guideline 2b if at least 45 days of anticoagulation can be tolerated); with high bleeding risk on anticoagulation it may be an alternative (ACC/AHA 2023, 2b). Postdating these (2026; AF populations not limited to stroke), device closure was not noninferior to physician-directed best medical care, including a DOAC if eligible, at high stroke and bleeding risk, with more primary events (16.8 vs 13.3 per 100 patient-years; CLOSURE-AF). Also in 2026, in anticoagulation candidates without stroke or TIA in the prior 30 days, closure was noninferior to a DOAC for 3-year cardiovascular death, stroke or systemic embolism (5.7 vs 4.8%; margin 4.8 points), with less non-procedural bleeding (10.9 vs 19.0%); reviews report numerically more ischemic strokes with closure (HR 1.61), and its 5-year ischemic stroke or embolism endpoint is pending (CHAMPION-AF). Pooling 6 RCTs of closure vs anticoagulation (7,004 patients with AF, not stroke-specific; 2026), closure had more ischemic strokes (3.2 vs 2.1%; RR 1.41, 95% CI 1.04–1.91) and less nonprocedural major bleeding (6.2 vs 10.7%), with no difference in any stroke, mortality or total major bleeding including procedural events; a second analysis of the same 6 trials rated the ischemic-stroke excess low certainty, sensitive to excluding single trials and short of the required information size. Rheumatic AF: rivaroxaban was worse than a VKA (INVICTUS).","consider":["Confirm how AF was documented, its clinical context and the actual thromboembolic indication. Review valve disease, renal function, interactions, prior bleeding and concurrent antiplatelets. For LAAO or device-detected AF, check the specific trial population and follow-up.","2025 SCAI/HRS LAAO guideline (GRADE; AF populations, not stroke-specific; evidence review searched to January 2024, before CHAMPION-AF and CLOSURE-AF): suggests LAAO over no therapy when anticoagulation is contraindicated (conditional recommendation, very low certainty), and suggests anticoagulation or LAAO as options for patients pursuing stroke prevention (moderate-certainty evidence from 3 RCTs), naming elevated bleeding risk, prior bleeding or a strong wish to avoid long-term anticoagulation as reasons to choose LAAO; it left LAAO for patients without a contraindication to anticoagulation outside its scope pending trials.","Stroke despite anticoagulation: check adherence, dose and interactions and look for a competing mechanism (large- or small-artery disease, cancer) before calling it anticoagulant failure. WSO 2025 (evidence review, not graded recommendations) found no definite evidence that switching anticoagulants changes recurrence, and adding a long-term antiplatelet can raise ICH risk without added protection; LAAO after a breakthrough stroke rests on one retrospective study with substantial bias, and RCTs are ongoing.","Rhythm control after stroke: in STABLED (249 patients in Japan with ECG-documented nonvalvular AF and ischemic stroke within 6 months, all on edoxaban), adding catheter ablation 1–6 months after the stroke did not reduce recurrent ischemic stroke, systemic embolism, death or heart-failure hospitalization (5.6 with ablation vs 4.9 per 100 person-years with standard therapy; HR 1.11, 95% CI 0.62–2.01). Safety signals were imprecise but went against ablation: deaths 2.8 vs 1.0 per 100 person-years (HR 2.79, 0.98–7.92), ISTH major bleeding 1.9 vs 0.6 (HR 2.99, 0.79–11.3) and hemorrhagic stroke in 3 vs 0 patients. 14% crossed over, and the trial was underpowered. Stopping anticoagulation after successful ablation: ALONE-AF (840 patients in Korea, arrhythmia-free ≥1 year after ablation; mean CHA₂DS₂-VASc 2.1) found fewer 2-year stroke, embolism or major bleeding events after stopping a DOAC (0.3 vs 2.2%), driven mainly by less major bleeding (0 vs 1.4%); OCEAN (1,284 patients ≥1 year after successful ablation) found no significant difference between rivaroxaban and aspirin in stroke, embolism or new covert embolic infarcts (0.31 vs 0.66 per 100 patient-years). Neither was restricted to patients with prior stroke, and neither establishes stopping anticoagulation after a stroke."],"caution":"Valve- and device-specific evidence overrides general AF risk scores.","sources":[{"title":"2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines","url":"https://pubmed.ncbi.nlm.nih.gov/38033089/","year":2023,"type":"Guideline","checkedAt":"2026-10-31","access":"Primary NLM identity and abstract checked. PMC full text (PMC11095842) read 2026-10-31 for section 6.4.1 (device-detected atrial high-rate episodes without a previous AF diagnosis: recommendation table, grades as published) and the literature-search dates (May 12 to November 3, 2022, before NOAH-AFNET 6 and ARTESiA); other recommendations not reviewed. Publisher-indexed text of corrections 38153996, 38408149 and 38857333 checked on 2026-10-02: trial names/disclosures, ATRIA hypertension entry and a rate-control figure footnote. None changes this overview. Direct correction PDFs unavailable."},{"title":"2024 ESC/EACTS atrial fibrillation guideline","url":"https://pubmed.ncbi.nlm.nih.gov/39210723/","year":2024,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary publication identity and official ESC overview checked live; complete corrected recommendations not reviewed for this companion source."},{"title":"CLOSURE-AF — Left Atrial Appendage Closure or Medical Therapy in Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/41849741/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-22","access":"Primary abstract re-read 2026-10-22 (control arm, primary event rates, restricted mean survival time); full report not reviewed."},{"title":"CHAMPION-AF — Left Atrial Appendage Closure or Anticoagulation for Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/41910347/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-22","access":"Primary abstract (noninferiority margin 4.8 percentage points) and ClinicalTrials.gov record NCT04394546 re-read 2026-10-22: excludes stroke or TIA within 30 days and LVEF <30%; the 5-year ischemic stroke or systemic embolism endpoint is pending (active, not recruiting). Full report not reviewed; the ischemic stroke signal is quoted from the 2026 review below, not from the primary abstract."},{"title":"Who can benefit from percutaneous left atrial appendage closure? Recent advances (narrative review of CHAMPION-AF and CLOSURE-AF).","url":"https://pubmed.ncbi.nlm.nih.gov/42747337/","year":2026,"type":"Report","checkedAt":"2026-10-22","access":"Abstract read 2026-10-22: \"Ischemic stroke alone, however, was numerically more frequent with LAAC (HR 1.61)\". A second 2026 review (PMID 42739532, abstract) agrees on direction. Secondary source; the CHAMPION-AF full report was not reachable."},{"title":"Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/36912134/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-02","access":"Primary NLM identity and abstract checked; full statement not reviewed. Publisher-indexed correction 37093973 checked on 2026-10-02: supplemental dabigatran renal/interaction conditions and apixaban dose-reduction criteria. This overview supplies no dosing rule. Direct correction PDF unavailable."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"Antithrombotic treatment for secondary prevention of stroke and other thromboembolic events in patients with stroke or transient ischemic attack and non-valvular atrial fibrillation: A European Stroke Organisation guideline","url":"https://pubmed.ncbi.nlm.nih.gov/31984228/","year":2019,"type":"Guideline","checkedAt":"2026-10-21","access":"Primary abstract read 2026-10-21; full recommendations not reviewed. Interpret with newer evidence."},{"title":"2025 SCAI/HRS Clinical Practice Guidelines on Transcatheter Left Atrial Appendage Occlusion","url":"https://pubmed.ncbi.nlm.nih.gov/41040442/","year":2025,"type":"Guideline","checkedAt":"2026-10-31","access":"PMC full text (PMC12485513) read 2026-10-31: recommendations 1.1 and 2.1 with their remarks and evidence certainty, and the statement that LAAO without a contraindication to anticoagulation is outside its scope; other recommendations not reviewed. Co-published in Heart Rhythm (PMID 40758072). Evidence search through January 5, 2024, per the companion SCAI/HRS technical review abstract (PMID 40758073)."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"Ischemic stroke prevention in patients with atrial fibrillation and a recent ischemic stroke, TIA, or intracranial hemorrhage: A World Stroke Organization (WSO) scientific statement","url":"https://pubmed.ncbi.nlm.nih.gov/39719823/","year":2025,"type":"Scientific statement","checkedAt":"2026-10-31","access":"PMC full text (PMC11951358) read 2026-10-31. It grades the strength of evidence for each statement (for example B2, C1) instead of making clinical recommendations; the AF prevention card uses its device-detected AF (statement 11) and breakthrough-stroke (statements 16–19) evidence statements. The CAA and ICH recurrence card uses its ENRICH-AF DSMB paragraph, the 412-patient meta-analysis paragraph and statements 23–25."},{"title":"AVERROES — Apixaban in patients with atrial fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/21309657/","year":2011,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ARTESiA — Apixaban for Stroke Prevention in Subclinical Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/37952132/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ARTESiA prior stroke or TIA subgroup — Apixaban versus aspirin for stroke prevention in people with subclinical atrial fibrillation and a history of stroke or transient ischaemic attack: subgroup analysis of the ARTESiA randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39862882/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Prespecified subgroup (346 participants, 8.6%), intention to treat."},{"title":"ARTESiA major bleeding subanalysis — Major Bleeding With Apixaban vs Aspirin: A Subanalysis of the ARTESiA Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41222953/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; PMC full text (PMC12613090) not read. Prespecified on-treatment subanalysis (3,961 patients)."},{"title":"STABLED — Catheter Ablation and Oral Anticoagulation for Secondary Stroke Prevention in Atrial Fibrillation: The STABLED Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41770549/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract and PMC full text (PMC12954600) read 2026-10-31; bibliographic record checked; the major-bleeding and hemorrhagic-stroke figures appear in both the Results text and Table 3. A JAMA Neurol 'Clarification to Table 3' (PMID 41973432, same issue; PMC13077508 has no text) could not be read and is not reconciled."},{"title":"ALONE-AF — Long-Term Anticoagulation Discontinuation After Catheter Ablation for Atrial Fibrillation: The ALONE-AF Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40886309/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract and PMC Key Points read 2026-10-31 (PMC body text not returned); bibliographic record checked. ClinicalTrials.gov NCT04432220 eligibility read: prior stroke neither required nor excluded."},{"title":"OCEAN — Antithrombotic Therapy after Successful Catheter Ablation for Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/41211931/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Patients at least 1 year after successful ablation; not selected for prior stroke."},{"title":"PRESTIGE-AF — Direct oral anticoagulants versus no anticoagulation for the prevention of stroke in survivors of intracerebral haemorrhage with atrial fibrillation (PRESTIGE-AF): a multicentre, open-label, randomised, phase 3 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40023176/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 2 corrections or notices; check them before applying results."},{"title":"ENRICH-AF — Anticoagulation in patients with cerebral amyloid angiopathy.","url":"https://pubmed.ncbi.nlm.nih.gov/37839419/","year":2023,"type":"Report","checkedAt":"2026-10-31","access":"PubMed bibliographic record re-checked 2026-10-31 (Lancet 2023;402:1418-1419, letter, no abstract); letter not read and not summarized (outcome interpretation unresolved, so no summary is shown). Main trial: ClinicalTrials.gov registry record NCT03950076 read 2026-10-31: randomized open-label (PROBE) design; edoxaban vs non-anticoagulant therapy, meaning no antithrombotic or antiplatelet monotherapy, after intracranial hemorrhage with AF and CHA₂DS₂-VASc ≥2; status completed, 948 enrolled, primary completion 2026-07-22, no posted results. Lobar ICH and isolated convexity SAH were enrolled until the DSMB stopped their enrollment and are now excluded; the DSMB also advised stopping study drug in that subgroup (WSO 2025 statement, PMC11951358, read 2026-10-31). News coverage reports an ESC Congress 2026 presentation, but no peer-reviewed report was found in PubMed as of 2026-10-31: presented only; do not summarize or apply its outcomes until published."},{"title":"SoSTART — Effects of oral anticoagulation for atrial fibrillation after spontaneous intracranial haemorrhage in the UK: a randomised, open-label, assessor-masked, pilot-phase, non-inferiority trial.","url":"https://pubmed.ncbi.nlm.nih.gov/34487722/","year":2021,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"APACHE-AF — Apixaban versus no anticoagulation after anticoagulation-associated intracerebral haemorrhage in patients with atrial fibrillation in the Netherlands (APACHE-AF): a randomised, open-label, phase 2 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/34687635/","year":2021,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"COCROACH — Effects of oral anticoagulation in people with atrial fibrillation after spontaneous intracranial haemorrhage (COCROACH): prospective, individual participant data meta-analysis of randomised trials.","url":"https://pubmed.ncbi.nlm.nih.gov/37839434/","year":2023,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"LAAOS III — Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/33999547/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"NOAH-AFNET 6 — Anticoagulation with Edoxaban in Patients with Atrial High-Rate Episodes.","url":"https://pubmed.ncbi.nlm.nih.gov/37622677/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"NOAH-AFNET 6 prior stroke or TIA analysis — Anticoagulation in Patients With Device-Detected Atrial Fibrillation With and Without a Prior Stroke or Transient Ischemic Attack: The NOAH-AFNET 6 Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39190564/","year":2024,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; PMC full text (PMC11646511) not read. 253 patients with prior stroke or TIA (edoxaban vs placebo); its authors call the analysis hypothesis-generating."},{"title":"INVICTUS — Rivaroxaban in Rheumatic Heart Disease-Associated Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/36036525/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"OPTION — Left Atrial Appendage Closure after Ablation for Atrial Fibrillation.","url":"https://pubmed.ncbi.nlm.nih.gov/39555822/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"LAAC vs anticoagulation meta-analysis (Circ Arrhythm Electrophysiol 2026) — Left Atrial Appendage Closure Versus Oral Anticoagulation in Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42626769/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Six RCTs, 7,004 patients with AF (not stroke-specific)."},{"title":"LAAO vs anticoagulation meta-analysis with trial sequential analysis (JACC Adv 2026) — Left Atrial Appendage Occlusion versus Oral Anticoagulation in Atrial Fibrillation: A Meta-Analysis of Randomized Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42954691/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Same 6 trials (N = 7,004); GRADE low certainty for the ischemic-stroke excess; trial sequential analysis reached 41% of the required information size."},{"title":"DOAC network meta-analysis in AF with prior stroke — Comparative Safety and Efficacy of Oral Anticoagulants in Patients With Atrial Fibrillation and Prior Ischemic Stroke: A Systematic Review and Network Meta-Analysis of Randomized-Controlled Clinical Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42953941/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31 (Stroke, published online 2026-10-29; no PMC full text); bibliographic record checked. Star-shaped network of 6 RCTs (18,395 patients); all between-DOAC comparisons indirect."},{"title":"LOOP — Implantable loop recorder detection of atrial fibrillation to prevent stroke (The LOOP Study): a randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/34469766/","year":2021,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."}],"related":[{"label":"AF timing after stroke","href":"#/evidence/af-timing"},{"label":"Anticoagulant label review","href":"#/evidence/anticoagulant-labels"}]},{"id":"lipid-management","title":"Lipids, vascular risk and treatment follow-up","category":"Prevention and antithrombotics","settings":["hospital","clinic"],"keywords":["LDL","statin","ezetimibe","PCSK9","Lp(a)","apolipoprotein B","triglycerides","hemorrhagic stroke"],"summary":"Atherosclerotic stroke or TIA: statin ± ezetimibe to LDL <70 mg/dL (AHA 2021, COR 1; Treat Stroke to Target events 8.5 vs 10.9%), but LDL-C <55 when very high risk (ischemic stroke plus another major ASCVD event or ≥2 high-risk conditions; ACC/AHA 2026, COR 1). No known coronary disease or major cardiac source and LDL >100: atorvastatin 80 mg (COR 1; SPARCL stroke 11.2 vs 13.1%, with more hemorrhagic strokes). ACC/AHA 2026, very high risk: high-intensity statin to LDL-C <55 and non-HDL-C <85 mg/dL, adding ezetimibe and/or a PCSK9 antibody as needed (COR 1); other atherosclerotic stroke: LDL-C <70 (COR 1), and adding a nonstatin toward <55 is reasonable (2a). Recheck lipids 4–12 weeks after starting or changing therapy.","consider":["Clarify the vascular indication, lipid profile, prior treatment and adherence.","Triglycerides 135–499 mg/dL on a statin: icosapent ethyl is reasonable in selected patients (2a).","After ICH, weigh statin benefit against hemorrhage risk individually (AHA 2022, 2b).","Published after the ACC/AHA 2026 guideline (evidence search Oct–Dec 2024): in Ez-PAVE (South Korea, open-label; 3,048 adults aged 19–80 with ASCVD, stroke or TIA eligible), targeting LDL-C <55 rather than <70 mg/dL (achieved median 56 vs 66) lowered the 3-year composite of cardiovascular death, nonfatal MI, nonfatal stroke, any revascularization or unstable-angina admission (6.6 vs 9.7%; HR 0.67). The share with prior stroke and stroke-specific results were not reviewed."],"caution":"The AHA 2021 <70 mg/dL goal predates the 2026 dyslipidemia guideline, which sets <55 mg/dL for very-high-risk ASCVD.","sources":[{"title":"2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines","url":"https://pubmed.ncbi.nlm.nih.gov/41824552/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract checked; section 4.2.6 (secondary prevention LDL-C goals) checked against the archived full-text transcription. Indexed correction(s) 42330109, 42709919 not reconciled."},{"title":"Aggressive LDL-C Lowering and the Brain: Impact on Risk for Dementia and Hemorrhagic Stroke: A Scientific Statement From the American Heart Association","url":"https://pubmed.ncbi.nlm.nih.gov/37706297/","year":2023,"type":"Scientific statement","checkedAt":"2026-10-01","access":"NLM title, PMID and DOI checked; full recommendations not reviewed. Interpret with newer evidence. Indexed correction(s) 37878679 not reconciled."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"VESALIUS-CV — Evolocumab in Patients without a Previous Myocardial Infarction or Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/41211925/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31: adults with atherosclerosis or diabetes, no prior MI or stroke, LDL ≥90 mg/dL; evolocumab vs placebo lowered 3-point MACE (CHD death, MI or ischemic stroke; 5-year estimate 6.2 vs 8.0%; HR 0.75); bibliographic record checked."},{"title":"Ez-PAVE — Intensive LDL Cholesterol Targeting in Atherosclerotic Cardiovascular Disease.","url":"https://pubmed.ncbi.nlm.nih.gov/41910315/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31 (<55 vs <70 mg/dL; composite 6.6 vs 9.7%, HR 0.67) and registry NCT04626973 (ages 19–80; stroke/TIA eligible); bibliographic record checked."},{"title":"ROCATIS-1 — The impact of concomitant use of rosuvastatin or atorvastatin plus clopidogrel on the platelet inhibition and clinical outcomes in acute large-vessel minor stroke or TIA: A randomized controlled multi-center trial, the ROCATIS-1 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42662137/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[]},{"id":"bp-prevention","title":"Long-term blood pressure prevention","category":"Prevention and antithrombotics","settings":["clinic","hospital"],"keywords":["hypertension","home BP","ambulatory BP","orthostasis","adherence","secondary prevention"],"summary":"For long-term prevention after stroke or TIA (not the acute phase), target office BP <130/80 for most (AHA 2021, COR 1), and treat an average office BP ≥130/80 even without prior hypertension (2a). PROGRESS: perindopril plus indapamide lowered BP by 12/5 mm Hg and stroke by 43%, whereas perindopril alone (5/3 mm Hg) gave no clear reduction. After ICH, long-term SBP <130 and DBP <80 is reasonable (AHA 2022, 2a). Postdating it, the TRIDENT low-dose triple pill reduced recurrent stroke (4.6 vs 7.4%; HR 0.61). The RECAP-ICH individual-participant meta-analysis (4 trials, 2,944 patients, 75% Asian) compared fixed-dose or target-based BP lowering with placebo or standard care (mean SBP difference 11 mm Hg). It found fewer recurrent strokes (6.5 vs 10.4%; HR 0.62), mainly through fewer recurrent ICH (2.2 vs 5.6%; HR 0.39). Lacunar stroke: SPS3 (<130) reduced ICH.","consider":["Confirm measurement technique, home readings and possible orthostatic symptoms.","Review adherence, reversible contributors and access to treatment.","Individualize the follow-up and medication plan using current guidance and comorbidities.","Lower targets: in ESPRIT (China, open-label; 11,255 high-risk hypertensive adults, 3,022 with prior stroke), an SBP target <120 vs <140 mm Hg (achieved 119 vs 135) reduced major vascular events (9.7 vs 11.1%; HR 0.88), with more serious syncope. Stroke, a secondary outcome, was not significantly reduced (4.7 vs 5.4%; HR 0.86). Fewer hemorrhagic strokes (0.4 vs 0.8%) came from a post hoc analysis."],"caution":"Long-term targets do not apply in the acute phase.","sources":[{"title":"2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines","url":"https://pubmed.ncbi.nlm.nih.gov/40811516/","year":2025,"type":"Guideline","checkedAt":"2026-10-02","access":"Primary NLM identity and abstract checked; complete recommendations not reviewed. Publisher-indexed corrections 41259465 and 42160500 checked on 2026-10-02: resistant-hypertension/table text and labetalol repeat interval, not reproduced by this overview. Correction 41984986 and complete tables remain unreviewed; direct correction PDFs unavailable."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"TRIDENT — Three Low-Dose Antihypertensive Agents in a Single Pill after Intracerebral Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/42019018/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ESPRIT (BP) — Lowering systolic blood pressure to less than 120 mm Hg versus less than 140 mm Hg in patients with high cardiovascular risk with and without diabetes or previous stroke: an open-label, blinded-outcome, randomised trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38945140/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31 (China; 11,255 participants, 3,022 with prior stroke; primary composite HR 0.88); bibliographic record checked. Stroke results from the prespecified JACC 2025 secondary analysis (PMID 40864014), abstract read 2026-10-31; subtype results post hoc."},{"title":"BPROAD — Intensive Blood-Pressure Control in Patients with Type 2 Diabetes.","url":"https://pubmed.ncbi.nlm.nih.gov/39555827/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CRHCP 7-year follow-up — Long-Term Effectiveness of Intensive Blood Pressure Management Led by Nonphysician Community Healthcare Providers on Cardiovascular Events: 7-Year Follow-Up of a Cluster Randomized Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42666029/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"RECAP-ICH — Intensive blood pressure lowering after spontaneous intracerebral haemorrhage for secondary stroke prevention (RECAP-ICH): a systematic review and individual participant data meta-analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42586098/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (2,944 participants; recurrent stroke HR 0.62, recurrent ICH HR 0.39); bibliographic record checked; full text not read. Individual-participant meta-analysis of 4 trials of BP-lowering treatment vs placebo or standard care, not a test of the <130/80 target. Included trials are not named in the abstract; overlap with TRIDENT not confirmed."}],"related":[{"label":"Acute BP context","href":"#/evidence/acute-bp"}]},{"id":"brain-avm","title":"Brain arteriovenous malformation","category":"Stroke mechanisms and vascular disorders","settings":["on-call","hospital","clinic"],"keywords":["AVM","bAVM","arteriovenous malformation","Spetzler Martin","ARUBA","embolization","radiosurgery"],"summary":"Separate ruptured from unruptured AVMs and decide with a multidisciplinary vascular team, weighing natural history against surgical, endovascular and radiosurgical risks (AHA/ASA 2017). In ARUBA (226 adults with unruptured AVMs judged suitable for intervention; non-blinded, mixed interventions), medical management alone had fewer deaths or symptomatic strokes over a mean 50 months (3.39 vs 12.32 per 100 patient-years; HR 0.31). In MARS (9 cohorts, 2 population-based; 3,030 people with unruptured brain AVMs; observational, censored at first treatment), first ICH occurred at 1.40 per 100 person-years, lower than the commonly quoted 2–4% per year; risk was higher with age 60+ at diagnosis (HR 2.01 vs <20 years), associated arterial aneurysms (HR 1.66) and deep or cerebellar location (HR 1.87).","consider":["Clarify rupture status, anatomy, symptoms and associated lesions.","Review expected natural history and treatment risks with a multidisciplinary vascular team.","Discuss the specific treatment goal and follow-up plan with the patient."],"caution":"The 2017 statement is dated, and no grading scale or single trial selects treatment for every AVM.","sources":[{"title":"AHA/ASA brain AVM statement — official key points","url":"https://professional.heart.org/en/science-news/management-of-brain-arteriovenous-malformations/top-things-to-know","year":2017,"type":"Scientific statement","checkedAt":"2026-10-01","access":"Official AHA key points page."},{"title":"ARUBA final follow-up (unruptured brain AVMs)","url":"https://pubmed.ncbi.nlm.nih.gov/32562682/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract read via PubMed."},{"title":"MARS — Risk of Future Hemorrhage From Unruptured Brain Arteriovenous Malformations: The Multicenter Arteriovenous Malformation Research Study (MARS).","url":"https://pubmed.ncbi.nlm.nih.gov/41051760/","year":2025,"type":"Observational study","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Pooled cohorts (2 population-based, 7 referral-based), censored at first AVM treatment, death or last visit."}],"related":[]},{"id":"cavernous-malformation","title":"Cerebral and spinal cavernous malformation","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["cavernoma","CCM","cavernous angioma","DVA","familial","hemorrhage","seizure"],"summary":"Establish lesion location, prior symptomatic hemorrhage, seizures and whether lesions are familial or multiple, then plan imaging, genetic counseling and any intervention in a specialist setting; evidence gaps remain substantial (2025 consensus). Brain MRI should include susceptibility-weighted sequences (Class 1). A cavernous malformation should not preclude needed antithrombotics (Class 2a, B-NR); with a known unruptured, untreated one, IV alteplase may be considered if otherwise indicated for AIS; its risk is not well established (Class 2b, C-LD).","consider":["Clarify lesion location, prior symptomatic hemorrhage, seizures and whether lesions are familial or multiple.","Review imaging, genetic counseling and follow-up needs in the appropriate specialty setting.","Compare intervention risks with the clinical history and the outcomes the patient values.","In a Scottish population-based cohort (190 people aged 16+ with symptomatic CCM; median 16-year follow-up; observational), the 37 who had intervention (35 resections) were younger and more often presented with ICH. Intervention was not associated with the primary outcome (OHS ≥2) but was associated with dependence or death (OHS ≥3; aHR 2.66) and with CCM- or intervention-related ICH or new focal deficit (aHR 3.59); the authors call for an RCT."],"caution":"Many recommendations rely on limited evidence, and incidental and symptomatic brainstem or spinal lesions need different discussions.","sources":[{"title":"Alliance to Cure CM 2025 guidelines for cavernous malformations of the brain and spinal cord","url":"https://pubmed.ncbi.nlm.nih.gov/40396744/","year":2025,"type":"Consensus statement","checkedAt":"2026-10-17","access":"PMC full text (PMC12680281) read 2026-10-17: graded recommendations."},{"title":"Scottish CCM intervention cohort — Intervention or Conservative Management for Symptomatic Cerebral Cavernous Malformations: A Prospective, Population-Based Cohort Study.","url":"https://pubmed.ncbi.nlm.nih.gov/42585604/","year":2026,"type":"Observational study","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Nonrandomized comparison; treated patients differed at baseline (younger, more ICH presentations, fewer brainstem lesions)."}],"related":[]},{"id":"sah-critical-care","title":"aSAH critical care and CSF diversion","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital"],"keywords":["subarachnoid hemorrhage","DCI","vasospasm","EVD","hydrocephalus","CSF drainage","transfusion","antifibrinolytic"],"summary":"Keep euvolemia (AHA 2023, 2a); induced hypervolemia and prophylactic hemodynamic augmentation are harmful (COR 3: Harm). Monitor for DCI with frequent neurological exams (COR 1); TCD, and CTA or CT perfusion with suspected vasospasm or an unreliable exam, are reasonable (2a). Symptomatic vasospasm: raising SBP may be reasonable; severe vasospasm: intra-arterial vasodilators or angioplasty may be reasonable (2b). ESO 2026 gives no evidence-based recommendation on these; its guidance reserves induced hypertension for after the aneurysm is secured and fluids have failed, and angioplasty for last-line rescue. Acute symptomatic hydrocephalus: EVD and/or lumbar drainage (COR 1) under a bundled EVD protocol. EARLYDRAIN (lumbar drain after securing) reduced poor outcome, but ESO 2026 makes no recommendation on prophylactic lumbar drainage.","consider":["Do not drain CSF for radiological hydrocephalus alone when consciousness is normal (ESO consensus).","Liberal transfusion (Hb ≤10 g/dL) did not improve 12-month outcome (SAHaRA).","Pharmacological or mechanical VTE prophylaxis is recommended once the aneurysm is secured (AHA 2023, COR 1, C-LD)."],"caution":"Drain management needs the full neurosurgical protocol.","sources":[{"title":"NCS 2023 neurocritical care of aneurysmal SAH","url":"https://pubmed.ncbi.nlm.nih.gov/37202712/","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Primary abstract and source scope checked; full recommendation text not reviewed."},{"title":"NCS insertion and management of external ventricular drains","url":"https://pubmed.ncbi.nlm.nih.gov/26738503/","year":2016,"type":"Consensus statement","checkedAt":"2026-10-01","access":"Primary abstract and source scope checked; full recommendation text not reviewed."},{"title":"European Stroke Organisation (ESO), European Association of Neurosurgical Societies (EANS) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on aneurysmal subarachnoid haemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/42095754/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendations from the archived full-text transcription (reviewed 2026-09-30); cited in topic summaries."},{"title":"2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/37212182/","year":2023,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 38011240 (Stroke 2023;54:e516) is indexed; its body was not re-read."},{"title":"SAHaRA — Liberal or Restrictive Transfusion Strategy in Aneurysmal Subarachnoid Hemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/39655786/","year":2025,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ULTRA — Ultra-early tranexamic acid after subarachnoid haemorrhage (ULTRA): a randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/33357465/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"EARLYDRAIN — Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/37330974/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here. PubMed lists 1 correction or notice; check it before applying results."}],"related":[{"label":"aSAH overview","href":"#/evidence/sah"}]},{"id":"research-adjuncts","title":"New and adjunct therapies: match the evidence","category":"Prevention and antithrombotics","settings":["on-call","hospital","clinic"],"keywords":["factor XI","asundexian","OCEANIC-STROKE","OCEANIC-AF","MOST","argatroban","eptifibatide","colchicine","CONVINCE","CHANCE-3","neuroprotection","nerinetide","ESCAPE-NEXT","remote ischemic conditioning","RESIST","SERIC-EVT","tirofiban","cytoprotection","minocycline","EMPHASIS","MIST-A","loberamisal","LAIS","edaravone","ERASE-STROKE","TASTE-2","glenzocimab","ACTISAVE"],"summary":"Asundexian (factor XIa inhibitor; confirm regulatory status), added to antiplatelets within 72 h of noncardioembolic ischemic stroke or high-risk TIA with a nonlacunar infarct or atherosclerosis, reduced ischemic stroke (OCEANIC-STROKE 6.2 vs 8.4%; major bleeding 1.9 vs 1.7%) but was worse than apixaban in AF (OCEANIC-AF). Adjunctive IV argatroban or eptifibatide after IVT did not help and increased mortality (MOST: 24% and 12% vs 8%). Nerinetide (ESCAPE-NEXT; post hoc signals of benefit when given within 3 h, at 90 days in a pooled 3-trial analysis and at 1 year, are hypothesis-generating), prehospital remote ischemic conditioning (RESIST) and colchicine (CONVINCE, CHANCE-3) were neutral; SERIC-EVT (conditioning after EVT) was positive, but EnTRIPS (postconditioning after EVT) was neutral.","consider":["Compare the population, background therapy and primary endpoint with your patient before applying a new result. Separate confirmatory results from subgroup signals, and look for independent replication.","Confirm regulatory approval and local availability before using any new agent.","Cytoprotection RCTs published after the AHA 2026 literature cutoff (March 2025), all double-blind, placebo-controlled and run only in China (replication awaited): minocycline orally within 72 h, NIHSS 4–25 (EMPHASIS: mRS 0–1 52.6 vs 47.4%); IV loberamisal within 48 h, NIHSS 7–20 (LAIS: 69.7 vs 56.3%); oral edaravone (TTYP01) within 24 h for disabling anterior-circulation stroke without reperfusion therapy (ERASE-STROKE: 65.4 vs 47.1%); edaravone dexborneol started before EVT for anterior LVO was borderline (TASTE-2: mRS 0–2 55.0 vs 49.6%; RR 1.11, 1.00–1.23; P=0.05). Minocycline after successful EVT did not reduce infarct growth (MIST-A, open-label phase 2), and the antiplatelet glenzocimab added to IVT did not improve outcome (ACTISAVE, international phase 2/3). AHA 2026 does not grade these trials.","Tirofiban (Chinese RCTs) improved 90-day function as an IV infusion after IVT in noncardioembolic stroke without EVT (ASSET-IT, mRS 0–1 65.9 vs 54.9%; sICH 1.7 vs 0%) or after inadequate response to tenecteplase without LVO, MeVO or cardioembolism (INSTANT, 63.8 vs 52.2%), and as an intra-arterial bolus plus IV infusion after successful EVT (ATTRACTION, mRS 0–2 49 vs 43%; sICH 12 vs 9%, not significant); IV tirofiban before EVT was neutral (RESCUE BT), and AHA 2026 rates preprocedural tirofiban before EVT as not useful (COR 3: No Benefit, B-R). With literature through March 2025, before ASSET-IT, INSTANT and ATTRACTION, AHA 2026 rates IV tirofiban efficacy as not well established (COR 2b, B-R)."],"caution":"AHA 2026 does not recommend neuroprotective agents to improve function (COR 3: No Benefit, LOE A), adjunctive argatroban with IVT (COR 3: No Benefit, LOE A) or adjunctive IV eptifibatide in patients given IVT within 3 h of onset (COR 3: No Benefit, LOE B-R).","sources":[{"title":"OCEANIC-STROKE: Asundexian for Secondary Stroke Prevention","url":"https://pubmed.ncbi.nlm.nih.gov/41985132/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract read via NLM; selected noncardioembolic add-on population and endpoint checked. No regulatory or availability inference."},{"title":"OCEANIC-AF: Asundexian versus Apixaban","url":"https://pubmed.ncbi.nlm.nih.gov/39225267/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked; no approval or availability inferred."},{"title":"ESCAPE-NEXT: Nerinetide with EVT without previous thrombolysis","url":"https://pubmed.ncbi.nlm.nih.gov/39955119/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked; no approval or availability inferred."},{"title":"RESIST: Remote Ischemic Conditioning for Acute Stroke","url":"https://pubmed.ncbi.nlm.nih.gov/37787796/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked; no approval or availability inferred."},{"title":"SERIC-EVT: Remote ischaemic conditioning after thrombectomy","url":"https://pubmed.ncbi.nlm.nih.gov/40796242/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked; no approval or availability inferred."},{"title":"CONVINCE: Long-term colchicine after noncardioembolic stroke","url":"https://pubmed.ncbi.nlm.nih.gov/38857611/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked; no approval or availability inferred."},{"title":"CHANCE-3: Colchicine after acute stroke or TIA","url":"https://pubmed.ncbi.nlm.nih.gov/38925803/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked; no approval or availability inferred."},{"title":"EnTRIPS: remote ischemic postconditioning after EVT","url":"https://pubmed.ncbi.nlm.nih.gov/42267436/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"ASSET-IT: tirofiban infusion after IVT","url":"https://pubmed.ncbi.nlm.nih.gov/40616232/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"INSTANT: IV tirofiban after tenecteplase","url":"https://pubmed.ncbi.nlm.nih.gov/42100960/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"ATTRACTION: tirofiban after successful EVT","url":"https://pubmed.ncbi.nlm.nih.gov/42341797/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"RESCUE BT: IV tirofiban before EVT","url":"https://pubmed.ncbi.nlm.nih.gov/35943471/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"STRATEGY: tirofiban for branch atheromatous disease","url":"https://pubmed.ncbi.nlm.nih.gov/42671865/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/41582814/","year":2026,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. July 2026 correction (42507797; partially recovered) applied to the tenecteplase-dose, perfusion-window IVT, dysphagia and pharyngeal-stimulation recommendations."},{"title":"ESO annual stroke evidence update 2025","url":"https://pubmed.ncbi.nlm.nih.gov/41706824/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PMC full text (PMC12915583) read 2026-10-31. ESO Guideline Board evidence review; its practice implications are the authors' interpretation, not guideline recommendations."},{"title":"LAIS — Loberamisal for Acute Ischemic Stroke: The LAIS Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42721021/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."},{"title":"ERASE-STROKE — Early and prolonged oral edaravone for neuroprotection in acute ischemic stroke: the ERASE-STROKE randomized controlled phase 3 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42705987/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Country (China) and the no-reperfusion criterion from the ClinicalTrials.gov registry record NCT06648304."},{"title":"CHOICE — Effect of Intra-arterial Alteplase vs Placebo Following Successful Thrombectomy on Functional Outcomes in Patients With Large Vessel Occlusion Acute Ischemic Stroke: The CHOICE Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35143603/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"CHOICE-2 — Adjunctive Intra-Arterial Alteplase After Successful Thrombectomy for Acute Ischemic Stroke: The CHOICE-2 Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42096239/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"RESCUE BT2 — Tirofiban for Stroke without Large or Medium-Sized Vessel Occlusion.","url":"https://pubmed.ncbi.nlm.nih.gov/37256974/","year":2023,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"CLEAR SYNERGY (colchicine) — Colchicine in Acute Myocardial Infarction.","url":"https://pubmed.ncbi.nlm.nih.gov/39555823/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"AXIOMATIC-SSP — Safety and efficacy of factor XIa inhibition with milvexian for secondary stroke prevention (AXIOMATIC-SSP): a phase 2, international, randomised, double-blind, placebo-controlled, dose-finding trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38101902/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"PEARL — Intra-Arterial Alteplase After Successful Endovascular Reperfusion in Acute Stroke: The PEARL Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42262770/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"ANGEL-TNK — Intra-arterial Tenecteplase for Acute Stroke After Successful Endovascular Therapy: The ANGEL-TNK Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40616323/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"IAT-TOP — Intra-arterial Alteplase Thrombolysis After Successful Thrombectomy for AIS in the Posterior Circulation: The IAT-TOP Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42026933/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"DATE (IA tenecteplase dose-escalation) — Intra-Arterial Tenecteplase After Successful Reperfusion in Large Vessel Occlusion Stroke: A Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/40616333/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"IA Thrombolysis Dose Network Meta-analysis — Dose-Specific Intra-Arterial Thrombolysis After Endovascular Thrombectomy for Large-Vessel Occlusion Stroke: A Network Meta-Analysis of Randomized Trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42088338/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-22","access":"Primary abstract re-read via PubMed on 2026-10-22: network meta-analysis of 7 randomized trials (2126 patients), hypothesis-generating per its authors; bibliographic record checked."},{"title":"MOST — Adjunctive Intravenous Argatroban or Eptifibatide for Ischemic Stroke.","url":"https://pubmed.ncbi.nlm.nih.gov/39231343/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card."},{"title":"ESCAPE-NA1 — Efficacy and safety of nerinetide for the treatment of acute ischaemic stroke (ESCAPE-NA1): a multicentre, double-blind, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/32087818/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"ACTISAVE — Glenzocimab Efficacy and Safety Added to Intravenous Thrombolysis With or Without Mechanical Thrombectomy in Patients With Acute Ischemic Stroke-ACTISAVE: A Prospective, Randomized, Double-Blind Study.","url":"https://pubmed.ncbi.nlm.nih.gov/42044230/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."},{"title":"TASTE (edaravone dexborneol) — Edaravone Dexborneol Versus Edaravone Alone for the Treatment of Acute Ischemic Stroke: A Phase III, Randomized, Double-Blind, Comparative Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/33588596/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"TASTE-2 — Edaravone dexborneol versus placebo on functional outcomes in patients with acute ischaemic stroke undergoing endovascular thrombectomy (TASTE-2): randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41500725/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."},{"title":"EMPHASIS — Efficacy and safety of minocycline in patients with acute ischaemic stroke (EMPHASIS): a multicentre, double-blind, randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41628627/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."},{"title":"MIST-A — Efficacy and safety of minocycline on patients with acute anterior circulation ischaemic stroke undergoing mechanical thrombectomy (MIST-A): a multicentre, prospective, randomised, open-label, blinded-endpoint, phase 2 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42305108/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read."},{"title":"ESCAPE-NEXT year 1 — Safety and Efficacy of Nerinetide at Year 1 in Participants Enrolled in ESCAPE-NEXT: A Multicenter, Double-Blind, Randomized Controlled Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/42333641/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (PMC13477396 not read); bibliographic record checked. Year-1 outcomes in 513 of 850; the early-window interaction was post hoc."},{"title":"RICAMIS — Effect of Remote Ischemic Conditioning vs Usual Care on Neurologic Function in Patients With Acute Moderate Ischemic Stroke: The RICAMIS Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/35972485/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Anti-inflammatory CV meta-analysis — Effects of anti-inflammatory agents on cardiovascular outcomes: A systematic review and meta-analysis of randomised controlled trials.","url":"https://pubmed.ncbi.nlm.nih.gov/42291081/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"Y-6 phase 2 — Efficacy and safety of sublingual cilostazol and dexborneol for the treatment of acute ischaemic stroke: a randomised phase 2 trial in China.","url":"https://pubmed.ncbi.nlm.nih.gov/42621146/","year":2026,"type":"Report","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"OPENS-2 — Normobaric hyperoxia combined with endovascular treatment for acute ischaemic stroke in China (OPENS-2 trial): a multicentre, randomised, single-blind, sham-controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39922675/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."},{"title":"POST-TNK — Intra-Arterial Tenecteplase Following Endovascular Reperfusion for Large Vessel Occlusion Acute Ischemic Stroke: The POST-TNK Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39804681/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"POST-UK — Intra-Arterial Urokinase After Endovascular Reperfusion for Acute Ischemic Stroke: The POST-UK Randomized Clinical Trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39804674/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."},{"title":"ATTENTION-IA — Intra-arterial tenecteplase after successful endovascular recanalisation in patients with acute posterior circulation arterial occlusion (ATTENTION-IA): multicentre randomised controlled trial.","url":"https://pubmed.ncbi.nlm.nih.gov/39809509/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed; bibliographic record checked."}],"related":[]},{"id":"evidence-interpretation","title":"Rapid appraisal of a trial or guideline","category":"Systems and transitions of care","settings":["on-call","hospital","clinic"],"keywords":["evidence based medicine","EBM","critical appraisal","relative risk","absolute risk","NNT","confidence interval","noninferiority","subgroup","systematic review"],"summary":"Use a structured appraisal before converting a study headline into a clinical decision: population, comparison, outcome, uncertainty and applicability.","consider":["Is the outcome patient-important, and is the quoted result the prespecified primary analysis?","Compare absolute and relative effects, confidence intervals, missing data and harms.","Check whether subgroup, noninferiority or composite-endpoint claims support the proposed inference."],"caution":"A neutral superiority trial does not prove equivalence.","sources":[{"title":"Oxford CEBM critical appraisal and EBM tools","url":"https://www.cebm.ox.ac.uk/resources/ebm-tools","year":2026,"type":"Educational resource","checkedAt":"2026-10-01","access":"Official resource index verified in live search; direct page returned 403. Year records this resource check, not a new guideline publication."}],"related":[]},{"id":"ich-expansion-ivh","title":"ICH expansion and intraventricular extension","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital"],"keywords":["hematoma expansion","IVH","intraventricular hemorrhage","EVD","CLEAR III","TICH-2","FASTEST","tranexamic acid","factor VIIa","hemostatic"],"summary":"In ICH without anticoagulant use, no hemostatic drug has been shown to improve function (anticoagulant-associated ICH still needs rapid reversal: AHA 2022, COR 1). Recombinant factor VIIa within 2 h (FASTEST) slowed growth by 3.7 mL but did not change 180-day mRS (cOR 1.09) and increased life-threatening thromboembolism (RR 3.41); tranexamic acid (TICH-2) also gave no functional benefit (aOR 0.88). A 2026 individual-patient meta-analysis (5 trials, 2,860 patients treated within 12 h) confirmed no 90-day functional benefit (cOR 0.93) but found small reductions in hematoma expansion (OR 0.81) and 7-day mortality (aOR 0.70). Hydrocephalus contributing to reduced consciousness: ventricular drainage (AHA 2022, COR 1); large IVH with impaired consciousness: EVD rather than medical management alone (COR 1). CLEAR III (stable supratentorial ICH <30 mL or primary IVH; IVH obstructing the third or fourth ventricle; routine EVD): intraventricular alteplase lowered 180-day mortality (18 vs 29%) without improving mRS ≤3 and increased mRS 5 (17 vs 9%). AHA 2022, for GCS >3 with primary IVH or IVH extension from supratentorial ICH <30 mL requiring EVD: reasonable to reduce mortality (2a); functional benefit uncertain (2b).","consider":["Is the problem expansion, ventricular obstruction, hydrocephalus or mass effect?","Repeat CT within 24 h, sooner with any decline, to catch expansion.","Discuss procedural risks and patient-valued outcomes with neurosurgery."],"caution":"Lower mortality without functional gain can mean more survivors with severe disability.","sources":[{"title":"TICH-2: Tranexamic acid for hyperacute primary ICH","url":"https://pubmed.ncbi.nlm.nih.gov/29778325/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-22","access":"PMC full text read (PMC5976950): excluded ICH secondary to anticoagulation, thrombolysis, trauma or a structural abnormality; no approval or availability inferred."},{"title":"CLEAR III: Thrombolytic removal of intraventricular hemorrhage","url":"https://pubmed.ncbi.nlm.nih.gov/28081952/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract and registry (NCT00784134) checked 2026-10-17; no approval or availability inferred."},{"title":"2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/35579034/","year":2022,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence."},{"title":"Tranexamic acid in ICH IPD meta-analysis — Effect of tranexamic acid for acute spontaneous intracerebral haemorrhage: a systematic review and individual patient data meta-analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42276775/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Individual data from 5 placebo-controlled trials (2,860 participants, 90% of those eligible), including TICH-2."},{"title":"FASTEST — Recombinant factor VIIa versus placebo for spontaneous intracerebral haemorrhage within 2 h of symptom onset (FASTEST): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/41653933/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract verified via PubMed; bibliographic record checked; summarized in its study card. PubMed lists 1 correction or notice; check it before applying results."},{"title":"STOP-MSU — Tranexamic acid versus placebo in individuals with intracerebral haemorrhage treated within 2 h of symptom onset (STOP-MSU): an international, double-blind, randomised, phase 2 trial.","url":"https://pubmed.ncbi.nlm.nih.gov/38648814/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"PubMed bibliographic record checked; outcomes not reviewed here."}],"related":[{"label":"ICH immediate priorities","href":"#/evidence/ich-management"},{"label":"ICH surgical options","href":"#/evidence/ich-surgery"}]},{"id":"antiphospholipid-syndrome","title":"Antiphospholipid syndrome and stroke","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["APS","antiphospholipid","aPL","lupus anticoagulant","anticardiolipin","beta-2 glycoprotein","thrombophilia","warfarin","DOAC","recurrent thrombosis"],"summary":"APS assessment connects the clinical thrombotic history with persistent antiphospholipid antibodies. An isolated positive test does not establish APS; acute illness and anticoagulants can distort lupus-anticoagulant testing. In a 2026 meta-analysis of mostly hospital-based case-control studies (single-time testing; diagnosed APS excluded; most studies before 2010), about 1 in 5 ischemic stroke patients had at least one positive antiphospholipid antibody (19.1%; highly heterogeneous, possibly overestimated). Seropositivity was associated with first ischemic stroke (OR 2.93; strongest for lupus anticoagulant) but not significantly with recurrence in 9 cohorts (OR 1.20; 95% CI 0.87–1.67; not adjusted for post-stroke treatment), which the authors say is not evidence against its relevance.","consider":["Does the stroke mechanism, age, vascular-risk profile or prior thrombotic/obstetric history justify targeted testing?","Review the antibody profile, assay conditions and repeat testing at least 12 weeks apart with hematology and the laboratory.","For established APS-associated stroke, review its specific antithrombotic evidence; DOAC results from AF should not be transferred to arterial APS."],"caution":"Classification criteria are not a standalone diagnostic test, and this card does not choose a drug, INR target or duration.","sources":[{"title":"BSH 2024 guidelines on the investigation and management of antiphospholipid syndrome","url":"https://onlinelibrary.wiley.com/doi/10.1111/bjh.19635","year":2024,"type":"Guideline","checkedAt":"2026-10-02","access":"BSH guideline, selected sections."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."},{"title":"Antiphospholipid antibodies in ischemic stroke meta-analysis — Prevalence and Clinical Relevance of Antiphospholipid Antibodies in Ischemic Stroke: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/42663055/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract and PMC full text (PMC13528693) read 2026-10-31; bibliographic record checked. Mostly hospital-based case-control studies with single-time antibody testing; patients with diagnosed APS excluded."}],"related":[{"label":"Stroke mechanism and workup","href":"#/evidence/stroke-workup"},{"label":"Anticoagulant label review","href":"#/evidence/anticoagulant-labels"},{"label":"Cerebral venous thrombosis","href":"#/evidence/cvt"}]},{"id":"thunderclap-sah-evaluation","title":"Sudden severe headache and suspected SAH","category":"Hemorrhage and neurocritical care","settings":["on-call","hospital"],"keywords":["thunderclap","worst headache","subarachnoid","SAH diagnosis","negative CT","lumbar puncture","LP","CTA","Ottawa SAH","acute headache"],"summary":"Sudden severe headache warrants prompt evaluation for SAH and other serious causes. Interpret a negative CT with the onset interval, neurologic findings, scanner quality and reader expertise.","consider":["Establish time to peak pain, onset time, examination findings and whether the presentation fits the source population.","AHA/ASA 2023 recommends LP after a negative CT when presentation is more than 6 hours after onset or there is a new neurologic deficit; early CT-only assessment has specific quality and examination requirements.","ACEP 2019 allows LP or CTA when SAH risk remains after negative CT, with shared discussion of limitations. Review these differing recommendations with the local diagnostic pathway.","In ED patients with non-traumatic acute headache, the Ottawa and Emerald SAH rules had pooled sensitivity of 99% but specificity of only 23–27%, and the Ottawa rule did not significantly reduce CT use (2025 meta-analysis). In a UK and Ireland neurosurgical-referral audit (10,187 spontaneous SAH), 55 aneurysmal SAHs had a CT reported negative within 6 h of onset and a positive LP; these were real-world reports, often not by neuroradiologists."],"caution":"A negative CT is not universal clearance, and CTA can find an incidental aneurysm.","sources":[{"title":"AHA/ASA 2023 aneurysmal SAH guideline: Section 4, clinical manifestations and diagnosis","url":"https://www.ahajournals.org/doi/10.1161/STR.0000000000000436","year":2023,"type":"Guideline","checkedAt":"2026-10-02","access":"Publisher-indexed Section 4 recommendation table read, including CT timing, examination/reader requirements and LP. Complete guideline and supplements not reviewed. Previously indexed correction PMID 38011240 remains unreconciled; no correction-access retry or full corrected-guideline claim."},{"title":"ACEP 2019 clinical policy: acute headache, diagnostic questions 3 and 4","url":"https://www.acep.org/siteassets/sites/acep/media/clinical-policies/cp-headache.pdf","year":2019,"type":"Guideline","checkedAt":"2026-10-02","access":"Official published policy PDF, questions 3 and 4 (pp. e50–e51), recommendations and diagnostic limitations read. Complete policy/evidence tables not reviewed. A 2026 update was listed as a draft for comment; draft recommendations were not used."},{"title":"SAH decision rules meta-analysis — Diagnostic Accuracy and Application of Subarachnoid Hemorrhage Decision Rules Among Patients With Non-Traumatic Acute Headache: A Systematic Review and Meta-Analysis.","url":"https://pubmed.ncbi.nlm.nih.gov/40605232/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; bibliographic record checked; full text not read. Emergency-department patients with non-traumatic acute headache."},{"title":"UK and Ireland SAH lumbar puncture audit — Multicentre study of the role of lumbar puncture in the diagnosis of spontaneous subarachnoid haemorrhage.","url":"https://pubmed.ncbi.nlm.nih.gov/40676358/","year":2025,"type":"Observational study","checkedAt":"2026-10-31","access":"PMC full text (PMC12270960) read 2026-10-31; bibliographic record checked. Retrospective multicentre audit of neurosurgical referrals; CT reports came mostly from referring hospitals, often not by an expert neuroradiologist, so it did not test the AHA 2023 early CT-only criteria."}],"related":[{"label":"Aneurysmal SAH","href":"#/evidence/sah"},{"label":"RCVS and PRES","href":"#/evidence/rcvs-pres"},{"label":"CVT","href":"#/evidence/cvt"},{"label":"Dissection","href":"#/evidence/dissection"}]},{"id":"fibromuscular-dysplasia","title":"Fibromuscular dysplasia: vascular assessment and follow-up","category":"Stroke mechanisms and vascular disorders","settings":["hospital","clinic"],"keywords":["FMD","fibromuscular dysplasia","beading","nonatherosclerotic","renal artery","multivessel","aneurysm screening","cervical dissection"],"summary":"FMD is a nonatherosclerotic arterial disorder that can involve several vascular beds. The ESH/SVM consensus requires a focal or multifocal arterial lesion; dissection, aneurysm or tortuosity alone does not establish FMD.","consider":["Review the vascular imaging diagnosis and any associated dissection, aneurysm or hypertension with an experienced team.","For established FMD, the 2019 consensus supports at least one brain-to-pelvis CTA or contrast-enhanced MRA assessment for additional disease, aneurysms and dissections.","Arrange longitudinal clinical review; customize subsequent imaging to the affected vessels, symptoms, prior procedures and aneurysm/dissection findings."],"caution":"Consensus guidance with limited treatment evidence; there is no universal follow-up imaging interval.","sources":[{"title":"ESH/SVM 2019 first international consensus on the diagnosis and management of fibromuscular dysplasia","url":"https://journals.sagepub.com/doi/pdf/10.1177/1358863X18821816","year":2019,"type":"Consensus statement","checkedAt":"2026-10-02","access":"Selected primary PDF passages read: diagnostic consensus points (p. 167), cerebrovascular assessment (p. 175), brain-to-pelvis imaging and antiplatelet evidence limits (p. 177), longitudinal follow-up (pp. 182–183). Full document and supplements not comprehensively reviewed."},{"title":"FMD consensus corrigendum: carotid stenosis wording","url":"https://journals.sagepub.com/doi/10.1177/1358863X19865703","year":2019,"type":"Correction","checkedAt":"2026-10-02","access":"Complete publisher-indexed notice text read; it replaces an erroneous reference to severe carotid stenting with severe carotid stenosis in a cervical-dissection procedural sentence. That sentence is not reproduced here. Direct notice-page fetch timed out."},{"title":"2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association","url":"https://pubmed.ncbi.nlm.nih.gov/34024117/","year":2021,"type":"Guideline","checkedAt":"2026-10-01","access":"Recommendation text from the archived full-text transcription (reviewed 2026-09-30); quoted in the topic cards with class and level of evidence. Correction 34181456 concerns the PFO summary, a diagnostic figure and an acronym, not the recommendation tables."}],"related":[{"label":"Cervical artery dissection","href":"#/evidence/dissection"},{"label":"Unruptured aneurysm review","href":"#/evidence/unruptured-aneurysms"},{"label":"Long-term blood pressure prevention","href":"#/evidence/bp-prevention"}]}],"studies":[{"id":"elan","title":"ELAN — timing of anticoagulation after AF-associated stroke","headline":"Early DOAC: composite 2.9 vs 4.1% (difference not significant)","year":2023,"settings":["hospital","clinic"],"keywords":["DOAC","atrial fibrillation","early anticoagulation"],"question":"How did earlier DOAC initiation compare with a later schedule?","population":"2,013 people with acute ischemic stroke and atrial fibrillation.","comparison":"Earlier: within 48 hours for minor/moderate stroke or days 6–7 for major stroke. Later: days 3–4, 6–7 or 12–14, respectively.","result":"The 30-day composite of recurrent ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage or vascular death was 2.9% versus 4.1% (risk difference −1.18 percentage points; 95% CI −2.84 to 0.47). Symptomatic intracranial hemorrhage was 0.2% in both groups.","limits":"The confidence interval includes no difference. Trial severity categories and exclusions require review; this is not an automatic start-date rule.","sources":[{"title":"ELAN primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37222476/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"af-timing"},{"id":"optimas","title":"OPTIMAS — early versus delayed DOAC initiation","headline":"DOAC ≤4 days noninferior to days 7–14 (3.3% each)","year":2024,"settings":["hospital","clinic"],"keywords":["DOAC","atrial fibrillation","early anticoagulation"],"question":"Was initiation within four days noninferior to starting at 7–14 days?","population":"3,621 analyzed adults with AF-associated ischemic stroke at 100 UK hospitals; clinicians were uncertain about timing.","comparison":"DOAC initiation within four days versus days 7–14.","result":"At 90 days, recurrent ischemic stroke, symptomatic intracranial hemorrhage, unclassifiable stroke or systemic embolism occurred in 3.3% of each group. Noninferiority met the two-percentage-point margin; superiority was not demonstrated. Symptomatic intracranial hemorrhage was 0.6% versus 0.7%.","limits":"Open-label treatment with masked adjudication. Apply the trial selection criteria; identical observed rates do not prove identical individual risk.","sources":[{"title":"OPTIMAS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/39491870/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract read via PubMed/NLM. January 2025 publisher correction checked: wording and figure-at-risk count corrected; no endpoint change stated."}],"relatedTopic":"af-timing"},{"id":"catalyst","title":"CATALYST — pooled randomized evidence on DOAC timing","headline":"DOAC ≤4 days: 2.1 vs 3.0% (OR 0.70); sICH 0.4% each","year":2025,"settings":["hospital","clinic"],"keywords":["IPD","meta-analysis","ELAN","OPTIMAS","TIMING","START","atrial fibrillation"],"question":"What does pooled participant-level evidence show about earlier initiation?","population":"5,441 participants from TIMING, ELAN, OPTIMAS and START; median NIHSS 5. Primary outcome data were available for 5,429.","comparison":"DOAC initiation within four days versus day five or later; individual participant data meta-analysis.","result":"At 30 days, recurrent ischemic stroke, symptomatic intracerebral hemorrhage or unclassified stroke occurred in 2.1% versus 3.0% (OR 0.70; 95% CI 0.50–0.98). Symptomatic intracerebral hemorrhage was 0.4% in each group.","limits":"This synthesis includes ELAN and OPTIMAS participants; it is not an independent additional randomized trial. Results retain the component trials’ selection limits.","sources":[{"title":"CATALYST primary report","url":"https://pubmed.ncbi.nlm.nih.gov/40570866/","year":2025,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"af-timing"},{"id":"point","title":"POINT — acute dual antiplatelet benefit and bleeding","headline":"DAPT: major ischemic events 5.0 vs 6.5%; major bleeding 0.9 vs 0.4%","year":2018,"settings":["on-call","hospital","clinic"],"keywords":["DAPT","clopidogrel","aspirin","minor stroke","TIA"],"question":"What was the benefit–bleeding tradeoff of adding clopidogrel?","population":"4,881 adults with minor ischemic stroke (NIHSS ≤3) or high-risk TIA (ABCD² ≥4), randomized within 12 hours at 269 sites in 10 countries (82.8% in the US).","comparison":"Clopidogrel plus aspirin versus aspirin alone for the 90-day trial period.","result":"Major ischemic events (ischemic stroke, myocardial infarction or ischemic vascular death) occurred in 5.0% versus 6.5% at 90 days (HR 0.75; 95% CI 0.59–0.95). Major hemorrhage occurred in 0.9% versus 0.4% (HR 2.32; 95% CI 1.10–4.87).","limits":"Stopped early. Most ischemic events occurred in the first week; the 90-day design alone does not establish the optimal DAPT duration or eligibility for other stroke populations.","sources":[{"title":"POINT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/29766750/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract and PMC full text (PMC6193486) checked."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"sammpris","title":"SAMMPRIS — medical management versus intracranial stenting","headline":"Stenting worse: 30-day stroke/death 14.7 vs 5.8%","year":2011,"settings":["hospital","clinic"],"keywords":["sICAS","intracranial stenosis","Wingspan","stent"],"question":"Did adding Wingspan stenting improve outcomes in severe symptomatic intracranial stenosis?","population":"451 patients with recent TIA or stroke attributed to 70–99% stenosis of a major intracranial artery.","comparison":"Aggressive medical management plus angioplasty/Wingspan stenting versus aggressive medical management alone.","result":"Stroke or death by 30 days was 14.7% with stenting versus 5.8% with medical management. Estimated one-year primary-event rates were 20.0% versus 12.2%; that endpoint included early stroke/death and later qualifying-territory stroke.","limits":"Enrollment stopped for safety concerns. This tested a specified stent strategy; it does not directly test balloon angioplasty alone or every later device and selection strategy.","sources":[{"title":"SAMMPRIS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/21899409/","year":2011,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and corrected NEJM report read; source updated July 2012. Protocol and supplements not reviewed."}],"relatedTopic":"sicas"},{"id":"close","title":"CLOSE — PFO closure in selected cryptogenic stroke","headline":"PFO closure: stroke 0/238 vs 14/235; AF 4.6 vs 0.9%","year":2017,"settings":["hospital","clinic"],"keywords":["patent foramen ovale","PFO","atrial septal aneurysm","large shunt"],"question":"Does PFO closure reduce recurrent stroke in patients with high-risk PFO features?","population":"663 patients aged 16–60 with recent stroke attributed to PFO and an atrial septal aneurysm or large shunt.","comparison":"Closure plus antiplatelet therapy versus antiplatelets alone; the study also included a separate anticoagulation comparison.","result":"Over mean follow-up of 5.3 years, stroke occurred in 0/238 closure patients versus 14/235 antiplatelet-only patients (HR 0.03; 95% CI 0–0.26). Procedural complications occurred in 5.9%; AF occurred in 4.6% versus 0.9%.","limits":"Selected younger population with an attributed PFO mechanism. These findings do not make an incidental PFO an indication for closure or establish closure superiority to anticoagulation.","sources":[{"title":"CLOSE primary report","url":"https://pubmed.ncbi.nlm.nih.gov/28902593/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"pfo"},{"id":"treat-cad","title":"TREAT-CAD — aspirin versus anticoagulation for dissection","headline":"Aspirin not shown noninferior to VKA (23 vs 15%)","year":2021,"settings":["hospital","clinic"],"keywords":["cervical artery dissection","carotid","vertebral","aspirin","VKA"],"question":"Was aspirin noninferior to a vitamin K antagonist after cervical dissection?","population":"194 adults with symptomatic, MRI-confirmed cervical artery dissection within two weeks; 173 were analyzed per protocol.","comparison":"Aspirin versus a vitamin K antagonist for 90 days.","result":"The clinical/MRI composite occurred in 23% versus 15% (absolute difference 8 percentage points; 95% CI −4 to 21). Aspirin noninferiority was not established. Seven ischemic strokes occurred with aspirin and none with anticoagulation.","limits":"Small open-label trial; the primary composite included MRI lesions at 14 days and clinical outcomes through 90 days. Failure of noninferiority does not establish universal anticoagulant superiority; DOACs were not tested.","sources":[{"title":"TREAT-CAD primary report","url":"https://pubmed.ncbi.nlm.nih.gov/33765420/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"dissection"},{"id":"select2","title":"SELECT2 — thrombectomy in selected large-core stroke","headline":"Large core: generalized OR 1.51; mRS 0–2 20 vs 7%","year":2023,"settings":["on-call","hospital"],"keywords":["EVT","large core","ASPECTS","ICA","M1"],"question":"Does thrombectomy improve outcome in selected large-core anterior-circulation stroke?","population":"352 patients with ICA/M1 occlusion within 24 hours and ASPECTS 3–5 or imaging core ≥50 mL.","comparison":"Thrombectomy plus medical care versus medical care alone.","result":"The 90-day mRS distribution favored thrombectomy (generalized OR 1.51; 95% CI 1.20–1.89). Functional independence, a secondary outcome, was 20% versus 7%.","limits":"Stopped early for efficacy; vascular complications occurred. Review complete selection criteria. The 2024 correction clarified core-volume measurement substitutions and stated that outcome direction and significance were unchanged. At 1 year (Lancet 2024), the mRS distribution still favored thrombectomy (generalized OR 1.43; 95% CI 1.14–1.78); 1-year mortality was 45% vs 52% (RR 0.89; 95% CI 0.71–1.11).","sources":[{"title":"SELECT2 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/36762865/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and January 2024 publisher correction read; full trial report and supplements not reviewed."},{"title":"SELECT2 1-year outcomes","url":"https://pubmed.ncbi.nlm.nih.gov/38346442/","year":2024,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; 1-year follow-up of the original randomized population."}],"relatedTopic":"large-core-evt"},{"id":"angel-aspect","title":"ANGEL-ASPECT — thrombectomy for large infarct in China","headline":"Large core: GOR 1.37; sICH 6.1 vs 2.7%","year":2023,"settings":["on-call","hospital"],"keywords":["large core","ASPECTS","thrombectomy","EVT"],"question":"Does EVT help anterior LVO with ASPECTS 3–5 or core 70–100 mL within 24 hours?","population":"456 patients in China; about 28% received IVT.","comparison":"EVT plus medical management versus medical management alone.","result":"The 90-day mRS shifted toward better outcomes with EVT (generalized OR 1.37; 95% CI 1.11–1.69). Symptomatic ICH 6.1% vs 2.7%; any ICH 49.1% vs 17.3%.","limits":"Stopped early for efficacy; open-label, single-country trial. At 1 year (Stroke 2025; 425 of 455 analyzed), the mRS shift still favored EVT (generalized OR 1.25; 95% CI 1.01–1.56; mRS 0–2 30.4 vs 17.1%), with mortality 31.3 vs 26.5% (RR 1.12; 95% CI 0.82–1.53); the mRS 0–2 difference narrowed from 18.5 to 13.3 points as the medical arm improved.","sources":[{"title":"ANGEL-ASPECT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/36762852/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"ANGEL-ASPECT 1-year outcomes","url":"https://pubmed.ncbi.nlm.nih.gov/40854041/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; prespecified 1-year analysis of the original randomized population (complete-case, 425 of 455)."}],"relatedTopic":"large-core-evt"},{"id":"rescue-japan-limit","title":"RESCUE-Japan LIMIT — thrombectomy for ASPECTS 3–5","headline":"ASPECTS 3–5: mRS 0–3 31.0 vs 12.7%","year":2022,"settings":["on-call","hospital"],"keywords":["large core","ASPECTS","thrombectomy","EVT","Japan"],"question":"Does EVT help LVO with ASPECTS 3–5?","population":"203 patients in Japan within 6 hours, or within 24 hours without early FLAIR change; about 27% received alteplase (0.6 mg/kg).","comparison":"EVT plus medical care versus medical care alone.","result":"mRS 0–3 at 90 days occurred in 31.0% vs 12.7% (RR 2.43; 95% CI 1.35–4.37). Any ICH occurred in 58.0% vs 31.4%.","limits":"Small open-label trial; used the Japanese alteplase dose.","sources":[{"title":"RESCUE-Japan LIMIT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/35138767/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"large-core-evt"},{"id":"tension","title":"TENSION — thrombectomy for established large infarct","headline":"ASPECTS 3–5 ≤12 h: cOR 2.58; lower mortality","year":2023,"settings":["on-call","hospital"],"keywords":["large core","ASPECTS","thrombectomy","EVT","non-contrast CT"],"question":"Does EVT help anterior LVO with ASPECTS 3–5 selected mainly by non-contrast CT?","population":"253 patients in Europe and Canada within 12 hours of onset.","comparison":"EVT plus medical treatment versus medical treatment alone.","result":"The 90-day mRS shifted toward better outcomes (adjusted cOR 2.58; 95% CI 1.60–4.15) with lower mortality (HR 0.67; 95% CI 0.46–0.98). Symptomatic ICH 6% vs 5%.","limits":"Stopped early for efficacy after the first interim analysis; open-label.","sources":[{"title":"TENSION primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37837989/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"large-core-evt"},{"id":"laste","title":"LASTE — thrombectomy for large infarct of unrestricted size","headline":"ASPECTS ≤5 ≤6.5 h: median mRS 4 vs 6; mortality 36.1 vs 55.5%","year":2024,"settings":["on-call","hospital"],"keywords":["large core","ASPECTS 0-2","thrombectomy","EVT"],"question":"Does EVT help anterior LVO with ASPECTS ≤5, without a lower limit, within 6.5 hours?","population":"333 randomized patients (324 analyzed); about 35% received thrombolysis.","comparison":"EVT plus medical care versus medical care alone.","result":"Median 90-day mRS was 4 vs 6 (generalized OR 1.63; 95% CI 1.29–2.06). Mortality 36.1% vs 55.5% (adjusted RR 0.65; 95% CI 0.50–0.84). Symptomatic ICH 9.6% vs 5.7%.","limits":"Stopped early because similar trials favored EVT; benefit was mainly less severe disability and death.","sources":[{"title":"LASTE primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38718358/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"large-core-evt"},{"id":"ninds-tpa","title":"NINDS rt-PA — alteplase within 3 hours","headline":"Alteplase ≤3 h: favorable outcome OR 1.7; sICH 6.4 vs 0.6%","year":1995,"settings":["on-call","hospital"],"keywords":["alteplase","tPA","thrombolysis","3 hours","NINDS"],"question":"Does IV alteplase started within 3 hours improve outcome after ischemic stroke?","population":"624 patients in two parts (291 and 333) treated within 3 hours of onset.","comparison":"IV alteplase versus placebo, double-blind.","result":"Part 2 confirmed 3-month benefit (global OR for favorable outcome 1.7; 95% CI 1.2–2.6); alteplase patients were at least 30% more likely to have minimal or no disability. Symptomatic ICH within 36 hours was 6.4% vs 0.6%; 3-month mortality 17% vs 21% (P=0.30). Part 1 showed no difference in 24-hour neurological improvement.","limits":"Treatment within 3 hours only; the 24-hour primary outcome of part 1 was neutral. Higher sICH requires the full eligibility and BP protocol.","sources":[{"title":"NINDS rt-PA primary report","url":"https://pubmed.ncbi.nlm.nih.gov/7477192/","year":1995,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"acute-reperfusion"},{"id":"ecass-3","title":"ECASS III — alteplase at 3 to 4.5 hours","headline":"Alteplase 3–4.5 h: mRS 0–1 52.4 vs 45.2%; sICH 2.4 vs 0.2%","year":2008,"settings":["on-call","hospital"],"keywords":["alteplase","tPA","thrombolysis","4.5 hours","ECASS"],"question":"Does IV alteplase 3 to 4.5 hours after onset improve outcome?","population":"821 patients without brain hemorrhage or major infarction on CT; median treatment time 3 h 59 min.","comparison":"Alteplase 0.9 mg/kg versus placebo, double-blind.","result":"mRS 0–1 at 90 days occurred in 52.4% vs 45.2% (OR 1.34; 95% CI 1.02–1.76). Symptomatic ICH 2.4% vs 0.2%; any ICH 27.0% vs 17.6%. Mortality 7.7% vs 8.4%.","limits":"Excluded major infarction on CT; the trial population and exclusions shape applicability beyond 3 hours.","sources":[{"title":"ECASS III primary report","url":"https://pubmed.ncbi.nlm.nih.gov/18815396/","year":2008,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"acute-reperfusion"},{"id":"baoche","title":"BAOCHE — basilar thrombectomy at 6–24 hours","headline":"Basilar 6–24 h: mRS 0–3 46 vs 24%","year":2022,"settings":["on-call","hospital"],"keywords":["EVT","basilar artery occlusion","posterior circulation"],"question":"Does late-window basilar thrombectomy improve functional outcome?","population":"217 analyzed patients in China with basilar-artery stroke presenting 6–24 hours after symptom onset.","comparison":"Thrombectomy plus medical treatment versus medical treatment alone.","result":"At 90 days, mRS 0–3 occurred in 46% versus 24% (adjusted rate ratio 1.81; 95% CI 1.26–2.60). Symptomatic intracranial hemorrhage was 6% versus 1%; procedural complications occurred in 11% of thrombectomy recipients.","limits":"Stopped at an interim analysis. The primary endpoint changed from mRS 0–4 to 0–3; the original endpoint did not show a conclusive difference. Review the trial’s full clinical/imaging selection rather than applying its time window alone.","sources":[{"title":"BAOCHE primary report","url":"https://pubmed.ncbi.nlm.nih.gov/36239645/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"basilar-occlusion"},{"id":"attention","title":"ATTENTION — thrombectomy for basilar occlusion within 12 hours","headline":"Basilar ≤12 h: mRS 0–3 46 vs 23%; mortality 37 vs 55%","year":2022,"settings":["on-call","hospital"],"keywords":["basilar","posterior circulation","thrombectomy","EVT"],"question":"Does EVT within 12 hours improve outcome in basilar artery occlusion?","population":"340 patients at 36 Chinese centers; about one third received IVT.","comparison":"EVT versus best medical care (2:1 randomization).","result":"mRS 0–3 at 90 days occurred in 46% vs 23% (adjusted rate ratio 2.06; 95% CI 1.46–2.91). Mortality 37% vs 55%; symptomatic ICH 5% vs 0%; procedural complications 14%.","limits":"Single-country trial; it required NIHSS ≥10, PC-ASPECTS ≥6 and prestroke mRS 0–2, and for age ≥80 PC-ASPECTS ≥8 and prestroke mRS 0 (registry NCT04751708). At 3 years (JAMA Neurol 2026; 307 of 340 followed), mRS 0–3 was 38.4% vs 18.3% (adjusted RR 2.05; 95% CI 1.35–3.11) and cumulative mortality 55.7% vs 73.1%; in a prespecified subgroup, no treatment effect was demonstrated at age ≥70.","sources":[{"title":"ATTENTION primary report","url":"https://pubmed.ncbi.nlm.nih.gov/36239644/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"ATTENTION 3-year outcomes","url":"https://pubmed.ncbi.nlm.nih.gov/41460644/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; 3-year follow-up of the original randomized population (307 of 340 completed)."}],"relatedTopic":"basilar-occlusion"},{"id":"trace-5","title":"TRACE-5 — tenecteplase for basilar occlusion within 24 hours","headline":"Basilar ≤24 h: mRS 0–1/baseline 38 vs 29%","year":2026,"settings":["on-call","hospital"],"keywords":["basilar","tenecteplase","late window","thrombolysis"],"question":"Does tenecteplase within 24 hours improve outcome in basilar artery occlusion?","population":"452 Chinese adults with basilar occlusion and prestroke mRS ≤3; 49% went on to EVT and 35% of controls received alteplase.","comparison":"Tenecteplase 0.25 mg/kg (max 25 mg) versus standard medical treatment, with or without EVT.","result":"mRS 0–1 or return to baseline at 90 days occurred in 38% vs 29% (adjusted rate ratio 1.50; 95% CI 1.09–2.08). Symptomatic ICH 2% vs 3%; mortality 29% vs 31%.","limits":"Open-label, single-country trial; the control arm mixed alteplase and no thrombolysis.","sources":[{"title":"TRACE-5 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/41655588/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"basilar-occlusion"},{"id":"attention-late","title":"ATTENTION LATE — tenecteplase before EVT for basilar occlusion at 4.5–24 hours","headline":"Tenecteplase before EVT: no gain (mRS 0–2 30 vs 30%)","year":2026,"settings":["on-call","hospital"],"keywords":["basilar","tenecteplase","thrombectomy","bridging","late window"],"question":"Does tenecteplase before EVT help basilar occlusion presenting 4.5–24 hours after onset?","population":"330 patients with NIHSS ≥10 admitted directly to 40 EVT-capable Chinese centers.","comparison":"Tenecteplase 0.25 mg/kg followed by EVT versus EVT alone.","result":"mRS 0–2 at 90 days occurred in 30% vs 30% (adjusted rate ratio 0.92; 95% CI 0.67–1.25). Symptomatic ICH 5% vs 4%; mortality 40% vs 43%.","limits":"Open-label; applies to direct admission to EVT centers, not drip-and-ship.","sources":[{"title":"ATTENTION LATE primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42776543/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"basilar-occlusion"},{"id":"distal","title":"DISTAL — medium and distal vessel thrombectomy","headline":"MeVO EVT: no benefit (cOR 0.90); sICH 5.9 vs 2.6%","year":2025,"settings":["on-call","hospital"],"keywords":["EVT","MeVO","DMVO","M2","M3","ACA","PCA"],"question":"Does EVT improve disability after selected medium/distal vessel occlusion?","population":"543 participants within 24 hours; nondominant/codominant M2 or selected more distal MCA, ACA or PCA occlusions. Median NIHSS was 6.","comparison":"EVT plus best medical treatment versus best medical treatment alone.","result":"The 90-day mRS distribution did not improve significantly (common OR 0.90; 95% CI 0.67–1.22). Symptomatic intracranial hemorrhage was 5.9% versus 2.6%; mortality was 15.5% versus 14.0%.","limits":"A neutral trial in its selected vessel/severity population; it does not establish equivalence or settle every medium-vessel treatment question. Dominant M2 was outside the stated M2 population. At 12 months there was still no benefit (adjusted common OR for better mRS 0.81; 95% CI 0.59–1.12; Lancet Neurol 2026).","sources":[{"title":"DISTAL primary report","url":"https://pubmed.ncbi.nlm.nih.gov/39908430/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."},{"title":"DISTAL 12-month outcomes","url":"https://pubmed.ncbi.nlm.nih.gov/42105785/","year":2026,"type":"Report","checkedAt":"2026-10-22","access":"Primary abstract read via PubMed on 2026-10-22; 12-month follow-up of the original randomized population (524 of 543 with 12-month data)."}],"relatedTopic":"medium-distal-evt"},{"id":"escape-mevo","title":"ESCAPE-MeVO — thrombectomy benefit and safety","headline":"MeVO EVT: no benefit; mortality 13.3 vs 8.4%","year":2025,"settings":["on-call","hospital"],"keywords":["EVT","MeVO","medium vessel","MCA"],"question":"Does EVT improve excellent functional outcome after medium-vessel occlusion?","population":"530 patients in five countries within 12 hours of last known well, with favorable baseline imaging; most occlusions were MCA branches.","comparison":"EVT plus usual care versus usual care alone.","result":"At 90 days, mRS 0–1 occurred in 41.6% versus 43.1% (adjusted rate ratio 0.95; 95% CI 0.79–1.15). Mortality was 13.3% versus 8.4% (adjusted HR 1.82; 95% CI 1.06–3.12); symptomatic intracranial hemorrhage was 5.4% versus 2.2%.","limits":"No primary-outcome benefit in this population. Vessel definition, imaging and time window matter; do not extrapolate large-vessel benefit automatically or infer a universal rule from one trial.","sources":[{"title":"ESCAPE-MeVO primary report","url":"https://pubmed.ncbi.nlm.nih.gov/39908448/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"medium-distal-evt"},{"id":"discount","title":"DISCOUNT — thrombectomy for medium or distal occlusion","headline":"MeVO EVT: no benefit (mRS 0–2 62 vs 68%); sICH 11 vs 3% if treated","year":2026,"settings":["on-call","hospital"],"keywords":["MeVO","DMVO","distal","thrombectomy","EVT"],"question":"Does thrombectomy improve outcome after a primary isolated medium or distal occlusion?","population":"244 adults at 22 French centers (median age 75, NIHSS 8) within 8 hours, or within 24 hours if FLAIR-negative; 488 planned.","comparison":"Thrombectomy plus medical treatment versus medical treatment alone.","result":"mRS 0–2 at 3 months occurred in 62% vs 68% (OR 0.73; 95% CI 0.40–1.31). Patients who received thrombectomy vs those who did not: symptomatic ICH 11% vs 3%, SAH 13% vs 2% and embolus migration 5% vs 1%. Mortality 6% vs 8%.","limits":"Stopped at interim analysis for futility and excess sICH; open-label; 81% of the EVT arm received thrombectomy. The third neutral MeVO trial after DISTAL and ESCAPE-MeVO.","sources":[{"title":"DISCOUNT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42485024/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"medium-distal-evt"},{"id":"enrich","title":"ENRICH — early minimally invasive ICH evacuation","headline":"Early MIS (mainly lobar): utility-weighted mRS 0.458 vs 0.374","year":2024,"settings":["on-call","hospital"],"keywords":["lobar hemorrhage","ICH surgery","minimally invasive"],"question":"Does early minimally invasive evacuation improve recovery after selected ICH?","population":"300 adults aged 18–80 (GCS 5–14, NIHSS ≥5, premorbid mRS 0–1) with lobar or anterior basal ganglia ICH of 30–80 mL, randomized within 24 hours of last known well; primary thalamic, infratentorial and large-IVH cases excluded.","comparison":"Minimally invasive evacuation plus guideline-based medical management versus medical management alone.","result":"Mean utility-weighted mRS (0–1; higher is better) at 180 days was 0.458 versus 0.374 (difference 0.084; 95% Bayesian credible interval 0.005–0.163). The benefit appeared attributable to lobar hemorrhage; 30-day mortality was 9.3% versus 18.0%.","limits":"Adaptive enrollment later restricted inclusion to lobar ICH. Findings concern the tested technique, timing and selected population, not all ICH surgery. Postoperative rebleeding with deterioration occurred in 3.3%.","sources":[{"title":"ENRICH primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38598795/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract checked; registry eligibility (NCT02880878) checked 2026-10-17."}],"relatedTopic":"ich-surgery"},{"id":"annexa-i","title":"ANNEXA-I — hemostatic efficacy and thrombotic harm","headline":"Andexanet: hemostasis 67.0 vs 53.1%; thrombotic events 10.3 vs 5.6%","year":2024,"settings":["on-call","hospital"],"keywords":["andexanet","factor Xa","PCC","anticoagulant reversal","ICH"],"question":"What were andexanet’s efficacy and safety tradeoffs in factor Xa inhibitor-associated ICH?","population":"530 patients with acute ICH (0.5–60 mL; GCS ≥7; NIHSS ≤35; baseline scan within 6 h of onset; no surgery planned within 12 h) after factor Xa inhibitor use within 15 hours; the interim efficacy analysis included 452.","comparison":"Andexanet versus usual care; 85.5% of usual-care patients received PCC.","result":"Composite hemostatic efficacy was 67.0% versus 53.1% (adjusted difference 13.4 percentage points; 95% CI 4.6–22.2). Thrombotic events occurred in 10.3% versus 5.6%, including ischemic stroke in 6.5% versus 1.5%. No appreciable difference in 30-day mRS or mortality was reported.","limits":"Hemostatic efficacy is not functional benefit. NCS/SCCM 2026 conditionally recommends 4F-PCC rather than andexanet, and andexanet was withdrawn from the US market effective 22 December 2025.","sources":[{"title":"ANNEXA-I primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38749032/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract checked; registry eligibility (NCT03661528) checked 2026-10-17."}],"relatedTopic":"antithrombotic-reversal"},{"id":"prestige-af","title":"PRESTIGE-AF — anticoagulation after ICH with AF","headline":"DOAC after ICH: fewer ischemic strokes, more recurrent ICH","year":2025,"settings":["hospital","clinic"],"keywords":["DOAC","ICH survivor","atrial fibrillation","anticoagulation resumption"],"question":"How did DOACs change ischemic and hemorrhagic stroke risk after ICH?","population":"319 survivors of spontaneous ICH with AF, an anticoagulation indication and mRS ≤4; median follow-up 1.4 years.","comparison":"A DOAC versus no anticoagulation.","result":"First ischemic stroke favored DOACs (HR 0.05; 95% CI 0.01–0.36), while recurrent ICH noninferiority was not established (HR 10.89; 90% CI 1.95–60.72). All-event rates per 100 patient-years were 0.83 versus 8.60 for ischemic stroke and 5.00 versus 0.82 for ICH.","limits":"The ischemic benefit and hemorrhagic harm require individualized assessment; this trial does not establish a universal restart date. Two indexed corrections could not be fully accessed.","sources":[{"title":"PRESTIGE-AF primary report","url":"https://pubmed.ncbi.nlm.nih.gov/40023176/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract read via PubMed/NLM. March and June 2025 corrections identified; publisher correction bodies inaccessible (403). No full corrected-report review."}],"relatedTopic":"caa-ich-recurrence"},{"id":"mind","title":"MIND — minimally invasive evacuation at up to 72 hours","headline":"MIS ≤72 h: no 180-day mRS benefit (OR 1.03)","year":2025,"settings":["on-call","hospital"],"keywords":["ICH surgery","Artemis","deep hemorrhage","minimally invasive"],"question":"Did the Artemis evacuation strategy improve disability or survival?","population":"236 adults aged 18–80 with 20–80 mL supratentorial ICH, NIHSS ≥6 and GCS 5–15; 69.5% had primarily deep hemorrhage.","comparison":"Minimally invasive surgery within 72 hours plus medical management versus medical management alone.","result":"There was no demonstrated improvement in 180-day ordinal mRS (OR 1.03; 96% CI 0.62–1.72). Thirty-day mortality was 7.2% versus 9.8% (difference −2.5 percentage points; 95% CI −11.7 to 4.8).","limits":"Enrollment stopped early after a feasibility analysis. Imprecision limits conclusions; do not treat the result as proof of equivalence or interchange its technique and timing with ENRICH.","sources":[{"title":"MIND primary report","url":"https://pubmed.ncbi.nlm.nih.gov/40892424/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract checked."}],"relatedTopic":"ich-surgery"},{"id":"switch","title":"SWITCH — decompression for severe deep ICH","headline":"Decompression in deep ICH: mRS 5–6 44 vs 58% (p=0.057)","year":2024,"settings":["on-call","hospital"],"keywords":["hemicraniectomy","decompressive craniectomy","basal ganglia","thalamic hemorrhage"],"question":"Does decompressive craniectomy improve outcome in severe deep ICH?","population":"Adults aged 18–75 with severe basal ganglia or thalamic ICH (GCS 8–13, NIHSS 10–30, stable volume 30–100 mL) randomized within 66 hours of onset; 197 randomized participants gave delayed consent (median volume 57 mL).","comparison":"Decompressive craniectomy plus best medical treatment versus best medical treatment alone.","result":"At 180 days, mRS 5–6 occurred in 44% versus 58% (adjusted risk ratio 0.77; 95% CI 0.59–1.01; p=0.057). The report characterized the evidence as weak.","limits":"Stopped early for funding; survival often involved severe disability. This is a decompression study in deep ICH, not evidence for every hemorrhage location or evacuation technique. Two indexed correction bodies were inaccessible.","sources":[{"title":"SWITCH primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38761811/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract read via PubMed/NLM. June and July 2024 corrections identified; publisher correction bodies inaccessible (403). No full corrected-report review. Registry eligibility (NCT02258919) checked 2026-10-17."}],"relatedTopic":"ich-surgery"},{"id":"oriental-mevo","title":"ORIENTAL-MeVO — thrombectomy in selected medium-vessel stroke","headline":"MeVO EVT (China): mRS 0–2 58.6 vs 46.6%; sICH 4.7 vs 2.2%","year":2026,"settings":["on-call","hospital"],"keywords":["MeVO","medium vessel","thrombectomy","NIHSS"],"question":"Did thrombectomy improve function in moderate-to-severe MeVO stroke?","population":"563 adults at 48 Chinese centers; eligible NIHSS ≥6 and presentation within 24 hours.","comparison":"Thrombectomy plus medical management versus medical management.","result":"At 90 days, mRS 0–2 occurred in 58.6% versus 46.6% (adjusted rate ratio 1.24; 95% CI 1.07–1.44). Symptomatic intracranial hemorrhage was 4.7% versus 2.2%; mortality 11.1% versus 10.2%.","limits":"Open-label, single-country trial. The prespecified binary endpoint replaced ordinal mRS after its proportional-odds assumption failed. Interpret alongside neutral MeVO trials; selection differences do not establish a universal EVT rule.","sources":[{"title":"ORIENTAL-MeVO primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42127389/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"medium-distal-evt"},{"id":"sparcl","title":"SPARCL — atorvastatin after stroke or TIA","headline":"Atorvastatin 80: stroke 11.2 vs 13.1%; more hemorrhagic strokes","year":2006,"settings":["hospital","clinic"],"keywords":["statin","atorvastatin","lipids","LDL","secondary prevention"],"question":"Did high-dose atorvastatin reduce recurrent stroke?","population":"4,731 patients with stroke/TIA 1–6 months earlier, LDL 100–190 mg/dL and no known coronary heart disease.","comparison":"Atorvastatin 80 mg daily versus placebo.","result":"Over median 4.9 years, fatal/nonfatal stroke occurred in 11.2% versus 13.1% (adjusted HR 0.84; 95% CI 0.71–0.99). Hemorrhagic strokes numbered 55 versus 33. Liver-enzyme elevations were more common with atorvastatin; overall mortality was similar.","limits":"A selected secondary-prevention population. Net stroke benefit does not settle lipid treatment for every ICH survivor or establish a patient-specific hemorrhage risk.","sources":[{"title":"SPARCL primary report","url":"https://pubmed.ncbi.nlm.nih.gov/16899775/","year":2006,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract read via PubMed/NLM. Publisher 2018 correction checked: baseline Table 1 SE/SD labeling, with no outcome revision stated; full report and supplements not reviewed."}],"relatedTopic":"lipid-management"},{"id":"treat-stroke-to-target","title":"Treat Stroke to Target — LDL goals after atherosclerotic stroke","headline":"LDL <70: events 8.5 vs 10.9% (HR 0.78)","year":2020,"settings":["hospital","clinic"],"keywords":["TST","lipids","statin","ezetimibe","LDL","atherosclerosis"],"question":"Did a lower LDL target reduce major cardiovascular events?","population":"2,860 patients with recent ischemic stroke/TIA and cerebrovascular or coronary atherosclerosis in France and South Korea.","comparison":"LDL target below 70 versus 90–110 mg/dL, using statin, ezetimibe or both.","result":"Over median 3.5 years, ischemic stroke, MI, urgent coronary/carotid revascularization or cardiovascular death occurred in 8.5% versus 10.9% (adjusted HR 0.78; 95% CI 0.61–0.98). Intracranial hemorrhage and new diabetes did not differ significantly.","limits":"Stopped administratively before the planned event count. This composite is broader than recurrent stroke; nonsignificant safety differences do not prove equivalence. The trial did not test a target below 55 mg/dL.","sources":[{"title":"Treat Stroke to Target primary report","url":"https://pubmed.ncbi.nlm.nih.gov/31738483/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract read via PubMed/NLM; online publication 2019, print issue 2020. Full report and supplements not reviewed."}],"relatedTopic":"lipid-management"},{"id":"sps3-bp","title":"SPS3 — blood-pressure targets after lacunar stroke","headline":"SBP <130: all stroke HR 0.81 (NS); ICH HR 0.37","year":2013,"settings":["hospital","clinic"],"keywords":["blood pressure","SBP","lacunar","small vessel","hypertension"],"question":"Did a systolic target below 130 reduce recurrent stroke?","population":"3,020 patients with recent MRI-defined symptomatic lacunar infarction; mean follow-up 3.7 years.","comparison":"Systolic BP below 130 versus 130–149 mmHg; achieved means at one year were 127 and 138 mmHg.","result":"The primary all-stroke reduction was not statistically significant (HR 0.81; 95% CI 0.64–1.03). Intracerebral hemorrhage was reduced (HR 0.37; 95% CI 0.15–0.95). Treatment-related serious adverse events were infrequent.","limits":"Open-label factorial trial. The ICH component does not convert the neutral primary endpoint into proven all-stroke benefit. This is the BP comparison, separate from the SPS3 antiplatelet comparison and from acute BP management.","sources":[{"title":"SPS3 blood-pressure comparison primary report","url":"https://pubmed.ncbi.nlm.nih.gov/23726159/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract read via PubMed/NLM. Indexed correction identifies addition of an author; full report and supplements not reviewed."}],"relatedTopic":"bp-prevention"},{"id":"progress","title":"PROGRESS — blood-pressure lowering after stroke or TIA","headline":"Perindopril ± indapamide: stroke 10 vs 14%","year":2001,"settings":["hospital","clinic"],"keywords":["blood pressure","perindopril","indapamide","secondary prevention"],"question":"Did a perindopril-based regimen reduce recurrent stroke?","population":"6,105 people with previous stroke/TIA, including hypertensive and non-hypertensive participants.","comparison":"Perindopril-based treatment, with indapamide at clinician discretion, versus matching placebo.","result":"Over four years, fatal/nonfatal stroke occurred in 307/3,051 (10%) versus 420/3,054 (14%): relative risk reduction 28% (95% CI 17–38). Mean BP fell by 9/4 mmHg relative to placebo. Perindopril plus indapamide lowered BP by 12/5 mmHg and stroke by 43% (30–54); perindopril alone (5/3 mmHg) produced no discernible stroke reduction.","limits":"A long-term regimen trial, not an acute BP target. Combination and single-drug strata were not a randomized comparison with each other. The abstract does not quantify detailed harms; indexed correction bodies were not fully accessible.","sources":[{"title":"PROGRESS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/11589932/","year":2001,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract read via PubMed/NLM. Corrections indexed in Lancet 2001;358:1556 and 2002;359:2120 were not fully reviewed; detailed tolerability and correction effects remain unverified."}],"relatedTopic":"bp-prevention"},{"id":"trident","title":"TRIDENT — low-dose triple antihypertensive pill after ICH","headline":"Triple pill after ICH: recurrent stroke 4.6 vs 7.4%","year":2026,"settings":["hospital","clinic"],"keywords":["blood pressure","ICH","polypill","secondary prevention","telmisartan","amlodipine","indapamide"],"question":"Does a low-dose triple antihypertensive pill added to usual care reduce recurrent stroke after ICH?","population":"1,670 patients with prior ICH and SBP 130–160 who completed a 2-week active run-in (mean age 58).","comparison":"Telmisartan 20 mg, amlodipine 2.5 mg and indapamide 1.25 mg in one pill versus placebo.","result":"Recurrent stroke over a median 2.5 years: 4.6% vs 7.4% (HR 0.61; 95% CI 0.41–0.92). Mean SBP 127 vs 138; major cardiovascular events 6.6% vs 9.8%. Discontinuation for adverse events 13.6% vs 6.0%, most often a creatinine rise ≥20%.","limits":"Run-in design selects tolerant patients; renal monitoring is needed.","sources":[{"title":"TRIDENT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42019018/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"bp-prevention"},{"id":"navigate-esus","title":"NAVIGATE ESUS — rivaroxaban versus aspirin","headline":"ESUS rivaroxaban: no benefit, more major bleeding","year":2018,"settings":["hospital","clinic"],"keywords":["ESUS","cryptogenic","rivaroxaban","anticoagulation","embolism"],"question":"Did rivaroxaban prevent recurrent stroke in ESUS?","population":"7,213 patients with recent presumed embolic stroke without arterial stenosis, lacune or an identified cardioembolic source.","comparison":"Rivaroxaban 15 mg daily versus aspirin 100 mg daily.","result":"Over median 11 months, recurrent stroke/systemic embolism was 5.1% versus 4.8% per year (HR 1.07; 95% CI 0.87–1.33). Major bleeding was 1.8% versus 0.7% per year (HR 2.72; 95% CI 1.68–4.39).","limits":"Stopped early for lack of efficacy and excess bleeding. This ESUS result does not address established AF or another definite anticoagulation indication.","sources":[{"title":"NAVIGATE ESUS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/29766772/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"stroke-workup"},{"id":"respect-esus","title":"RE-SPECT ESUS — dabigatran versus aspirin","headline":"ESUS dabigatran: no significant benefit (HR 0.85)","year":2019,"settings":["hospital","clinic"],"keywords":["ESUS","cryptogenic","dabigatran","anticoagulation","embolism"],"question":"Did dabigatran reduce recurrent stroke after ESUS?","population":"5,390 patients with an embolic stroke of undetermined source; median follow-up 19 months.","comparison":"Dabigatran 150 or 110 mg twice daily versus aspirin 100 mg daily.","result":"Recurrent stroke was 4.1% versus 4.8% per year (HR 0.85; 95% CI 0.69–1.03); superiority was not demonstrated. Major bleeding was 1.7% versus 1.4% per year (HR 1.19; 95% CI 0.85–1.66); clinically relevant nonmajor bleeding was 1.6% versus 0.9% per year.","limits":"Neutral superiority is not equivalence. The result does not establish benefit in retrospectively selected subgroups or apply to known AF.","sources":[{"title":"RE-SPECT ESUS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/31091372/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"stroke-workup"},{"id":"arcadia","title":"ARCADIA — atrial cardiopathy without AF","headline":"Atrial cardiopathy apixaban: no benefit (4.4%/yr each)","year":2024,"settings":["hospital","clinic"],"keywords":["ESUS","cryptogenic","atrial cardiopathy","apixaban","NT-proBNP"],"question":"Did apixaban reduce recurrent stroke in atrial cardiopathy without AF?","population":"1,015 patients with cryptogenic stroke and atrial cardiopathy defined by ECG, NT-proBNP or indexed left-atrial diameter; no AF at randomization.","comparison":"Apixaban, with dose reduction when indicated, versus aspirin 81 mg daily.","result":"Recurrent stroke was 4.4% per year in both groups (HR 1.00; 95% CI 0.64–1.55). Symptomatic intracranial hemorrhage occurred in 0 versus 7 patients; other major hemorrhage in 5 versus 5.","limits":"Stopped for futility; mean follow-up 1.8 years. A 2026 secondary bleeding analysis reported fewer intracranial hemorrhages with apixaban than aspirin (annualized difference −1.4% in the on-treatment safety sample; −1.0% by intention to treat); the symptomatic ICH difference was not significant by intention to treat, other major and minor bleeding did not differ, and event counts were small, so this does not establish a safety advantage or change the neutral efficacy result. Biomarker-defined atrial cardiopathy is distinct from documented AF.","sources":[{"title":"ARCADIA primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38324415/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."},{"title":"ARCADIA hemorrhage analysis","url":"https://pubmed.ncbi.nlm.nih.gov/41741942/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; secondary analysis (primary safety sample censored at permanent study-drug discontinuation; intention-to-treat sensitivity analysis)."}],"relatedTopic":"stroke-workup"},{"id":"crystal-af","title":"CRYSTAL AF — prolonged monitoring after cryptogenic stroke","headline":"Implantable monitor: AF 12.4 vs 2.0% at 12 months","year":2014,"settings":["hospital","clinic"],"keywords":["cryptogenic","rhythm monitoring","loop recorder","atrial fibrillation","ICM"],"question":"Did an insertable monitor increase AF detection?","population":"441 patients aged at least 40 with cryptogenic stroke, no AF on at least 24-hour ECG monitoring, randomized within 90 days.","comparison":"Insertable cardiac monitor versus conventional follow-up.","result":"The primary endpoint, detection of AF lasting over 30 seconds within six months, occurred in 8.9% versus 1.4% (HR 6.4; 95% CI 1.9–21.7). At 12 months, detection was 12.4% versus 2.0%.","limits":"This was a detection trial, not proof of reduced recurrent stroke or a universal anticoagulation threshold for every device-detected episode. The abstract does not detail implantation harms.","sources":[{"title":"CRYSTAL AF primary report","url":"https://pubmed.ncbi.nlm.nih.gov/24963567/","year":2014,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."}],"relatedTopic":"stroke-workup"},{"id":"crest-2","title":"CREST-2 — revascularization for asymptomatic carotid stenosis","headline":"Asymptomatic: stenting 2.8 vs 6.0%; CEA 3.7 vs 5.3% (NS)","year":2026,"settings":["clinic","hospital"],"keywords":["carotid","stenting","endarterectomy","asymptomatic","intensive medical management"],"question":"Did adding revascularization improve outcomes on intensive medical therapy?","population":"Two parallel trials of ≥70% stenosis without carotid-territory stroke, TIA or amaurosis fugax for 180 days: 1,245 in the stenting trial and 1,240 in the endarterectomy trial.","comparison":"Each procedure plus intensive medical management versus intensive medical management alone.","result":"The four-year composite of stroke/death through day 44 or later ipsilateral ischemic stroke was 2.8% versus 6.0% with stenting (P=0.02), and 3.7% versus 5.3% with endarterectomy (P=0.24). Early events included seven strokes and one death with stenting versus none medically; nine versus three strokes in the endarterectomy trial. Prespecified cognitive outcomes (2,165 US patients, up to 4 years) did not differ with either procedure (composite z-score differences 0.03 and 0.02).","limits":"Separate trials did not compare stenting directly with endarterectomy. Only certified high-volume operators took part, and 17–18% of medical-therapy patients later underwent revascularization. Results concern selected asymptomatic disease and include procedural harms; they do not establish a universal procedure choice.","sources":[{"title":"CREST-2 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/41269206/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"PMC full text (PMC13148431) read 2026-10-21; online publication 2025, print issue 2026. Supplement not reviewed."},{"title":"CREST-2 cognitive outcomes","url":"https://pubmed.ncbi.nlm.nih.gov/42747844/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; prespecified secondary outcomes of both randomized trials."},{"title":"CREST-H hemodynamic-impairment substudy","url":"https://pubmed.ncbi.nlm.nih.gov/42747834/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; randomized substudy of CREST-2."}],"relatedTopic":"carotid"},{"id":"ecst-2","title":"ECST-2 — two-year interim carotid revascularization evidence","headline":"Lower-risk carotid stenosis: no difference at 2 years","year":2025,"settings":["clinic","hospital"],"keywords":["carotid","endarterectomy","stenting","asymptomatic","low risk","interim"],"question":"Did revascularization add benefit in lower-risk carotid stenosis?","population":"429 randomized patients with ≥50% asymptomatic or symptomatic stenosis and CAR-score predicted five-year ipsilateral stroke risk below 20%.","comparison":"Optimized medical therapy alone versus medical therapy plus revascularization.","result":"At two years, the hierarchical composite of periprocedural death/fatal stroke/fatal MI, nonfatal stroke, nonfatal MI and new silent infarction showed no difference (medical/procedure win ratio 1.01; 95% CI 0.60–1.70). One periprocedural death followed endarterectomy.","limits":"Interim analysis with wide uncertainty, a selected risk population and an endpoint that includes silent infarction. It does not establish equivalence or negate benefit in higher-risk symptomatic disease.","sources":[{"title":"ECST-2 interim analysis primary report","url":"https://pubmed.ncbi.nlm.nih.gov/40252662/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract read via PubMed/NLM. January 2026 publisher correction checked: two appendix investigator names corrected; no outcome change stated. Full report and supplements not reviewed."}],"relatedTopic":"carotid"},{"id":"vns-rehab","title":"VNS-REHAB — paired stimulation for chronic arm weakness","headline":"Paired VNS: Fugl-Meyer +5.0 vs +2.4","year":2021,"settings":["clinic"],"keywords":["rehabilitation","recovery","upper limb","vagus nerve stimulation","motor","Fugl-Meyer"],"question":"Did paired vagus stimulation improve chronic upper-limb impairment?","population":"108 patients with moderate-to-severe arm weakness at least nine months after ischemic stroke.","comparison":"Implanted active versus sham vagus stimulation paired with six weeks of rehabilitation; all participants received implants.","result":"The primary Fugl-Meyer upper-extremity improvement immediately after therapy was 5.0 versus 2.4 points (difference 2.6; 95% CI 1.0–4.2). One serious surgery-related vocal-cord paresis occurred in the sham group.","limits":"Small, selected chronic-stroke trial. The endpoint measures impairment, not independent living; both arms carried implantation risks. Trial efficacy does not establish individual candidacy, device availability or coverage. A 2026 Cochrane review (10 RCTs, 7 transcutaneous; mostly high risk of bias) rated the arm-motor evidence very uncertain; 2-year gains (post hoc) are uncontrolled because both arms then received active stimulation.","sources":[{"title":"VNS-REHAB primary report","url":"https://pubmed.ncbi.nlm.nih.gov/33894832/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract checked."},{"title":"VNS-REHAB 2-year follow-up (post hoc)","url":"https://pubmed.ncbi.nlm.nih.gov/42447422/","year":2026,"type":"Report","checkedAt":"2026-10-21","access":"Primary abstract read."},{"title":"Cochrane review of VNS for post-stroke motor function","url":"https://pubmed.ncbi.nlm.nih.gov/41823357/","year":2026,"type":"Meta-analysis","checkedAt":"2026-10-21","access":"Primary abstract read."}],"relatedTopic":"motor-recovery"},{"id":"avert","title":"AVERT — dose and timing of early mobilization","headline":"Very early high-dose mobilization: mRS 0–2 46 vs 50% (harm)","year":2015,"settings":["hospital"],"keywords":["rehabilitation","mobilization","mobilisation","early recovery","stroke unit"],"question":"Did a higher-dose mobilization protocol within 24 hours improve recovery?","population":"2,104 adults with ischemic or hemorrhagic stroke meeting physiological criteria at 56 stroke units.","comparison":"Frequent, higher-dose very early mobilization plus usual care versus usual stroke-unit care.","result":"At three months, mRS 0–2 was less frequent with the intervention: 46% versus 50% (adjusted OR 0.73; 95% CI 0.59–0.90). Mortality was 8% versus 7% (OR 1.34; 95% CI 0.93–1.93). Nonfatal serious adverse events were 19% versus 20%.","limits":"This tests a timing-and-dose package, not a mandate for bed rest or an isolated timing threshold. Most usual-care patients also mobilized within 24 hours. Detailed protocol and 2015 correction effects remain unverified.","sources":[{"title":"AVERT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/25892679/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract read via PubMed/NLM. The 2017 correction changes licensing only; the 2015 correction body was inaccessible. Full protocol and supplements not reviewed."}],"relatedTopic":"inpatient-care"},{"id":"hermes","title":"HERMES — pooled early thrombectomy evidence","headline":"EVT ≤12 h (5 RCTs, most ≤6 h): mRS shift cOR 2.49; NNT 2.6","year":2016,"settings":["on-call","hospital"],"keywords":["MR CLEAN","ESCAPE","REVASCAT","SWIFT PRIME","EXTEND-IA","large vessel occlusion","meta-analysis"],"question":"What did the five foundational thrombectomy trials show together?","population":"1,287 participants from five randomized trials of proximal anterior-circulation occlusion.","comparison":"Thrombectomy plus standard care versus standard care alone, within the individual trial windows.","result":"The 90-day mRS distribution favored thrombectomy (adjusted common odds ratio 2.49; 95% CI 1.76–3.53). The reported NNT of 2.6 means one additional person improves by at least one mRS category. Mortality and symptomatic intracranial hemorrhage did not differ significantly.","limits":"The NNT is not for functional independence. Trial-specific selection varied; this pooled result does not establish benefit for every vessel, infarct size or time window.","sources":[{"title":"HERMES primary report","url":"https://pubmed.ncbi.nlm.nih.gov/26898852/","year":2016,"type":"Meta-analysis","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"evt-selection"},{"id":"dawn","title":"DAWN — clinical–core mismatch at 6–24 hours","headline":"6–24 h clinical–core mismatch: mRS 0–2 49 vs 13%","year":2018,"settings":["on-call","hospital"],"keywords":["thrombectomy","late window","clinical core mismatch"],"question":"Did selected patients benefit from thrombectomy up to 24 hours?","population":"206 participants with intracranial ICA or proximal MCA occlusion, last known well 6–24 hours earlier, and age-dependent mismatch between clinical deficit and infarct volume.","comparison":"Thrombectomy plus standard care versus standard care alone.","result":"At 90 days, the coprimary outcomes favored thrombectomy: utility-weighted mRS (0–10 scale) 5.5 versus 3.4 and mRS 0–2 in 49% versus 13% (adjusted difference 33 percentage points; 95% credible interval 24–44). Symptomatic intracranial hemorrhage was 6% versus 3%; mortality was 19% versus 18%, without significant differences.","limits":"Stopped early after a prespecified interim analysis. Age, deficit and core criteria matter; clinical–core mismatch is not interchangeable with perfusion mismatch.","sources":[{"title":"DAWN primary report","url":"https://pubmed.ncbi.nlm.nih.gov/29129157/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"evt-selection"},{"id":"defuse-3","title":"DEFUSE 3 — perfusion selection at 6–16 hours","headline":"6–16 h perfusion mismatch: mRS 0–2 45 vs 17%","year":2018,"settings":["on-call","hospital"],"keywords":["thrombectomy","late window","perfusion mismatch"],"question":"Did perfusion-selected patients benefit beyond six hours?","population":"182 participants with ICA or proximal MCA occlusion, last known well 6–16 hours earlier, core <70 mL and perfusion lesion-to-core ratio ≥1.8.","comparison":"Thrombectomy plus standard medical therapy versus medical therapy alone.","result":"The primary 90-day mRS shift favored thrombectomy (odds ratio 2.77; P<0.001). Functional independence was 45% versus 17%; mortality 14% versus 26% (P=0.05). Symptomatic intracranial hemorrhage was 7% versus 4% (P=0.75).","limits":"Stopped early for efficacy. This is a selected mismatch population; the abbreviated criteria here do not replace the complete imaging and eligibility protocol.","sources":[{"title":"DEFUSE 3 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/29364767/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"evt-selection"},{"id":"swift-direct","title":"SWIFT DIRECT — thrombectomy alone versus alteplase plus thrombectomy","headline":"EVT alone not noninferior: mRS 0–2 57 vs 65%","year":2022,"settings":["on-call","hospital"],"keywords":["bridging","direct thrombectomy","alteplase","EVT"],"question":"Is thrombectomy alone noninferior to alteplase plus thrombectomy?","population":"408 analyzed patients with LVO admitted to endovascular centers in Europe and Canada.","comparison":"Stent-retriever thrombectomy alone versus IV alteplase plus thrombectomy.","result":"mRS 0–2 at 90 days occurred in 57% vs 65% (adjusted risk difference −7.3%), crossing the 12% noninferiority margin. Symptomatic ICH 2% vs 3%; successful reperfusion 91% vs 96%.","limits":"Open-label; tested one stent-retriever device and alteplase.","sources":[{"title":"SWIFT DIRECT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/35810756/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"evt-selection"},{"id":"mr-clean-no-iv","title":"MR CLEAN-NO IV — thrombectomy with or without alteplase","headline":"EVT alone neither superior nor noninferior (cOR 0.84)","year":2021,"settings":["on-call","hospital"],"keywords":["bridging","direct thrombectomy","alteplase","EVT"],"question":"Is EVT alone superior or noninferior to alteplase followed by EVT?","population":"539 European patients presenting directly to EVT-capable hospitals.","comparison":"EVT alone versus IV alteplase plus EVT.","result":"Median mRS was 3 vs 2 (adjusted cOR 0.84; 95% CI 0.62–1.15): neither superiority nor noninferiority. Mortality 20.5% vs 15.8%; symptomatic ICH 5.9% vs 5.3%.","limits":"Open-label; direct admissions only.","sources":[{"title":"MR CLEAN-NO IV primary report","url":"https://pubmed.ncbi.nlm.nih.gov/34758251/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"evt-selection"},{"id":"direct-mt","title":"DIRECT-MT — thrombectomy with or without alteplase in China","headline":"EVT alone noninferior (cOR 1.07), less reperfusion","year":2020,"settings":["on-call","hospital"],"keywords":["bridging","direct thrombectomy","alteplase","EVT"],"question":"Is EVT alone noninferior to alteplase plus EVT?","population":"656 Chinese patients with anterior-circulation LVO at 41 academic centers.","comparison":"EVT alone versus IV alteplase within 4.5 hours followed by EVT.","result":"EVT alone was noninferior for the mRS distribution (adjusted cOR 1.07; 95% CI 0.81–1.40) with a 20% margin, but successful reperfusion was lower before EVT (2.4% vs 7.0%) and overall (79.4% vs 84.5%). Mortality 17.7% vs 18.8%.","limits":"Wide noninferiority margin; European and Canadian trials (SWIFT DIRECT, MR CLEAN-NO IV) did not confirm noninferiority.","sources":[{"title":"DIRECT-MT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/32374959/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"evt-selection"},{"id":"bridge-tnk","title":"BRIDGE-TNK — tenecteplase before thrombectomy","headline":"Tenecteplase before EVT: mRS 0–2 52.9 vs 44.1%","year":2025,"settings":["on-call","hospital"],"keywords":["bridging","tenecteplase","thrombectomy","EVT","TNK"],"question":"Does tenecteplase before EVT improve outcome in LVO within 4.5 hours?","population":"550 Chinese patients with LVO eligible for thrombolysis within 4.5 hours.","comparison":"IV tenecteplase followed by EVT versus EVT alone.","result":"mRS 0–2 at 90 days occurred in 52.9% vs 44.1% (RR 1.20; 95% CI 1.01–1.43). Symptomatic ICH within 48 hours 8.5% vs 6.7%; mortality 22.3% vs 19.9%.","limits":"Open-label, single-country trial; the margin of benefit was modest.","sources":[{"title":"BRIDGE-TNK primary report","url":"https://pubmed.ncbi.nlm.nih.gov/40396577/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"evt-selection"},{"id":"mild-mt","title":"MILD-MT — thrombectomy for mild stroke with large-vessel occlusion","headline":"NIHSS <6 LVO (China): mRS 0–1 69.4 vs 50.0%; serious procedural complications 13.2%","year":2026,"settings":["on-call","hospital"],"keywords":["EVT","thrombectomy","mild stroke","low NIHSS","LVO","perfusion mismatch","MILD-MT"],"question":"Does EVT help mild (NIHSS <6) anterior-circulation LVO stroke with a small core and a large perfusion mismatch within 24 hours?","population":"304 randomized in China (300 in the modified intention-to-treat analysis: 144 EVT, 156 medical) within 24 hours of onset or last known well, with NIHSS <6 and ICA, M1 or M2 occlusion, core ≤50 mL and perfusion mismatch ≥50 mL (protocol); the registry also lists age 18–80, prestroke mRS 0 and ASPECTS ≥6.","comparison":"EVT plus medical management versus medical management alone.","result":"mRS 0–1 at 90 days occurred in 69.4% vs 50.0% (OR 2.32; 95% CI 1.41–3.81). Symptomatic ICH within 48 h occurred in 3 patients in each group; serious procedure-related complications occurred in 19 EVT patients (13.2%); one death overall (EVT group).","limits":"Open-label (blinded endpoint per protocol), single-country and perfusion-selected. It postdates AHA/ASA 2026, whose graded anterior-circulation EVT recommendations require NIHSS ≥6, so it is not a graded recommendation. Serious procedural complications were frequent. Eligibility is from the registry and protocol abstract; the full NEJM report was not reviewed.","sources":[{"title":"MILD-MT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42929671/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; NEJM full text not reachable. Registry eligibility (NCT06179017) read 2026-10-31."},{"title":"MILD-MT protocol","url":"https://pubmed.ncbi.nlm.nih.gov/41974578/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31."}],"relatedTopic":"evt-selection"},{"id":"late-mt","title":"LATE-MT — thrombectomy 24 to 72 hours after onset","headline":"24–72 h LVO (China): mRS cOR 1.74; sICH 4.8 vs 0%; 90-day mortality 6.0 vs 1.8%","year":2026,"settings":["on-call","hospital"],"keywords":["EVT","thrombectomy","very late window","beyond 24 hours","CT perfusion","LVO","LATE-MT"],"question":"Does EVT help anterior-circulation LVO with salvageable tissue 24–72 hours after onset or last known well?","population":"336 patients in the intention-to-treat population (168 per group) at comprehensive stroke centers in China with anterior-circulation LVO and imaging-identified salvageable tissue at 24–72 h (median 38.5 h to randomization). Registry: age ≥18, ICA (including extracranial segment) to M1/M2, NIHSS ≥6 at randomization, major prestroke disability (mRS ≥2) excluded, CTP core <50 mL with mismatch ratio ≥1.8 and mismatch volume ≥15 mL.","comparison":"EVT plus standard medical care versus standard medical care alone.","result":"The 90-day mRS distribution favored EVT (common OR 1.74; 95% CI 1.19–2.55). Symptomatic ICH 4.8% vs 0%; 90-day case fatality 6.0% vs 1.8%.","limits":"Open-label with blinded outcome assessment; single country; CTP selection required. Benefit came with more intracranial hemorrhage and death. Postdates AHA/ASA 2026, whose graded EVT recommendations extend only to 24 h; not a graded recommendation. Eligibility is from the registry; the full NEJM report was not reviewed.","sources":[{"title":"LATE-MT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42929656/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; NEJM full text not reachable. Registry eligibility (NCT05326932) read 2026-10-31."}],"relatedTopic":"evt-selection"},{"id":"act","title":"AcT — tenecteplase versus alteplase","headline":"Tenecteplase noninferior: mRS 0–1 36.9 vs 34.8%","year":2022,"settings":["on-call","hospital"],"keywords":["TNK","tenecteplase","alteplase","noninferiority"],"question":"Was tenecteplase noninferior to alteplase in routine thrombolysis candidates?","population":"1,600 adults randomized in Canada with disabling ischemic stroke within 4.5 hours and eligibility under Canadian thrombolysis criteria; 1,577 entered the intention-to-treat population.","comparison":"Tenecteplase 0.25 mg/kg (maximum 25 mg) versus alteplase 0.9 mg/kg (maximum 90 mg).","result":"mRS 0–1 at 90–120 days occurred in 36.9% versus 34.8% (risk difference 2.1 percentage points; 95% CI −2.6 to 6.9), meeting the prespecified −5-point noninferiority margin. Symptomatic intracerebral hemorrhage within 24 hours was 3.4% versus 3.2%.","limits":"Noninferiority is not superiority or identical safety. Open-label pragmatic trial; results concern this dose and standard-window eligible population, not every thrombolytic regimen.","sources":[{"title":"AcT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/35779553/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"thrombolytic-choice"},{"id":"trace-2","title":"TRACE-2 — tenecteplase versus alteplase in China","headline":"Tenecteplase noninferior: mRS 0–1 62 vs 58%","year":2023,"settings":["on-call","hospital"],"keywords":["tenecteplase","alteplase","noninferiority","TNK"],"question":"Is tenecteplase noninferior to alteplase within 4.5 hours in patients not having EVT?","population":"1,430 Chinese adults, NIHSS 5–25, prestroke mRS ≤1, ineligible for or declining EVT.","comparison":"Tenecteplase 0.25 mg/kg (max 25 mg) versus alteplase 0.9 mg/kg (max 90 mg).","result":"mRS 0–1 at 90 days occurred in 62% vs 58% (RR 1.07; 95% CI 0.98–1.16), meeting noninferiority. Symptomatic ICH 2% in each group; mortality 7% vs 5%.","limits":"Open-label with blinded outcome; excluded EVT candidates.","sources":[{"title":"TRACE-2 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/36774935/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"thrombolytic-choice"},{"id":"original","title":"ORIGINAL — tenecteplase versus alteplase within 4.5 hours","headline":"Tenecteplase noninferior: mRS 0–1 72.7 vs 70.3%","year":2024,"settings":["on-call","hospital"],"keywords":["tenecteplase","alteplase","noninferiority","TNK"],"question":"Is tenecteplase 0.25 mg/kg noninferior to alteplase within 4.5 hours?","population":"1,489 randomized Chinese patients with NIHSS 1–25 (1,465 analyzed).","comparison":"Tenecteplase 0.25 mg/kg versus alteplase 0.9 mg/kg.","result":"mRS 0–1 at 90 days occurred in 72.7% vs 70.3% (RR 1.03; 95% CI 0.97–1.09), meeting noninferiority. Symptomatic ICH 1.2% in each group; mortality 4.6% vs 5.8%.","limits":"Open-label, single-country trial including mild strokes.","sources":[{"title":"ORIGINAL primary report","url":"https://pubmed.ncbi.nlm.nih.gov/39264623/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"thrombolytic-choice"},{"id":"extend","title":"EXTEND — perfusion-selected alteplase beyond 4.5 hours","headline":"Perfusion-selected 4.5–9 h: mRS 0–1 35.4 vs 29.5%; sICH 6.2 vs 0.9%","year":2019,"settings":["on-call","hospital"],"keywords":["alteplase","perfusion mismatch","wake-up","late window"],"question":"Did alteplase help selected patients beyond the standard window?","population":"225 participants with salvageable tissue on automated perfusion imaging, 4.5–9 hours after onset or waking with symptoms within nine hours of the sleep midpoint.","comparison":"Alteplase versus placebo.","result":"mRS 0–1 at 90 days occurred in 35.4% versus 29.5% (adjusted risk ratio 1.44; 95% CI 1.01–2.06). Symptomatic intracerebral hemorrhage occurred in 6.2% versus 0.9%. The secondary ordinal mRS analysis did not show a significant difference.","limits":"Stopped before planned enrollment after external evidence changed equipoise. Imaging-selected trial, not a time-only extension. A 2021 correction changes tertiary neurologic-improvement results; those values are not reproduced here.","sources":[{"title":"EXTEND primary report","url":"https://pubmed.ncbi.nlm.nih.gov/31067369/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices read via PubMed/NLM. Publisher correction text reviewed; full trial report and supplements not reviewed."},{"title":"EXTEND correction: tertiary neurologic-improvement calculations","url":"https://www.nejm.org/doi/full/10.1056/NEJMx200014","year":2021,"type":"Report","checkedAt":"2026-10-01","access":"Publisher correction text recovered in web search; direct page fetch returned 403. The notice concerns tertiary neurologic-improvement results and associated tables."}],"relatedTopic":"extended-window-ivt"},{"id":"wake-up","title":"WAKE-UP — MRI-guided alteplase for unknown onset","headline":"DWI–FLAIR mismatch: mRS 0–1 53.3 vs 41.8%","year":2018,"settings":["on-call","hospital"],"keywords":["wake-up","unknown onset","DWI-FLAIR mismatch","alteplase","MRI"],"question":"Does alteplase help unknown-onset stroke with DWI–FLAIR mismatch?","population":"503 patients with unknown onset, a DWI lesion and no marked FLAIR change; patients with planned thrombectomy excluded.","comparison":"IV alteplase versus placebo.","result":"mRS 0–1 at 90 days occurred in 53.3% vs 41.8% (adjusted OR 1.61; 95% CI 1.09–2.36). Deaths 4.1% vs 1.2% and symptomatic ICH 2.0% vs 0.4% (both not significant).","limits":"Stopped early for lack of funding (503 of 800 planned). Applies to MRI mismatch selection, not perfusion or CT-only selection.","sources":[{"title":"WAKE-UP primary report","url":"https://pubmed.ncbi.nlm.nih.gov/29766770/","year":2018,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."}],"relatedTopic":"extended-window-ivt"},{"id":"trace-iii","title":"TRACE-III — tenecteplase at 4.5–24 hours without thrombectomy","headline":"LVO 4.5–24 h, no EVT: mRS 0–1 33.0 vs 24.2%; sICH 3.0 vs 0.8%","year":2024,"settings":["on-call","hospital"],"keywords":["tenecteplase","late window","LVO","perfusion","no EVT access"],"question":"Does tenecteplase help LVO with salvageable tissue at 4.5–24 hours when EVT is not available?","population":"516 Chinese patients with MCA or ICA occlusion and perfusion mismatch, 4.5–24 hours from last known well; under 2% had rescue EVT.","comparison":"Tenecteplase 0.25 mg/kg (max 25 mg) versus standard medical treatment.","result":"mRS 0–1 at 90 days occurred in 33.0% vs 24.2% (relative rate 1.37; 95% CI 1.04–1.81). Mortality 13.3% vs 13.1%; symptomatic ICH within 36 hours 3.0% vs 0.8%.","limits":"Single-country trial without EVT access; it does not apply when EVT is available (see TIMELESS).","sources":[{"title":"TRACE-III primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38884324/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"extended-window-ivt"},{"id":"timeless","title":"TIMELESS — tenecteplase at 4.5–24 hours before planned EVT","headline":"Late tenecteplase with EVT: no benefit (cOR 1.13)","year":2024,"settings":["on-call","hospital"],"keywords":["tenecteplase","late window","LVO","perfusion","thrombectomy"],"question":"Does tenecteplase at 4.5–24 hours improve outcome in perfusion-selected MCA or ICA occlusion?","population":"458 patients; 77.3% went on to thrombectomy; median time to randomization about 12–13 hours.","comparison":"Tenecteplase 0.25 mg/kg versus placebo, double-blind.","result":"Median 90-day mRS was 3 in both groups (adjusted cOR 1.13; 95% CI 0.82–1.57). Mortality 19.7% vs 18.2%; symptomatic ICH 3.2% vs 2.3%.","limits":"Most patients received EVT, which may have masked any thrombolytic effect.","sources":[{"title":"TIMELESS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38329148/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"extended-window-ivt"},{"id":"chance","title":"CHANCE — short initial dual antiplatelet therapy","headline":"DAPT 21 days: stroke 8.2 vs 11.7%","year":2013,"settings":["on-call","hospital","clinic"],"keywords":["clopidogrel","aspirin","DAPT","minor stroke","TIA"],"question":"Did an initial dual-antiplatelet course reduce recurrent stroke?","population":"5,170 participants in China with minor ischemic stroke or high-risk TIA, randomized within 24 hours.","comparison":"Clopidogrel for 90 days with aspirin during the first 21 days versus aspirin for 90 days.","result":"Stroke by 90 days occurred in 8.2% versus 11.7% (hazard ratio 0.68; 95% CI 0.57–0.81). Moderate or severe hemorrhage was 0.3% in each group.","limits":"The combination lasted 21 days, not 90. Selected minor-stroke/TIA population in China; the low observed bleeding rate is not proof of no bleeding risk or justification for long-term dual therapy.","sources":[{"title":"CHANCE primary report","url":"https://pubmed.ncbi.nlm.nih.gov/23803136/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"thales","title":"THALES — ticagrelor plus aspirin after mild-to-moderate stroke","headline":"Ticagrelor + aspirin: stroke/death 5.5 vs 6.6%; severe bleeding 0.5 vs 0.1%","year":2020,"settings":["on-call","hospital","clinic"],"keywords":["ticagrelor","aspirin","DAPT","NIHSS 5","TIA"],"question":"What were the benefits and harms of 30-day ticagrelor–aspirin?","population":"11,016 participants with noncardioembolic stroke (NIHSS ≤5) or qualifying TIA, treated within 24 hours; thrombolysis and thrombectomy recipients were excluded.","comparison":"Ticagrelor plus aspirin versus aspirin alone for 30 days.","result":"Stroke or death at 30 days occurred in 5.5% versus 6.6% (hazard ratio 0.83; 95% CI 0.71–0.96). Severe bleeding occurred in 0.5% versus 0.1%. Disability did not differ significantly.","limits":"This trial did not compare ticagrelor with clopidogrel. Review the qualifying TIA criteria and bleeding exclusions; do not extrapolate to reperfusion-treated patients or long-term dual therapy.","sources":[{"title":"THALES primary report","url":"https://pubmed.ncbi.nlm.nih.gov/32668111/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"chance-2","title":"CHANCE-2 — antiplatelet choice in CYP2C19 loss-of-function carriers","headline":"CYP2C19 LOF: ticagrelor 6.0 vs clopidogrel 7.6%","year":2021,"settings":["hospital","clinic"],"keywords":["CYP2C19","genotype","ticagrelor","clopidogrel","DAPT"],"question":"Did ticagrelor improve outcomes in selected clopidogrel-metabolism genotypes?","population":"6,412 participants in China with minor stroke or TIA and CYP2C19 loss-of-function alleles, randomized within 24 hours; 98% were Han Chinese.","comparison":"Ticagrelor versus clopidogrel for 90 days; both groups received aspirin for the first 21 days.","result":"Stroke by 90 days occurred in 6.0% versus 7.6% (hazard ratio 0.77; 95% CI 0.64–0.94). Moderate or severe bleeding was 0.3% in each group, but any bleeding was 5.3% versus 2.5%.","limits":"Genotype-selected trial with limited population diversity. It does not establish the preferred drug for every patient or the value of universal genotyping.","sources":[{"title":"CHANCE-2 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/34708996/","year":2021,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"oceanic-stroke","title":"OCEANIC-STROKE — asundexian added to antiplatelets","headline":"Asundexian: ischemic stroke 6.2 vs 8.4%; major bleeding 1.9 vs 1.7%","year":2026,"settings":["on-call","hospital","clinic"],"keywords":["factor XI","asundexian","secondary prevention","noncardioembolic"],"question":"Does asundexian added to antiplatelet therapy prevent recurrent ischemic stroke?","population":"12,327 patients within 72 hours of noncardioembolic ischemic stroke or high-risk TIA with atherosclerosis or nonlacunar infarct.","comparison":"Asundexian 50 mg daily versus placebo, on top of single or dual antiplatelet therapy.","result":"Ischemic stroke 6.2% vs 8.4% (cause-specific HR 0.74; 95% CI 0.65–0.84). Major bleeding 1.9% vs 1.7% (HR 1.10; 95% CI 0.85–1.44); lower gastrointestinal bleeding 1.7% vs 1.0% (csHR 1.75).","limits":"Industry-funded; regulatory status and availability are separate questions. Asundexian was inferior to apixaban in AF (OCEANIC-AF). Milvexian, a different factor XIa inhibitor, was stopped for futility after acute coronary syndrome (LIBREXIA-ACS: cardiovascular death, MI or ischemic stroke 5.4 vs 5.1%; HR 1.05). Its stroke trial (LIBREXIA-STROKE) had not reported as of October 2026.","sources":[{"title":"OCEANIC-STROKE primary report","url":"https://pubmed.ncbi.nlm.nih.gov/41985132/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"OCEANIC-STROKE bleeding report","url":"https://pubmed.ncbi.nlm.nih.gov/42866879/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"LIBREXIA-ACS (milvexian after acute coronary syndrome)","url":"https://pubmed.ncbi.nlm.nih.gov/42670965/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"Primary abstract read 2026-10-31; ACS population, not stroke. LIBREXIA-STROKE registry NCT05702034 checked 2026-10-31: active, not recruiting, no results."}],"relatedTopic":"research-adjuncts"},{"id":"most","title":"MOST — adjunctive argatroban or eptifibatide after IV thrombolysis","headline":"Adjunct argatroban/eptifibatide: no benefit; mortality 24% and 12% vs 8%","year":2024,"settings":["on-call","hospital"],"keywords":["argatroban","eptifibatide","thrombolysis","adjunct"],"question":"Does adding IV argatroban or eptifibatide to thrombolysis reduce disability?","population":"514 patients given IVT within 3 hours at 57 US sites; 44% had EVT.","comparison":"Argatroban or eptifibatide versus placebo, within 75 minutes of thrombolysis.","result":"Neither improved utility-weighted mRS (0–10): 5.2 with argatroban, 6.3 with eptifibatide, 6.8 with placebo. Symptomatic ICH 4%, 3% and 2%; mortality 24%, 12% and 8%.","limits":"Adaptive design with a small argatroban arm; results do not support routine adjunctive antithrombotics. In the prespecified thrombectomy cohort (254 planned for EVT), neither agent improved reperfusion or 90-day outcome.","sources":[{"title":"MOST primary report","url":"https://pubmed.ncbi.nlm.nih.gov/39231343/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."},{"title":"MOST thrombectomy-cohort analysis (preplanned)","url":"https://pubmed.ncbi.nlm.nih.gov/40824660/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (PMC12362272 not read)."}],"relatedTopic":"research-adjuncts"},{"id":"inspires","title":"INSPIRES — dual antiplatelets started within 72 hours","headline":"DAPT up to 72 h: stroke 7.3 vs 9.2%; moderate-to-severe bleeding 0.9 vs 0.4%","year":2023,"settings":["on-call","hospital","clinic"],"keywords":["clopidogrel","aspirin","DAPT","atherosclerosis","72 hours"],"question":"Did a selected population benefit when antiplatelet treatment began later?","population":"6,100 participants in China with mild ischemic stroke or high-risk TIA attributed to presumed atherosclerosis, without thrombolysis or thrombectomy; 87.2% were randomized after 24 through 72 hours.","comparison":"Clopidogrel for 90 days plus aspirin for 21 days versus aspirin for 90 days.","result":"New stroke by 90 days occurred in 7.3% versus 9.2% (hazard ratio 0.79; 95% CI 0.66–0.94). Moderate-to-severe bleeding was 0.9% versus 0.4% (hazard ratio 2.08; 95% CI 1.07–4.04).","limits":"This was an atherosclerosis-selected factorial trial. Results do not extend the treatment window for every stroke mechanism, severity or reperfusion-treated patient.","sources":[{"title":"INSPIRES primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38157499/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"aramis","title":"ARAMIS — DAPT versus alteplase for minor non-disabling stroke","headline":"Non-disabling minor stroke: DAPT noninferior (mRS 0–1 93.8 vs 91.4%)","year":2023,"settings":["on-call","hospital"],"keywords":["minor stroke","nondisabling","DAPT","alteplase","clopidogrel"],"question":"Is DAPT noninferior to alteplase for minor non-disabling stroke within 4.5 hours?","population":"760 Chinese patients with NIHSS ≤5 and ≤1 point on key items (median NIHSS 2).","comparison":"Clopidogrel plus aspirin for 12 days then guideline antiplatelets, versus alteplase followed by antiplatelets after 24 hours.","result":"mRS 0–1 at 90 days occurred in 93.8% vs 91.4% (risk difference 2.3%; 95% CI −1.5 to 6.2), meeting noninferiority. Symptomatic ICH 0.3% vs 0.9%.","limits":"Open-label, single-country trial with a −4.5% margin; applies only to non-disabling deficits.","sources":[{"title":"ARAMIS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37367978/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"tempo-2","title":"TEMPO-2 — tenecteplase for minor stroke with occlusion","headline":"Minor stroke with occlusion: no benefit; deaths 5 vs 1%","year":2024,"settings":["on-call","hospital"],"keywords":["minor stroke","tenecteplase","occlusion","thrombolysis"],"question":"Does tenecteplase help minor stroke (NIHSS 0–5) with intracranial occlusion or a focal perfusion abnormality?","population":"886 patients with NIHSS 0–5 and intracranial occlusion or focal perfusion abnormality at 48 hospitals in 10 countries, enrolled within 12 hours.","comparison":"Tenecteplase 0.25 mg/kg versus non-thrombolytic standard care.","result":"Return to baseline mRS at 90 days occurred in 72% vs 75% (RR 0.96; 95% CI 0.88–1.04). Deaths 5% vs 1% (adjusted HR 3.8; 1.4–10.2); symptomatic ICH 2% vs <1%.","limits":"Stopped early for futility; open-label. In a secondary analysis (JAMA Neurol 2025), the 100 patients with disabling deficits (TREAT Task Force definition) showed no benefit either (return to baseline 54.7 vs 68.1%; aRR 0.81, 0.60–1.10; interaction P=.32), but most were treated after 4.5 h (median onset to treatment 411 min), so it says little about disabling deficits within 4.5 h. A prespecified analysis by baseline occlusion (Eur Stroke J 2026; 881 patients) found no benefit with complete occlusion (aRR 1.00, 0.89–1.12), near occlusion (0.85, 0.71–1.01) or a perfusion deficit without visible occlusion (1.03, 0.90–1.18); it was not powered for subgroups, and most occlusions were medium-vessel (LVO about 1 in 6), so it says little about minor stroke with LVO.","sources":[{"title":"TEMPO-2 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38768626/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract verified via PubMed."},{"title":"TEMPO-2 secondary analysis by disabling deficit (TREAT Task Force definition)","url":"https://pubmed.ncbi.nlm.nih.gov/41143808/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"Primary abstract read via PubMed on 2026-10-31; secondary analysis of the original randomized population (884 analyzed), not a new trial; PMC full text (PMC12560024) not reviewed."},{"title":"TEMPO-2 secondary analysis by baseline occlusion status","url":"https://pubmed.ncbi.nlm.nih.gov/42734928/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PMC full text (PMC13573578) read 2026-10-31; prespecified secondary analysis of the original randomized population, not a new trial."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"tapis","title":"TAPIS — aspirin plus ticagrelor started with IV thrombolysis","headline":"DAPT within 6 h of onset with IVT: mRS 0–1 68.7 vs 62.0%","year":2026,"settings":["on-call","hospital"],"keywords":["DAPT","ticagrelor","thrombolysis","early antiplatelet","moderate stroke"],"question":"Does oral aspirin plus ticagrelor within 6 hours improve outcome in IVT-treated stroke?","population":"1,382 Chinese patients treated with IVT, NIHSS 4–10.","comparison":"Aspirin plus ticagrelor started before, during or after IVT (ticagrelor through day 7) versus placebo; open-label aspirin from day 2.","result":"mRS 0–1 at 90 days occurred in 68.7% vs 62.0% (RR 1.11; 95% CI 1.03–1.20). Symptomatic ICH within 36 hours 0.9% vs 0.7% (RR 1.20; 95% CI 0.37–3.93).","limits":"Single-country trial; the wide sICH confidence interval cannot exclude harm, and it challenges the usual 24-hour wait after IVT.","sources":[{"title":"TAPIS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42114550/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"minor-stroke-antiplatelets"},{"id":"artesia","title":"ARTESiA — apixaban for device-detected subclinical AF","headline":"Subclinical AF apixaban: stroke 0.78 vs 1.24%/yr; more bleeding","year":2024,"settings":["hospital","clinic"],"keywords":["device detected","subclinical AF","apixaban","aspirin","atrial fibrillation"],"question":"How did anticoagulation affect stroke and bleeding in subclinical AF?","population":"4,012 participants with subclinical AF lasting six minutes to 24 hours; mean CHA₂DS₂-VASc 3.9.","comparison":"Apixaban versus aspirin; trial therapy stopped and anticoagulation begun if AF exceeded 24 hours or clinical AF developed.","result":"Over mean follow-up of 3.5 years, stroke or systemic embolism was 0.78% versus 1.24% per patient-year (hazard ratio 0.63; 95% CI 0.45–0.88; intention-to-treat). Major bleeding was 1.71% versus 0.94% per patient-year (hazard ratio 1.80; 95% CI 1.26–2.57; on-treatment). Prespecified subanalyses: with prior stroke or TIA (346 patients; intention to treat), stroke or systemic embolism was 1.20 vs 3.14% per year (HR 0.40; 95% CI 0.17–0.95) and major bleeding 2.26 vs 1.16% per year (HR 1.94; 95% CI 0.77–4.87). In the on-treatment bleeding analysis, intracranial (0.33 vs 0.40 per 100 patient-years; HR 0.82) and fatal bleeding were similar, gastrointestinal bleeding was higher with apixaban (0.89 vs 0.40; HR 2.23), and most major bleeds were nonemergency hemoglobin drops of ≥2 g/dL.","limits":"Benefit and harm use different analysis populations. These are annualized rates, not cumulative risks; findings concern selected subclinical AF and require individualized risk assessment.","sources":[{"title":"ARTESiA primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37952132/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."},{"title":"ARTESiA prior stroke or TIA subgroup","url":"https://pubmed.ncbi.nlm.nih.gov/39862882/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; prespecified subgroup (346 participants), intention to treat."},{"title":"ARTESiA major bleeding subanalysis","url":"https://pubmed.ncbi.nlm.nih.gov/41222953/","year":2025,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31 (PMC12613090 not read); prespecified on-treatment subanalysis (3,961 patients)."}],"relatedTopic":"af-prevention"},{"id":"noah-afnet6","title":"NOAH-AFNET 6 — edoxaban for atrial high-rate episodes","headline":"Device-detected AHRE edoxaban: no benefit, more harm","year":2023,"settings":["hospital","clinic"],"keywords":["device detected","atrial high rate episodes","AHRE","edoxaban","subclinical AF"],"question":"Did device-detected atrial high-rate episodes justify edoxaban?","population":"2,536 participants aged ≥65 years with implanted-device episodes ≥6 minutes and another stroke risk factor, without ECG-documented AF.","comparison":"Edoxaban versus placebo.","result":"Cardiovascular death, stroke or systemic embolism was 3.2% versus 4.0% per patient-year (hazard ratio 0.81; 95% CI 0.60–1.08). Death or major bleeding was 5.9% versus 4.5% per patient-year (hazard ratio 1.31; 95% CI 1.02–1.67). Stroke was about 1% per year in both groups.","limits":"Stopped early for safety concerns and futility assessment. Its composite efficacy and safety endpoints differ from ARTESiA; it does not test anticoagulation for established clinical AF.","sources":[{"title":"NOAH-AFNET 6 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37622677/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"af-prevention"},{"id":"invictus","title":"INVICTUS — anticoagulation in rheumatic heart disease with AF","headline":"Rheumatic AF: rivaroxaban worse than VKA","year":2022,"settings":["hospital","clinic"],"keywords":["rheumatic","mitral stenosis","rivaroxaban","warfarin","vitamin K antagonist"],"question":"Could rivaroxaban replace a vitamin K antagonist in rheumatic AF?","population":"4,531 analyzed participants with AF, echocardiographic rheumatic heart disease and trial-defined thromboembolic risk features.","comparison":"Rivaroxaban versus a dose-adjusted vitamin K antagonist.","result":"The composite of stroke, systemic embolism, myocardial infarction, or vascular/unknown-cause death occurred in 560 versus 446 participants. Restricted mean event-free survival was 76 days shorter with rivaroxaban (95% CI 31–121 days shorter). Death was also more frequent; major bleeding did not differ significantly.","limits":"Survival curves were nonproportional, and rivaroxaban discontinuation was more frequent. Do not extrapolate routine nonvalvular-AF DOAC evidence to this rheumatic-heart-disease population.","sources":[{"title":"INVICTUS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/36036525/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"af-prevention"},{"id":"re-align","title":"RE-ALIGN — dabigatran in mechanical heart valves","headline":"Mechanical valves: dabigatran worse than warfarin","year":2013,"settings":["hospital","clinic"],"keywords":["mechanical valve","dabigatran","warfarin","DOAC"],"question":"Could dabigatran replace warfarin after mechanical valve replacement?","population":"252 participants with mechanical aortic or mitral valves, either implanted within seven days or at least three months earlier.","comparison":"Kidney-function- and concentration-adjusted dabigatran versus warfarin.","result":"This phase 2 study, whose primary endpoint was dabigatran trough concentration, stopped early for excess thromboembolism and bleeding. In the as-treated analysis, ischemic or unspecified stroke occurred in nine dabigatran recipients versus none with warfarin; major bleeding occurred in seven versus two.","limits":"A dose-validation study with adverse clinical outcomes, not a successful clinical noninferiority trial. Findings in ordinary AF cannot be transferred to mechanical valves.","sources":[{"title":"RE-ALIGN primary report","url":"https://pubmed.ncbi.nlm.nih.gov/23991661/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"cardiac-sources"},{"id":"proact-xa","title":"PROACT Xa — apixaban in an On-X mechanical aortic valve","headline":"On-X valve: apixaban worse than warfarin","year":2023,"settings":["hospital","clinic"],"keywords":["mechanical valve","On-X","apixaban","warfarin","DOAC"],"question":"Was apixaban noninferior to warfarin with this mechanical aortic valve?","population":"863 participants with an On-X mechanical aortic valve implanted at least three months earlier; 94% also took aspirin.","comparison":"Apixaban versus warfarin targeting INR 2.0–3.0.","result":"Stopped early for excess thromboembolic events. Valve thrombosis or valve-related thromboembolism occurred at 4.2% versus 1.3% per patient-year (rate difference 2.9 percentage points per year; 95% CI 0.8–5.0), failing noninferiority. Major bleeding was 3.6% versus 4.5% per patient-year.","limits":"These are event rates, not percentages of participants: 20 events occurred in 16 apixaban recipients versus six events in six warfarin recipients. Results do not support replacing warfarin with apixaban in this valve population.","sources":[{"title":"PROACT Xa primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38320162/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"cardiac-sources"},{"id":"interact2","title":"INTERACT2 — acute ICH blood-pressure lowering","headline":"ICH SBP <140: primary outcome NS (OR 0.87); ordinal shift favored","year":2013,"settings":["on-call","hospital"],"keywords":["ICH","blood pressure","SBP","INTERACT"],"question":"Did early intensive BP lowering improve 90-day function?","population":"2,839 patients with spontaneous ICH within six hours and elevated systolic BP; 2,794 had primary-outcome data.","comparison":"SBP target <140 mmHg within one hour versus <180 mmHg, using clinician-selected agents.","result":"Death or major disability (mRS 3–6) was 52.0% versus 55.6% (OR 0.87; 95% CI 0.75–1.01; P=0.06). The prespecified ordinal analysis favored intensive treatment (OR for greater disability 0.87; 95% CI 0.77–1.00; P=0.04). Mortality was 11.9% versus 12.0%; nonfatal serious adverse events were similar.","limits":"The dichotomous primary outcome was not statistically significant. Distinguish the tested early ICH strategy from post-EVT BP targets and from more aggressive lowering in ATACH-2.","sources":[{"title":"INTERACT2 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/23713578/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"ich-management"},{"id":"atach-2","title":"ATACH-2 — intensive BP lowering and renal adverse events","headline":"ICH SBP 110–139: no benefit; renal events 9.0 vs 4.0%","year":2016,"settings":["on-call","hospital"],"keywords":["ICH","blood pressure","nicardipine","renal injury"],"question":"Was an SBP target of 110–139 better than 140–179 mmHg?","population":"1,000 patients with acute ICH <60 cm³ and GCS ≥5; IV nicardipine began within 4.5 hours of symptom onset.","comparison":"SBP target 110–139 versus 140–179 mmHg.","result":"Death or disability (mRS 4–6) at three months was 38.7% versus 37.7% (adjusted RR 1.04; 95% CI 0.85–1.27). Renal adverse events within seven days were more frequent with intensive treatment: 9.0% versus 4.0% (P=0.002).","limits":"Stopped for futility. The selected volume/GCS population and different BP targets limit comparison with INTERACT2; these results do not support pushing all acute ICH patients to the lower tested range.","sources":[{"title":"ATACH-2 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/27276234/","year":2016,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"ich-management"},{"id":"interact3","title":"INTERACT3 — coordinated acute ICH care bundle","headline":"ICH care bundle: better mRS (cOR 0.86)","year":2023,"settings":["on-call","hospital"],"keywords":["ICH","care bundle","blood pressure","glucose","temperature","warfarin"],"question":"Did implementing a coordinated physiological-care bundle improve function?","population":"7,036 adults with spontaneous ICH within six hours at 121 hospitals in ten countries; 6,255 had primary-outcome data.","comparison":"Hospital implementation of early BP lowering, glucose and temperature management, and warfarin reversal for abnormal values versus usual care; stepped-wedge cluster randomization.","result":"At six months the bundle improved the ordinal mRS distribution (common OR for worse outcome 0.86; 95% CI 0.76–0.97). Serious adverse events occurred in 16.0% versus 20.1%.","limits":"A hospital-level implementation trial, predominantly in low- and middle-income settings with inconsistent existing protocols. Benefit cannot be assigned to BP lowering or another single component; missing outcomes and site withdrawals require attention.","sources":[{"title":"INTERACT3 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37245517/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked. July 2023 correction body read: investigator-name spellings in the appendix were corrected."},{"title":"INTERACT3 correction","url":"https://pubmed.ncbi.nlm.nih.gov/37453751/","year":2023,"type":"Report","checkedAt":"2026-10-01","access":"Correction body read: two appendix investigator names corrected; no outcome change stated."}],"relatedTopic":"ich-management"},{"id":"fastest","title":"FASTEST — recombinant factor VIIa within 2 hours of ICH","headline":"rFVIIa: less growth (−3.7 mL), no functional benefit; more thromboembolism","year":2026,"settings":["on-call","hospital"],"keywords":["factor VIIa","hemostatic","hematoma expansion","ICH"],"question":"Does recombinant factor VIIa within 2 hours improve outcome after spontaneous ICH?","population":"626 adults aged 18–80 with ICH 2–60 mL, limited IVH, GCS ≥8, treated within 2 hours.","comparison":"Recombinant factor VIIa 80 µg/kg versus placebo.","result":"No difference in 180-day mRS (adjusted cOR 1.09; 95% CI 0.79–1.51); stopped for futility. Life-threatening thromboembolism within 4 days: RR 3.41 (1.14–10.15). ICH growth was 3.7 mL less at 24 hours.","limits":"Excluded recent anticoagulation and large hematomas; slowed growth did not translate into function.","sources":[{"title":"FASTEST primary report","url":"https://pubmed.ncbi.nlm.nih.gov/41653933/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"ich-expansion-ivh"},{"id":"enchanted2-mt","title":"ENCHANTED2/MT — avoid extrapolating aggressive post-EVT BP lowering","headline":"Post-EVT SBP <120: worse outcome (OR 1.37)","year":2022,"settings":["on-call","hospital"],"keywords":["EVT","thrombectomy","reperfusion","SBP","blood pressure"],"question":"What happened with SBP <120 after successful thrombectomy?","population":"821 randomized adults in China with persistent SBP ≥140 mmHg after successful reperfusion for intracranial large-vessel occlusion; 810 had primary-outcome data.","comparison":"SBP <120 versus 140–180 mmHg, reached within one hour and maintained for 72 hours.","result":"Intensive treatment worsened the 90-day ordinal mRS outcome (common OR for worse outcome 1.37; 95% CI 1.07–1.76) and increased early neurological deterioration (common OR 1.53; 95% CI 1.18–1.97). Symptomatic ICH and mortality did not differ significantly.","limits":"Stopped early for efficacy/safety concerns. These are selected successfully reperfused patients; neither the comparator nor this result establishes one BP target for every reperfusion grade or clinical situation.","sources":[{"title":"ENCHANTED2/MT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/36341753/","year":2022,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked. December 2022 correction is indexed; its body was inaccessible, so the scope of that correction remains unverified."},{"title":"ENCHANTED2/MT indexed correction","url":"https://pubmed.ncbi.nlm.nih.gov/36463906/","year":2022,"type":"Report","checkedAt":"2026-10-01","access":"Correction identity and link verified in NLM; publisher body inaccessible and correction scope not determined."}],"relatedTopic":"acute-bp"},{"id":"optimal-bp","title":"OPTIMAL-BP — functional outcomes after post-EVT BP reduction","headline":"Post-EVT SBP <140: mRS 0–2 39.4 vs 54.4%","year":2023,"settings":["on-call","hospital"],"keywords":["EVT","thrombectomy","successful reperfusion","blood pressure"],"question":"Did SBP <140 improve function after successful EVT?","population":"306 randomized patients with large-vessel ischemic stroke, mTICI ≥2b reperfusion and SBP ≥140 mmHg on two readings within 2 h of recanalization, at 19 South Korean centers; 305 were confirmed eligible.","comparison":"SBP <140 versus 140–180 mmHg for 24 hours after enrollment.","result":"Three-month independence (mRS 0–2) was 39.4% versus 54.4% (adjusted OR 0.56; 95% CI 0.33–0.96). Symptomatic ICH was 9.0% versus 8.1%; the difference was not significant. Stroke-related death was 7.7% versus 5.4%, also not significantly different.","limits":"Stopped early for safety concerns. The result concerns the tested lowering strategy after successful reperfusion; it does not establish a universal target for unsuccessful EVT or individualized reperfusion-guided management. At 1 year (Stroke 2026; 294 of 306 followed), mRS 0–2 was 40.5% with SBP <140 vs 52.7% with 140–180 (adjusted OR 0.59; 95% CI 0.34–1.00; P=.051; per-protocol 41.1 vs 54.7%, adjusted OR 0.56; 95% CI 0.32–0.97); 1-year mortality did not differ.","sources":[{"title":"OPTIMAL-BP primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37668619/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."},{"title":"OPTIMAL-BP 1-year outcomes","url":"https://pubmed.ncbi.nlm.nih.gov/42212393/","year":2026,"type":"Report","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; 1-year follow-up extension of the original randomized population (294 of 306 completed)."}],"relatedTopic":"acute-bp"},{"id":"hope-post-evt-bp","title":"HOPE (post-EVT BP) — reperfusion-guided blood pressure targets","headline":"Reperfusion-guided SBP: mRS 0–2 60.0 vs 47.1%","year":2026,"settings":["on-call","hospital"],"keywords":["blood pressure","post EVT","mTICI","reperfusion-guided"],"question":"Do reperfusion-guided SBP targets after successful EVT improve outcome?","population":"440 previously independent adults (prestroke mRS 0–2) with anterior-circulation LVO and mTICI ≥2b after EVT within 24 h at 11 Spanish centers (mean age 75); elevated SBP was not required.","comparison":"SBP 140–160 for mTICI 2b or 100–140 for 2c/3 for 72 hours, using antihypertensives or vasopressors as needed, versus guideline management (SBP <180).","result":"mRS 0–2 at 90 days occurred in 60.0% vs 47.1% (difference 13.3 points; 95% CI 4.1–22.6). Hemorrhagic transformation 22.3% vs 31.6%; symptomatic ICH 3.5% vs 3.9%; mortality 15.4% vs 15.6% (abstract figures).","limits":"Open-label, single-country, stopped early for lack of funding (446 of 786 planned; 440 analyzed). Only 9.8% had mTICI 2b, with no clear benefit in that subgroup. The authors call it hypothesis-generating. It postdates AHA/ASA 2026 (COR 3: Harm for SBP <140 after mTICI 2b–3) and does not change that guidance.","sources":[{"title":"HOPE (post-EVT BP) primary report","url":"https://pubmed.ncbi.nlm.nih.gov/42258192/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-17","access":"Primary abstract and PMC full text (PMC13247842) read."}],"relatedTopic":"acute-bp"},{"id":"interact4","title":"INTERACT4 — ambulance BP lowering in undifferentiated stroke","headline":"Prehospital SBP lowering: overall neutral; harm in ischemic stroke (cOR 1.30)","year":2024,"settings":["on-call","hospital"],"keywords":["prehospital","blood pressure","ambulance","undifferentiated stroke"],"question":"Does ambulance-delivered BP lowering improve outcome in suspected acute stroke?","population":"2,404 Chinese patients with a motor deficit and SBP ≥150 within 2 hours; 46.5% of confirmed strokes were hemorrhagic.","comparison":"Immediate lowering to SBP 130–140 versus usual care.","result":"No overall difference in 90-day mRS (cOR 1.00; 95% CI 0.87–1.15). Hemorrhagic stroke: cOR 0.75 (0.60–0.92); ischemic stroke: cOR 1.30 (1.06–1.60), i.e., worse outcome.","limits":"Subgroup effects by stroke type; a very high hemorrhage proportion limits transfer to other regions.","sources":[{"title":"INTERACT4 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/38752650/","year":2024,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"acute-bp"},{"id":"clots-3","title":"CLOTS 3 — intermittent pneumatic compression after stroke","headline":"IPC: proximal DVT 8.5 vs 12.1%","year":2013,"settings":["on-call","hospital"],"keywords":["DVT","VTE","IPC","immobility","compression"],"question":"Did intermittent pneumatic compression reduce proximal DVT?","population":"2,876 acute stroke patients unable to walk to the toilet without another person’s help, enrolled during admission days 0–3 at 94 UK centers.","comparison":"Intermittent pneumatic compression plus routine care versus no IPC.","result":"Proximal DVT, detected by screening ultrasound or symptomatic imaging within 30 days, occurred in 8.5% versus 12.1% (absolute reduction 3.6 percentage points; 95% CI 1.4–5.8). Skin breaks were more frequent with IPC: 3% versus 1%. The 30-day mortality difference was not statistically significant.","limits":"The endpoint includes asymptomatic DVT. This evaluates IPC rather than graduated compression stockings; device suitability and skin monitoring remain important.","sources":[{"title":"CLOTS 3 primary report","url":"https://pubmed.ncbi.nlm.nih.gov/23727163/","year":2013,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked. Two corrections are indexed (Lancet 2013;382:506 and 1020); their full bodies could not be retrieved, so correction scope is unresolved."}],"relatedTopic":"vte-prevention"},{"id":"food-feeding-route","title":"FOOD — PEG versus nasogastric feeding after stroke","headline":"PEG vs nasogastric: more death or poor outcome (+7.8 points)","year":2005,"settings":["hospital"],"keywords":["dysphagia","nutrition","enteral feeding","PEG","nasogastric"],"question":"Should PEG routinely replace nasogastric feeding early after stroke?","population":"321 dysphagic stroke patients in the feeding-route randomization at 47 hospitals in 11 countries.","comparison":"Percutaneous endoscopic gastrostomy (PEG) versus nasogastric feeding.","result":"At six months, PEG increased death or poor outcome by 7.8 percentage points (95% CI 0.0–15.5; P=0.05). The mortality difference alone was 1.0 percentage point higher with PEG (95% CI −10.0 to 11.9), without statistical significance.","limits":"The report contains a separate early-versus-delayed feeding trial; do not mix its population or outcomes with this route comparison. The results do not establish that later PEG for persistent dysphagia is never appropriate.","sources":[{"title":"FOOD primary report","url":"https://pubmed.ncbi.nlm.nih.gov/15733717/","year":2005,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"poststroke-dysphagia"},{"id":"shine","title":"SHINE — intensive glucose control in acute ischemic stroke","headline":"Intensive insulin: no benefit; severe hypoglycemia 2.6%","year":2019,"settings":["on-call","hospital"],"keywords":["glucose","hyperglycemia","insulin","hypoglycemia"],"question":"Did intensive insulin treatment improve 90-day function?","population":"1,151 adults with hyperglycemic ischemic stroke enrolled within 12 hours at 63 US sites.","comparison":"IV insulin targeting glucose 80–130 mg/dL versus subcutaneous sliding-scale insulin targeting 80–179 mg/dL for up to 72 hours.","result":"Severity-adjusted favorable 90-day mRS outcome occurred in 20.5% versus 21.6% (adjusted RR 0.97; 95% CI 0.87–1.08). Severe hypoglycemia occurred only with intensive treatment: 15 patients (2.6%).","limits":"Stopped for futility. The outcome threshold depended on baseline stroke severity. Failure of this intensive strategy does not support leaving marked hyperglycemia untreated or attributing QASC’s bundle benefit to tight glucose control.","sources":[{"title":"SHINE primary report","url":"https://pubmed.ncbi.nlm.nih.gov/31334795/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked. November 2019 correction body read; reversed figure-arm labels and demographic/minor text values were corrected. The card avoids the uncorrected demographic values still present in the indexed abstract."},{"title":"SHINE correction","url":"https://pubmed.ncbi.nlm.nih.gov/31688865/","year":2019,"type":"Report","checkedAt":"2026-10-01","access":"Full correction read: figure treatment labels, demographics, missing-data percentage, race/ethnicity values and investigator spelling corrected."}],"relatedTopic":"inpatient-medical-complications"},{"id":"qasc","title":"QASC — implementing fever, glucose and swallowing care","headline":"Nurse fever/glucose/swallow protocols: death or dependency 42 vs 58%","year":2011,"settings":["hospital"],"keywords":["nursing","stroke unit","dysphagia","fever","glucose","care bundle"],"question":"Did organized implementation improve stroke-unit outcomes?","population":"19 Australian stroke units, with 687 patients before and 1,009 after implementation; adults with ischemic stroke or ICH presenting within 48 hours.","comparison":"Nurse-initiated fever, glucose and swallowing protocols plus multidisciplinary implementation workshops versus abridged guideline provision; units were randomized.","result":"At 90 days, death or dependency (mRS ≥2) was 42% versus 58% in post-intervention cohorts (adjusted absolute difference 15.7 percentage points; 95% CI 5.8–25.4). Mortality alone did not differ significantly.","limits":"Cluster randomization and pre/post cohorts differ from individual patient randomization. This supports implementation of the package; it cannot isolate which component produced benefit or establish an intensive glucose target.","sources":[{"title":"QASC primary report","url":"https://pubmed.ncbi.nlm.nih.gov/21996470/","year":2011,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"stroke-unit-nursing"},{"id":"destiny-ii","title":"DESTINY II — hemicraniectomy in older patients","headline":"Hemicraniectomy 61–82 y: survival with mRS 0–4 38 vs 18%","year":2014,"settings":["on-call","hospital"],"keywords":["decompression","hemicraniectomy","malignant MCA","goals of care","disability"],"question":"What survival and disability tradeoff accompanied surgery after age 60?","population":"112 patients aged 61–82 with malignant middle-cerebral-artery infarction, randomized within 48 hours; median age 70.","comparison":"Hemicraniectomy versus conservative intensive-care treatment.","result":"At six months, survival with mRS 0–4 was 38% versus 18% (OR 2.91; 95% CI 1.06–7.49). Mortality was 33% versus 70%. No participant achieved mRS 0–2; most survivors needed help with bodily needs. Infections were more frequent after surgery.","limits":"The primary endpoint included mRS 4 and must not be described as functional independence. Discuss the full disability distribution and the person’s acceptable outcomes; age alone is not a complete selection rule.","sources":[{"title":"DESTINY II primary report","url":"https://pubmed.ncbi.nlm.nih.gov/24645942/","year":2014,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"malignant-edema"},{"id":"restart","title":"RESTART — antiplatelet therapy after antithrombotic-associated ICH","headline":"Antiplatelet restart after ICH: recurrent ICH 4 vs 9% (NS)","year":2019,"settings":["hospital","clinic"],"keywords":["ICH","antiplatelet","aspirin","recurrence","secondary prevention"],"question":"Did restarting antiplatelet therapy increase recurrent ICH?","population":"537 ICH survivors previously taking antithrombotic therapy for occlusive vascular disease; randomized a median of 76 days after ICH.","comparison":"Start versus avoid antiplatelet therapy.","result":"Over a median two years, recurrent symptomatic ICH occurred in 12/268 (4%) versus 23/268 (9%) (adjusted HR 0.51; 95% CI 0.25–1.03). Major hemorrhagic events were 7% versus 9%; major occlusive events were 15% versus 14%, without significant differences.","limits":"The confidence interval does not prove antiplatelets prevent recurrent ICH. This selected survivor cohort does not establish immediate restart timing, safety for every CAA phenotype, or anticoagulant resumption. The smaller STATICH-Antiplatelets trial (Stroke 2026; 69 ICH survivors with an antiplatelet indication; stopped early for slow recruitment) had numerically more recurrent ICH with antiplatelets (5/34 [15%] vs 1/35 [3%]) and fewer major ischemic events (3/34 [9%] vs 7/35 [20%]), with wide confidence intervals.","sources":[{"title":"RESTART primary report","url":"https://pubmed.ncbi.nlm.nih.gov/31128924/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."},{"title":"STATICH-Antiplatelets randomized trial","url":"https://pubmed.ncbi.nlm.nih.gov/42312355/","year":2026,"type":"Randomized trial","checkedAt":"2026-10-31","access":"PubMed abstract read 2026-10-31; full text not read. Stopped early for slow recruitment (69 of 500 planned)."}],"relatedTopic":"caa-ich-recurrence"},{"id":"earlydrain","title":"EARLYDRAIN — lumbar CSF drainage after secured aSAH","headline":"Lumbar drain after aSAH: mRS 3–6 32.6 vs 44.8%","year":2023,"settings":["on-call","hospital"],"keywords":["SAH","lumbar drain","CSF","delayed ischemia","infarction"],"question":"Did early lumbar drainage improve outcome after aneurysm treatment?","population":"287 analyzable adults with aneurysmal SAH across clinical grades; aneurysms were clipped or coiled within 48 hours.","comparison":"Additional lumbar drainage at 5 mL/hour, begun within 72 hours, versus standard care.","result":"Six-month mRS 3–6 occurred in 32.6% versus 44.8% (RR 0.73; 95% CI 0.52–0.98). Secondary infarction at discharge was 28.5% versus 39.9%. Drain complications included a pressure gradient stopping drainage, a local skin infection needing excision and a torn-off drain needing surgical removal.","limits":"Lumbar-drain contraindications included absent/compressed basal cisterns and therapeutic anticoagulation. Use the full neurosurgical drainage and pressure-monitoring protocol; this was not unrestricted drainage for every SAH presentation.","sources":[{"title":"EARLYDRAIN primary report","url":"https://pubmed.ncbi.nlm.nih.gov/37330974/","year":2023,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract, full-report eligibility and adverse-event passages read via NLM/Europe PMC. August 2023 correction body read: lumbar-drain mRS-5 figure count changed from 24 to 9. Supplementary protocol not comprehensively reviewed."},{"title":"EARLYDRAIN figure correction","url":"https://pubmed.ncbi.nlm.nih.gov/37578477/","year":2023,"type":"Report","checkedAt":"2026-10-01","access":"Full correction read: the lumbar-drain group’s six-month mRS-5 value in Figure 2 changed from 24 to 9."}],"relatedTopic":"sah-critical-care"},{"id":"sahara","title":"SAHaRA — liberal versus restrictive transfusion in aSAH","headline":"Liberal transfusion in aSAH: no benefit (33.5 vs 37.7%)","year":2025,"settings":["on-call","hospital"],"keywords":["SAH","anemia","hemoglobin","transfusion","red cells"],"question":"Did a more liberal transfusion threshold improve neurological outcome?","population":"742 critically ill adults with acute aneurysmal SAH and anemia at 23 centers; 725 contributed to the primary analysis.","comparison":"Mandatory red-cell transfusion at hemoglobin ≤10 g/dL versus optional transfusion at ≤8 g/dL.","result":"At 12 months, unfavorable outcome (mRS ≥4) occurred in 33.5% versus 37.7% (RR 0.88; 95% CI 0.72–1.09; P=0.22). Functional-independence and quality-of-life measures did not show significant differences; adverse-event incidence was similar.","limits":"No superiority was demonstrated; the confidence interval does not establish equivalence. The restrictive strategy allowed clinical discretion and must not be recast as mandatory transfusion at 8 g/dL or a universal rule for all acute brain injuries.","sources":[{"title":"SAHaRA primary report","url":"https://pubmed.ncbi.nlm.nih.gov/39655786/","year":2025,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"sah-critical-care"},{"id":"cadiss","title":"CADISS — antiplatelet versus anticoagulant treatment for dissection","headline":"Dissection: antiplatelet vs anticoagulant, few events (3 vs 1)","year":2015,"settings":["on-call","hospital","clinic"],"keywords":["cervical artery dissection","carotid","vertebral","antiplatelet","anticoagulation"],"question":"Did antithrombotic strategy alter early stroke recurrence?","population":"250 patients with symptomatic extracranial carotid or vertebral dissection within seven days; central imaging review did not confirm dissection in 52.","comparison":"Clinician-selected antiplatelet versus anticoagulant treatment for three months.","result":"Ipsilateral stroke or death occurred in 3/126 versus 1/124 patients (P=0.63); there were no deaths. One major bleed, a subarachnoid hemorrhage, occurred with anticoagulation.","limits":"Very few events and wide uncertainty prevent an equivalence conclusion. This extracranial-dissection study does not settle intracranial dissection management or which individual drug is best; consider it alongside TREAT-CAD.","sources":[{"title":"CADISS primary report","url":"https://pubmed.ncbi.nlm.nih.gov/25684164/","year":2015,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked. June 2015 correction is indexed; its publisher body was inaccessible and the scope remains unverified."},{"title":"CADISS indexed correction","url":"https://pubmed.ncbi.nlm.nih.gov/25987273/","year":2015,"type":"Report","checkedAt":"2026-10-01","access":"Correction identity and link verified in NLM; publisher body inaccessible and correction scope not determined."}],"relatedTopic":"dissection"},{"id":"respect","title":"RESPECT — PFO closure, extended follow-up","headline":"PFO closure: recurrent stroke HR 0.55 over 5.9 years","year":2017,"settings":["hospital","clinic"],"keywords":["PFO","closure","cryptogenic stroke"],"question":"Does PFO closure reduce recurrent stroke after cryptogenic stroke over long-term follow-up?","population":"980 patients aged 18–60 with PFO and cryptogenic ischemic stroke (mean age 45.9), followed a median 5.9 years.","comparison":"PFO closure versus medical therapy (antiplatelet or warfarin).","result":"Recurrent ischemic stroke 0.58 vs 1.07 per 100 patient-years (HR 0.55; 95% CI 0.31–0.999); stroke of undetermined cause HR 0.38 (0.18–0.79). Venous thromboembolism was more common with closure.","limits":"Extended follow-up analysis was exploratory; unequal dropout between groups.","sources":[{"title":"RESPECT extended follow-up primary report","url":"https://pubmed.ncbi.nlm.nih.gov/28902590/","year":2017,"type":"Randomized trial","checkedAt":"2026-10-21","access":"Primary abstract verified via PubMed."}],"relatedTopic":"pfo"},{"id":"to-act","title":"TO-ACT — endovascular treatment for severe CVT","headline":"Severe CVT EVT: no benefit (mRS 0–1 67 vs 68%)","year":2020,"settings":["on-call","hospital"],"keywords":["cerebral venous thrombosis","EVT","thrombectomy","intrasinus thrombolysis"],"question":"Did adding EVT improve outcome in severe CVT?","population":"67 adults with CVT and at least one poor-outcome risk feature: mental-status change, coma, ICH or deep cerebral venous thrombosis.","comparison":"Mechanical thrombectomy and/or local thrombolysis plus medical care versus medical care alone; EVT within 24 hours of randomization.","result":"At 12 months, mRS 0–1 occurred in 67% versus 68% (RR 0.99; 95% CI 0.71–1.38). Mortality was 12% versus 3% and symptomatic ICH 3% versus 9%; neither difference was significant.","limits":"Stopped early for futility and too small to exclude important benefit or harm. Mixed endovascular techniques and selected severe CVT limit extrapolation; the trial does not establish routine EVT or resolve every rescue situation.","sources":[{"title":"TO-ACT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/32421159/","year":2020,"type":"Randomized trial","checkedAt":"2026-10-01","access":"Primary abstract and indexed notices checked."}],"relatedTopic":"cvt"},{"id":"respect-cvt","title":"RE-SPECT CVT — dabigatran versus warfarin for cerebral venous thrombosis","headline":"CVT: no recurrent VTE; major bleeding 1.7 vs 3.3%","year":2019,"settings":["hospital","clinic"],"keywords":["CVT","dabigatran","DOAC","warfarin","anticoagulation"],"question":"Is dabigatran as safe and effective as warfarin after CVT?","population":"120 adults with acute CVT, stable after 5–15 days of parenteral heparin; ICH from the CVT was allowed.","comparison":"Dabigatran 150 mg twice daily versus dose-adjusted warfarin for 24 weeks.","result":"No recurrent venous thromboembolism in either group. Major bleeding 1.7% (1, intestinal) vs 3.3% (2, intracranial); recanalization 60.0% vs 67.3%.","limits":"Small exploratory open-label trial with blinded adjudication.","sources":[{"title":"RE-SPECT CVT primary report","url":"https://pubmed.ncbi.nlm.nih.gov/31479105/","year":2019,"type":"Randomized trial","checkedAt":"2026-10-03","access":"Primary abstract verified via PubMed."}],"relatedTopic":"cvt"}],"calculators":[{"id":"abcd2","name":"ABCD²","category":"TIA & secondary prevention","fn":"calculateReviewedABCD2","module":"supplementary-calculators","route":"#/tools/abcd2","sourceEndpoint":"data/sources.json","sourceIds":["abcd2-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/17258668/","sourceLabel":"Johnston et al., Lancet 2007","limits":"For a clinically diagnosed TIA. Use the first recorded BP after the TIA, with the event symptoms and duration. Later treatment BP is separate. The score does not diagnose TIA or determine disposition.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"ABCD2 TIA","fields":[{"key":"tiaConfirmed","label":"Clinical TIA diagnosis confirmed","type":"truth"},{"key":"initialSystolic","label":"First BP after TIA: systolic (mmHg)","type":"number","min":1,"max":400},{"key":"initialDiastolic","label":"First BP after TIA: diastolic (mmHg)","type":"number","min":1,"max":300},{"key":"clinicalFeatures","label":"TIA clinical features","type":"select","options":[["weakness","Unilateral weakness (2)"],["speech","Speech disturbance without weakness (1)"],["other","Neither feature (0)"]]},{"key":"duration","label":"TIA symptom duration","type":"select","options":[["under10","Less than 10 min (0)"],["10to59","10–59 min (1)"],["60plus","At least 60 min (2)"]]},{"key":"diabetes","label":"History of diabetes","type":"truth"}],"reviewedAt":"2026-10-01","reviewScope":"Point assignments and score completeness only; no absolute risk, outcome prediction or treatment-selection review.","shared":["age"],"verificationUrl":"https://www.ahajournals.org/doi/10.1161/STROKEAHA.109.571844"},{"id":"chadsvasc","name":"CHA₂DS₂-VASc","category":"TIA & secondary prevention","fn":"calculateReviewedCHADS2VASc","module":"supplementary-calculators","route":"#/tools/chadsvasc","sourceEndpoint":"data/sources.json","sourceIds":["chadsvasc-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/19762550/","sourceLabel":"Lip et al., Chest 2010","limits":"For nonvalvular atrial fibrillation. Sex category follows the original instrument; no annual risk estimate or anticoagulant choice is generated. The 2023 ACC/AHA/ACCP/HRS AF guideline names CHA₂DS₂-VASc as a validated score; the 2024 ESC AF guideline uses CHA₂DS₂-VA, which omits the sex category and is not calculated here.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"CHA2DS2VASc CHADS VASC atrial fibrillation AF stroke risk","fields":[{"key":"afConfirmed","label":"Nonvalvular atrial fibrillation confirmed","type":"truth"},{"key":"chf","label":"Heart failure / LV dysfunction","type":"truth"},{"key":"hypertension","label":"History of hypertension","type":"truth"},{"key":"diabetes","label":"History of diabetes","type":"truth"},{"key":"strokeTia","label":"History of stroke / TIA / systemic thromboembolism","type":"truth"},{"key":"vascular","label":"Vascular disease: prior MI, peripheral arterial disease or aortic plaque","type":"truth"}],"reviewedAt":"2026-10-21","reviewScope":"Point assignments and score completeness only. Components and doubled age ≥75 and stroke/TIA weights rechecked on 2026-10-21 against the 2023 ACC/AHA/ACCP/HRS AF guideline (full text); the ESC 2024 change is from a secondary full-text report. No absolute risk, outcome prediction or treatment-selection review.","shared":["age","sex"],"verificationUrl":"https://academic.oup.com/europace/article/12/9/1349/530959"},{"id":"has-bled","name":"HAS-BLED","category":"TIA & secondary prevention","fn":"calculateReviewedHASBLED","module":"supplementary-calculators","route":"#/tools/has-bled","sourceEndpoint":"data/sources.json","sourceIds":["has-bled-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/20299623/","sourceLabel":"Pisters et al., Chest 2010","limits":"Original AF bleeding instrument. Review its definitions, including renal/liver impairment and labile INR. A score does not justify withholding anticoagulation; no bleeding probability is generated.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"HASBLED bleeding risk atrial fibrillation AF","fields":[{"key":"afConfirmed","label":"Atrial fibrillation confirmed","type":"truth"},{"key":"uncontrolledHypertension","label":"Uncontrolled hypertension: systolic BP over 160 mmHg","type":"truth"},{"key":"renal","label":"Renal: dialysis, kidney transplant, or creatinine ≥200 µmol/L (about 2.26 mg/dL)","type":"truth"},{"key":"liver","label":"Liver: chronic hepatic disease (e.g. cirrhosis), or bilirubin >2× ULN with AST/ALT/ALP >3× ULN","type":"truth"},{"key":"stroke","label":"History of stroke","type":"truth"},{"key":"bleeding","label":"Bleeding history or predisposition (including anemia)","type":"truth"},{"key":"labileINR","label":"Labile INR / time in therapeutic range below 60%","type":"truth"},{"key":"drugs","label":"Concomitant antiplatelet or NSAID use","type":"truth"},{"key":"alcohol","label":"Excess alcohol: ≥8 drinks/week","type":"truth"}],"reviewedAt":"2026-10-01","reviewScope":"Input definitions and points checked in Methods/Table 2; no absolute bleeding risk or treatment recommendation.","shared":["age"],"verificationUrl":"https://www.acforum-excellence.org/sites/default/files/Pisters.HAS-BLED.pdf"},{"id":"rope","name":"RoPE","category":"PFO assessment","fn":"calculateReviewedRoPE","module":"supplementary-calculators","route":"#/tools/rope","sourceEndpoint":"data/sources.json","sourceIds":["rope-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/23864310/","sourceLabel":"Kent et al., Neurology 2013","limits":"For otherwise cryptogenic ischemic stroke with PFO, not undifferentiated symptoms or TIA. The score does not establish causality or recommend closure.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"risk of paradoxical embolism PFO patent foramen ovale","fields":[{"key":"cryptogenicStrokeWithPfo","label":"Otherwise cryptogenic ischemic stroke with PFO confirmed","type":"truth"},{"key":"hypertension","label":"History of hypertension","type":"truth"},{"key":"diabetes","label":"History of diabetes","type":"truth"},{"key":"priorStrokeTia","label":"Prior stroke / TIA","type":"truth"},{"key":"smoker","label":"Smoker","type":"truth"},{"key":"corticalInfarct","label":"Cortical infarct on imaging","type":"truth"}],"reviewedAt":"2026-10-01","reviewScope":"Point assignments and score completeness only; no absolute risk, outcome prediction or treatment-selection review.","shared":["age"],"verificationUrl":"https://www.ncbi.nlm.nih.gov/books/NBK592989/table/tbl001/"},{"id":"pascal","name":"PASCAL","category":"PFO assessment","fn":"classifyReviewedPASCAL","module":"supplementary-calculators","route":"#/tools/pascal","sourceEndpoint":"data/sources.json","sourceIds":["pascal-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/34905030/","sourceLabel":"Kent et al., JAMA 2021 / SCOPE study","limits":"Simplified three-category classification for the source population aged 18–60 with otherwise cryptogenic stroke and PFO. Shunt/ASA definitions require specialist review; category does not establish individual causality or closure benefit. In pooled trial data, closure reduced stroke in possible/probable but not unlikely categories; AF after day 45 rose with closure in unlikely (+4.4%) and possible (+1.5%).","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"PFO patent foramen ovale associated stroke causal likelihood","fields":[{"key":"largeShunt","label":"Large shunt under source definition (over 20 LA bubbles on TEE)","type":"truth"},{"key":"atrialSeptalAneurysm","label":"Atrial septal aneurysm under source definition (excursion at least 10 mm)","type":"truth"}],"reviewedAt":"2026-10-01","reviewScope":"Point assignments and score completeness only; no absolute risk, outcome prediction or treatment-selection review.","shared":["age"],"verificationUrl":"https://www.ncbi.nlm.nih.gov/books/NBK592989/table/tbl001/"},{"id":"phases","name":"PHASES","category":"Aneurysm & SAH","fn":"calculateReviewedPHASES","module":"supplementary-calculators","route":"#/tools/phases","sourceEndpoint":"data/sources.json","sourceIds":["phases-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/24290159/","sourceLabel":"Greving et al., Lancet Neurology 2014","limits":"For an unruptured saccular intracranial aneurysm. Geographic groups follow the original cohorts and must be explicitly selected. Score only; no rupture probability or management recommendation.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"aneurysm unruptured intracranial rupture","fields":[{"key":"unrupturedSaccular","label":"Unruptured saccular intracranial aneurysm confirmed","type":"truth"},{"key":"population","label":"PHASES source population","type":"select","options":[["northAmericaEurope","North America / Europe other than Finland (0)"],["japanese","Japanese (3)"],["finnish","Finnish (5)"]]},{"key":"hypertension","label":"Hypertension under PHASES source definition","type":"truth"},{"key":"sizeMm","label":"Maximum aneurysm diameter (mm)","type":"number","min":0,"step":"any"},{"key":"earlierSAH","label":"Earlier SAH from another aneurysm","type":"truth"},{"key":"site","label":"Aneurysm site","type":"select","options":[["ica","ICA (0)"],["mca","MCA (2)"],["acaPcommPosterior","ACA / PCom / posterior circulation (4)"]]}],"reviewedAt":"2026-10-01","reviewScope":"Point assignments and score completeness only; no absolute risk, outcome prediction or treatment-selection review.","shared":["age"],"verificationUrl":"https://square.umin.ac.jp/~ucas-j/data/2014_TLN_PHASES%20score.pdf"},{"id":"mrs-descriptors","name":"Modified Rankin scale descriptors","category":"Disability & grading","fn":"describeReviewedMRS","module":"supplementary-calculators","route":"#/tools/mrs-descriptors","sourceEndpoint":"data/sources.json","sourceIds":["mrs-descriptors-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/3363593/","sourceLabel":"van Swieten et al., Stroke 1988","limits":"Describes the existing baseline mRS entry; does not assign a grade from an interview or forecast recovery. Original descriptor wording retained in paraphrase; primary full-text review remains limited. Grade 6 (death) is the outcome-reporting convention added to the original 0–5 scale.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"mRS modified Rankin scale disability","fields":[],"shared":["mrs"],"reviewedAt":null,"reviewScope":"Existing descriptor aid retained; no new questionnaire or prognostic validation."},{"id":"hunt-hess","name":"Hunt–Hess grade","category":"Aneurysm & SAH","fn":"describeReviewedHuntHess","module":"supplementary-calculators","route":"#/tools/hunt-hess","sourceEndpoint":"data/sources.json","sourceIds":["hunt-hess-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/5635959/","sourceLabel":"Hunt and Hess, J Neurosurg 1968","limits":"Clinician-assigned SAH grade. Descriptions are an aid, not an examination or individualized prognosis; clinical confounders require review.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"Hunt Hess subarachnoid hemorrhage SAH","fields":[{"key":"sahConfirmed","label":"Subarachnoid hemorrhage confirmed","type":"truth"},{"key":"grade","label":"Clinician-assigned Hunt–Hess grade","type":"select","options":[["1","1: Asymptomatic or mild headache with slight neck stiffness."],["2","2: Moderate to severe headache and neck stiffness; no neurologic deficit except a cranial nerve palsy."],["3","3: Drowsiness, confusion or a mild focal neurologic deficit."],["4","4: Stupor with moderate to severe weakness; early decerebrate posturing may be present."],["5","5: Deep coma with decerebrate posturing."]]}],"reviewedAt":"2026-10-01","reviewScope":"Grade descriptors checked against the Joint Commission data-element definition; original paper full text was unavailable.","verificationUrl":"https://manual.jointcommission.org/bin/view/releases/TJC2024A1/DataElem0555.html"},{"id":"wfns","name":"WFNS grade","category":"Aneurysm & SAH","fn":"calculateReviewedWFNS","module":"supplementary-calculators","route":"#/tools/wfns","sourceEndpoint":"data/sources.json","sourceIds":["wfns-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/3131498/","sourceLabel":"WFNS Committee, J Neurosurg 1988","limits":"SAH grade from complete Encounter GCS and reviewed motor deficit. The original table leaves GCS 15 with motor deficit unclassified here. No mortality or recovery prediction.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"World Federation of Neurosurgical Societies subarachnoid hemorrhage SAH","fields":[{"key":"sahConfirmed","label":"Subarachnoid hemorrhage confirmed","type":"truth"},{"key":"motorDeficit","label":"Motor deficit present","type":"truth"}],"shared":["gcs"],"reviewedAt":"2026-10-01","reviewScope":"Grade bands cross-checked in a primary 2008 validation study; original committee full text was unavailable.","verificationUrl":"https://doi.org/10.1161/STROKEAHA.107.498345"},{"id":"modified-fisher","name":"Modified Fisher grade","category":"Aneurysm & SAH","fn":"calculateReviewedModifiedFisher","module":"supplementary-calculators","route":"#/tools/modified-fisher","sourceEndpoint":"data/sources.json","sourceIds":["modified-fisher-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/16823296/","sourceLabel":"Frontera et al., Neurosurgery 2006, Table 1","limits":"For aneurysmal SAH: select SAH and its aneurysmal cause in Encounter. Grade the admission CT using clinician-reviewed blood thickness and IVH. No numerical thickness cutoff, vasospasm probability or prognosis is assigned.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"modified Fisher CT blood subarachnoid hemorrhage SAH IVH","fields":[{"key":"bloodThickness","label":"Admission CT subarachnoid blood","type":"select","options":[["absent","No visible subarachnoid blood"],["thin","Thin blood"],["thick","Thick blood"]]},{"key":"ivh","label":"Admission CT intraventricular blood present","type":"truth"}],"shared":["sahCause"],"reviewedAt":"2026-10-01","reviewScope":"Original report Table 1 and grading methods checked in an accessible primary-paper copy; grade mapping only.","verificationUrl":"https://cmp-manual.wbs.cz/skaly/prediction_of_symptomatic_vasospasm_after_subarachnoid_hemorrhage_-_the_modified_fisher_scale.pdf"},{"id":"mtici","name":"mTICI reperfusion grade","category":"Imaging","fn":"describeReviewedMTICI","module":"supplementary-calculators","route":"#/tools/mtici","sourceEndpoint":"data/sources.json","sourceIds":["mtici-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/23390038/","sourceLabel":"Goyal et al., J Neurointerv Surg 2014, Table 3","limits":"Describes the recorded mTICI grade in an acute ischemic Encounter. Uses the revision including 2c; this is not eTICI. Confirm the angiographic report and grading system. No grade is inferred from imaging text or used to predict recovery.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"TICI reperfusion thrombectomy angiography","fields":[],"shared":["mtici"],"reviewedAt":"2026-10-01","reviewScope":"Descriptors checked against the indexed primary manuscript and revised grading table; no outcome or procedural recommendation review.","verificationUrl":"https://pmc.ncbi.nlm.nih.gov/articles/PMC4156591/"},{"id":"nascet","name":"NASCET carotid stenosis","category":"Imaging","fn":"calculateReviewedNASCET","module":"supplementary-calculators","route":"#/tools/nascet","sourceEndpoint":"data/sources.json","sourceIds":["nascet-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/16418349/","sourceLabel":"Bartlett et al., AJNR 2006; NASCET measurement method","limits":"Patent extracranial ICA only. Use minimum residual lumen and normal distal ICA diameters from the same side, measured perpendicular to the vessel; the distal reference must be beyond bulb tapering. Excludes occlusion and suspected near-occlusion. Formula: 100 × (1 − minimum/distal). Rounded to 0.1%; values above 99.9% remain below complete occlusion. No revascularization recommendation.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"carotid stenosis ICA diameter","fields":[{"key":"side","label":"Measured ICA side","type":"select","options":[["left","Left"],["right","Right"]]},{"key":"minimumDiameterMm","label":"Minimum residual lumen diameter (mm)","type":"number","min":0,"step":"any"},{"key":"distalDiameterMm","label":"Normal distal ICA diameter (mm)","type":"number","min":0,"step":"any"},{"key":"patentExtracranialICA","label":"Patent extracranial ICA and suitable distal reference confirmed","type":"truth"},{"key":"nearOcclusion","label":"Near-occlusion suspected or present","type":"truth"}],"reviewedAt":"2026-10-01","reviewScope":"Primary methods checked for the diameter ratio, distal reference and near-occlusion exclusion; measurement arithmetic only.","verificationUrl":"https://pmc.ncbi.nlm.nih.gov/articles/PMC7976065/"},{"id":"aspects-regions","name":"ASPECTS regional worksheet","category":"Imaging","fn":"calculateReviewedRegionalASPECTS","module":"supplementary-calculators","route":"#/tools/aspects-regions","sourceEndpoint":"data/sources.json","sourceIds":["aspects-regions-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/10905241/","sourceLabel":"Barber et al., Lancet 2000","limits":"One MCA hemisphere on source-appropriate imaging. All ten regions require explicit review. Worksheet arithmetic is separate from image interpretation and EVT eligibility.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"Alberta stroke program early CT score anterior","fields":[{"key":"hemisphere","label":"ASPECTS hemisphere","type":"select","options":[["left","Left"],["right","Right"]]}],"reviewedAt":"2026-10-01","reviewScope":"Ten regions and subtraction cross-checked against the original ASPECTS investigators’ 2001 methods report; no image interpretation or treatment-threshold review.","verificationUrl":"https://pmc.ncbi.nlm.nih.gov/articles/PMC7974585/","regions":[{"key":"C","label":"Caudate","weight":1},{"key":"L","label":"Lentiform nucleus","weight":1},{"key":"IC","label":"Internal capsule","weight":1},{"key":"I","label":"Insular ribbon","weight":1},{"key":"M1","label":"M1","weight":1},{"key":"M2","label":"M2","weight":1},{"key":"M3","label":"M3","weight":1},{"key":"M4","label":"M4","weight":1},{"key":"M5","label":"M5","weight":1},{"key":"M6","label":"M6","weight":1}]},{"id":"pc-aspects-regions","name":"pc-ASPECTS regional worksheet","category":"Imaging","fn":"calculateReviewedRegionalPCASPECTS","module":"supplementary-calculators","route":"#/tools/pc-aspects-regions","sourceEndpoint":"data/sources.json","sourceIds":["pc-aspects-regions-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/18617663/","sourceLabel":"Puetz et al., Stroke 2008","limits":"Original posterior-circulation CT/CTA-source-image instrument. All eight regions require explicit review; pons and midbrain each subtract two points. No universal treatment cutoff or prognosis.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"posterior circulation ASPECTS basilar vertebrobasilar","fields":[],"reviewedAt":"2026-10-01","reviewScope":"Point assignments and score completeness only; no absolute risk, outcome prediction or treatment-selection review.","regions":[{"key":"pons","label":"Pons","weight":2},{"key":"midbrain","label":"Midbrain","weight":2},{"key":"cerebellumLeft","label":"Left cerebellum","weight":1},{"key":"cerebellumRight","label":"Right cerebellum","weight":1},{"key":"pcaLeft","label":"Left PCA territory","weight":1},{"key":"pcaRight","label":"Right PCA territory","weight":1},{"key":"thalamusLeft","label":"Left thalamus","weight":1},{"key":"thalamusRight","label":"Right thalamus","weight":1}]},{"id":"phq2","name":"PHQ-2","category":"Follow-up screening","fn":"calculateReviewedPHQ2","module":"supplementary-calculators","route":"#/tools/phq2","sourceEndpoint":"data/sources.json","sourceIds":["phq2-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/14583691/","sourceLabel":"Kroenke et al., Medical Care 2003","limits":"Two-week symptom-frequency screening, not a depression diagnosis. Both responses must be entered; no management plan is generated. The source identified a score of 3 or more as the optimal screening cutpoint for major depression (sensitivity 83%, specificity 92%) in primary care and obstetrics-gynecology clinics, not a stroke population.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"PHQ2 patient health questionnaire depression","fields":[{"key":"phq2_q1","label":"Over the last 2 weeks: little interest or pleasure in doing things","type":"select","options":[["0","Not at all (0)"],["1","Several days (1)"],["2","More than half the days (2)"],["3","Nearly every day (3)"]]},{"key":"phq2_q2","label":"Over the last 2 weeks: feeling down, depressed or hopeless","type":"select","options":[["0","Not at all (0)"],["1","Several days (1)"],["2","More than half the days (2)"],["3","Nearly every day (3)"]]}],"reviewedAt":"2026-10-21","reviewScope":"Item scoring (0–3 each, total 0–6) and the 3-point cutpoint rechecked against the primary abstract on 2026-10-21. No diagnostic, management or post-stroke validation review.","verificationUrl":"https://www.ihs.gov/sites/crs/themes/responsive2017/display_objects/documents/phq_2_medical_care.pdf"},{"id":"stop-bang","name":"STOP-BANG","category":"Follow-up screening","fn":"calculateReviewedSTOPBANG","module":"supplementary-calculators","route":"#/tools/stop-bang","sourceEndpoint":"data/sources.json","sourceIds":["stop-bang-instrument"],"sourceUrl":"https://pubmed.ncbi.nlm.nih.gov/18431116/","sourceLabel":"Chung et al., Anesthesiology 2008","limits":"Original eight-item sleep-apnea screening instrument, initially studied in surgical patients. Age, sex and BMI use Encounter values. Screening score only; no diagnosis, severity prediction or management plan.","scope":"Reviewed instrument score or grade only; no treatment selection or individualized prognosis","aliases":"STOPBANG sleep apnea OSA","fields":[{"key":"sb_snoring","label":"Loud snoring","type":"truth"},{"key":"sb_tired","label":"Frequent daytime tiredness / sleepiness","type":"truth"},{"key":"sb_observed","label":"Observed stopping breathing during sleep","type":"truth"},{"key":"sb_pressure","label":"High blood pressure or treatment for hypertension","type":"truth"},{"key":"neckCm","label":"Measured neck circumference (cm)","type":"number","min":10,"max":100,"step":"any"}],"reviewedAt":"2026-10-01","reviewScope":"Point assignments and score completeness only; no absolute risk, outcome prediction or treatment-selection review.","shared":["age","sex","weight","height"],"verificationUrl":"https://journal.chestnet.org/article/S0012-3692(15)00018-5/fulltext"}]}} diff --git a/data/generic-protocols.json b/data/generic-protocols.json index 2ad3c548..638ba1f1 100644 --- a/data/generic-protocols.json +++ b/data/generic-protocols.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "generic-protocols", "schemaVersion": "2.0.0", - 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"appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-adult-moyamoya-disease-2023.json b/data/guidelines/aha-adult-moyamoya-disease-2023.json index fcb30b5e..c7ff0565 100644 --- a/data/guidelines/aha-adult-moyamoya-disease-2023.json +++ b/data/guidelines/aha-adult-moyamoya-disease-2023.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-adult-moyamoya-disease-2023.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-af-guideline-2023.json b/data/guidelines/aha-af-guideline-2023.json index 3764a625..c58c03a4 100644 --- a/data/guidelines/aha-af-guideline-2023.json +++ b/data/guidelines/aha-af-guideline-2023.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-af-guideline-2023.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-aggressive-ldl-lowering-2023.json b/data/guidelines/aha-aggressive-ldl-lowering-2023.json index 133c2115..a79ad1c0 100644 --- a/data/guidelines/aha-aggressive-ldl-lowering-2023.json +++ b/data/guidelines/aha-aggressive-ldl-lowering-2023.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-aggressive-ldl-lowering-2023.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-antiamyloid-immunotherapy-2024.json b/data/guidelines/aha-antiamyloid-immunotherapy-2024.json index 65bbbb53..dc3b1028 100644 --- a/data/guidelines/aha-antiamyloid-immunotherapy-2024.json +++ b/data/guidelines/aha-antiamyloid-immunotherapy-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-antiamyloid-immunotherapy-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-atrial-fibrillation-occurring-2023.json b/data/guidelines/aha-atrial-fibrillation-occurring-2023.json index e0b14a1b..f9d40b83 100644 --- a/data/guidelines/aha-atrial-fibrillation-occurring-2023.json +++ b/data/guidelines/aha-atrial-fibrillation-occurring-2023.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-atrial-fibrillation-occurring-2023.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-brain-health-life-span-2026.json b/data/guidelines/aha-brain-health-life-span-2026.json index ca3112ff..a64c4e36 100644 --- a/data/guidelines/aha-brain-health-life-span-2026.json +++ b/data/guidelines/aha-brain-health-life-span-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-brain-health-life-span-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-cadasil-2023.json b/data/guidelines/aha-cadasil-2023.json index 0f050f3c..cacda2fb 100644 --- a/data/guidelines/aha-cadasil-2023.json +++ b/data/guidelines/aha-cadasil-2023.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-cadasil-2023.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-care-ais-evt-icu-2021.json b/data/guidelines/aha-care-ais-evt-icu-2021.json index 96d84e65..e47ad385 100644 --- a/data/guidelines/aha-care-ais-evt-icu-2021.json +++ b/data/guidelines/aha-care-ais-evt-icu-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-care-ais-evt-icu-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-care-ais-posthyperacute-2021.json b/data/guidelines/aha-care-ais-posthyperacute-2021.json index cf6738db..13a04013 100644 --- a/data/guidelines/aha-care-ais-posthyperacute-2021.json +++ b/data/guidelines/aha-care-ais-posthyperacute-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-care-ais-posthyperacute-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-care-ais-prehospital-2021.json b/data/guidelines/aha-care-ais-prehospital-2021.json index 3a01f081..44b0bda5 100644 --- a/data/guidelines/aha-care-ais-prehospital-2021.json +++ b/data/guidelines/aha-care-ais-prehospital-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-care-ais-prehospital-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-cervical-artery-dissection-2024.json b/data/guidelines/aha-cervical-artery-dissection-2024.json index 31938b46..2feba98c 100644 --- a/data/guidelines/aha-cervical-artery-dissection-2024.json +++ b/data/guidelines/aha-cervical-artery-dissection-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-cervical-artery-dissection-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-clinical-performance-measures-2021.json b/data/guidelines/aha-clinical-performance-measures-2021.json index 37a7216c..fb75fa56 100644 --- a/data/guidelines/aha-clinical-performance-measures-2021.json +++ b/data/guidelines/aha-clinical-performance-measures-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-clinical-performance-measures-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-crao-2021.json b/data/guidelines/aha-crao-2021.json index d319d820..902a0a77 100644 --- a/data/guidelines/aha-crao-2021.json +++ b/data/guidelines/aha-crao-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-crao-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-creating-virtual-networks-2025.json b/data/guidelines/aha-creating-virtual-networks-2025.json index 35c942d8..be0dfe02 100644 --- a/data/guidelines/aha-creating-virtual-networks-2025.json +++ b/data/guidelines/aha-creating-virtual-networks-2025.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-creating-virtual-networks-2025.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-dyslipidemia-2026.json b/data/guidelines/aha-dyslipidemia-2026.json index 9b315677..52da226e 100644 --- a/data/guidelines/aha-dyslipidemia-2026.json +++ b/data/guidelines/aha-dyslipidemia-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-dyslipidemia-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-hypertension-guideline-2025.json b/data/guidelines/aha-hypertension-guideline-2025.json index 848602aa..f7cc37ed 100644 --- a/data/guidelines/aha-hypertension-guideline-2025.json +++ b/data/guidelines/aha-hypertension-guideline-2025.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-hypertension-guideline-2025.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-ich-performance-measures-2024.json b/data/guidelines/aha-ich-performance-measures-2024.json index 55873dd6..9f3827b6 100644 --- a/data/guidelines/aha-ich-performance-measures-2024.json +++ b/data/guidelines/aha-ich-performance-measures-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-ich-performance-measures-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-ideal-foundational-requirements-2023.json b/data/guidelines/aha-ideal-foundational-requirements-2023.json index 3464374c..fabfe093 100644 --- a/data/guidelines/aha-ideal-foundational-requirements-2023.json +++ b/data/guidelines/aha-ideal-foundational-requirements-2023.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-ideal-foundational-requirements-2023.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-impact-sleep-disorders-2024.json b/data/guidelines/aha-impact-sleep-disorders-2024.json index e72c1a26..dae2bd49 100644 --- a/data/guidelines/aha-impact-sleep-disorders-2024.json +++ b/data/guidelines/aha-impact-sleep-disorders-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-impact-sleep-disorders-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-improving-access-rehabilitation-2025.json b/data/guidelines/aha-improving-access-rehabilitation-2025.json index 01d1046a..be08a3f4 100644 --- a/data/guidelines/aha-improving-access-rehabilitation-2025.json +++ b/data/guidelines/aha-improving-access-rehabilitation-2025.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-improving-access-rehabilitation-2025.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-in-hospital-stroke-2022.json b/data/guidelines/aha-in-hospital-stroke-2022.json index 66b9e352..b838cd7d 100644 --- a/data/guidelines/aha-in-hospital-stroke-2022.json +++ b/data/guidelines/aha-in-hospital-stroke-2022.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-in-hospital-stroke-2022.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-lv-systolic-dysfunction-2026.json b/data/guidelines/aha-lv-systolic-dysfunction-2026.json index f3c99c73..d4fae48f 100644 --- a/data/guidelines/aha-lv-systolic-dysfunction-2026.json +++ b/data/guidelines/aha-lv-systolic-dysfunction-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-lv-systolic-dysfunction-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-lv-thrombus-2022.json b/data/guidelines/aha-lv-thrombus-2022.json index f7267eda..9b845a9a 100644 --- a/data/guidelines/aha-lv-thrombus-2022.json +++ b/data/guidelines/aha-lv-thrombus-2022.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-lv-thrombus-2022.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-mis-ich-evacuation-2026.json b/data/guidelines/aha-mis-ich-evacuation-2026.json index ddbf9c38..3a56b26e 100644 --- a/data/guidelines/aha-mis-ich-evacuation-2026.json +++ b/data/guidelines/aha-mis-ich-evacuation-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-mis-ich-evacuation-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-nursing-role-psychosocial-2024.json b/data/guidelines/aha-nursing-role-psychosocial-2024.json index 842713fb..995e2134 100644 --- a/data/guidelines/aha-nursing-role-psychosocial-2024.json +++ b/data/guidelines/aha-nursing-role-psychosocial-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-nursing-role-psychosocial-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-palliative-end-life-2024.json b/data/guidelines/aha-palliative-end-life-2024.json index 5f2ac9cb..74dc59b5 100644 --- a/data/guidelines/aha-palliative-end-life-2024.json +++ b/data/guidelines/aha-palliative-end-life-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-palliative-end-life-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-primary-agenda-brain-2021.json b/data/guidelines/aha-primary-agenda-brain-2021.json index a0c0293b..efdad7b4 100644 --- a/data/guidelines/aha-primary-agenda-brain-2021.json +++ b/data/guidelines/aha-primary-agenda-brain-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-primary-agenda-brain-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-recommendations-regional-destination-2021.json b/data/guidelines/aha-recommendations-regional-destination-2021.json index f03b146c..ce4238ae 100644 --- a/data/guidelines/aha-recommendations-regional-destination-2021.json +++ b/data/guidelines/aha-recommendations-regional-destination-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-recommendations-regional-destination-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-rural-stroke-care-2024.json b/data/guidelines/aha-rural-stroke-care-2024.json index 6833e4ce..491c2c3d 100644 --- a/data/guidelines/aha-rural-stroke-care-2024.json +++ b/data/guidelines/aha-rural-stroke-care-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-rural-stroke-care-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-sex-gender-evt-2022.json b/data/guidelines/aha-sex-gender-evt-2022.json index 0f68517b..2a3cc99c 100644 --- a/data/guidelines/aha-sex-gender-evt-2022.json +++ b/data/guidelines/aha-sex-gender-evt-2022.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-sex-gender-evt-2022.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-social-environmental-determinants-2026.json b/data/guidelines/aha-social-environmental-determinants-2026.json index ea4acb49..acd9ca7b 100644 --- a/data/guidelines/aha-social-environmental-determinants-2026.json +++ b/data/guidelines/aha-social-environmental-determinants-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-social-environmental-determinants-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-standards-postacute-rehabilitation-2025.json b/data/guidelines/aha-standards-postacute-rehabilitation-2025.json index df96ad32..8ed48e88 100644 --- a/data/guidelines/aha-standards-postacute-rehabilitation-2025.json +++ b/data/guidelines/aha-standards-postacute-rehabilitation-2025.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-standards-postacute-rehabilitation-2025.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-stroke-rehabilitation-2026.json b/data/guidelines/aha-stroke-rehabilitation-2026.json index 80a5c69c..6b8f9bf7 100644 --- a/data/guidelines/aha-stroke-rehabilitation-2026.json +++ b/data/guidelines/aha-stroke-rehabilitation-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-stroke-rehabilitation-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-targeted-nursing-interventions-2025.json b/data/guidelines/aha-targeted-nursing-interventions-2025.json index c4c6cc6a..c2a44a64 100644 --- a/data/guidelines/aha-targeted-nursing-interventions-2025.json +++ b/data/guidelines/aha-targeted-nursing-interventions-2025.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-targeted-nursing-interventions-2025.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-transitions-of-care-2024.json b/data/guidelines/aha-transitions-of-care-2024.json index d82e5869..366242db 100644 --- a/data/guidelines/aha-transitions-of-care-2024.json +++ b/data/guidelines/aha-transitions-of-care-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-transitions-of-care-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-use-marijuana-effect-2022.json b/data/guidelines/aha-use-marijuana-effect-2022.json index 2e51c816..076ac766 100644 --- a/data/guidelines/aha-use-marijuana-effect-2022.json +++ b/data/guidelines/aha-use-marijuana-effect-2022.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-use-marijuana-effect-2022.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/aha-vascular-contributions-cognitive-2026.json b/data/guidelines/aha-vascular-contributions-cognitive-2026.json index c16c1828..ef4d9867 100644 --- a/data/guidelines/aha-vascular-contributions-cognitive-2026.json +++ b/data/guidelines/aha-vascular-contributions-cognitive-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/aha-vascular-contributions-cognitive-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/ais-2026.json b/data/guidelines/ais-2026.json index ff33641f..3694d3fc 100644 --- a/data/guidelines/ais-2026.json +++ b/data/guidelines/ais-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/ais-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/caa-icaa-wso-2025.json b/data/guidelines/caa-icaa-wso-2025.json index bc919b36..c5255c54 100644 --- a/data/guidelines/caa-icaa-wso-2025.json +++ b/data/guidelines/caa-icaa-wso-2025.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/caa-icaa-wso-2025.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/cancer-stroke-2026.json b/data/guidelines/cancer-stroke-2026.json index 9db68465..2383590a 100644 --- a/data/guidelines/cancer-stroke-2026.json +++ b/data/guidelines/cancer-stroke-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/cancer-stroke-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/cardiac-brain-health-2024.json b/data/guidelines/cardiac-brain-health-2024.json index d6d81929..3a285ca2 100644 --- a/data/guidelines/cardiac-brain-health-2024.json +++ b/data/guidelines/cardiac-brain-health-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/cardiac-brain-health-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/cvt-2024.json b/data/guidelines/cvt-2024.json index aa8c3180..5f84100a 100644 --- a/data/guidelines/cvt-2024.json +++ b/data/guidelines/cvt-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/cvt-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/esc-endocarditis-2023.json b/data/guidelines/esc-endocarditis-2023.json index 2f16547e..af57dfd2 100644 --- a/data/guidelines/esc-endocarditis-2023.json +++ b/data/guidelines/esc-endocarditis-2023.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/esc-endocarditis-2023.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-af-secondary-prevention-2019.json b/data/guidelines/eso-af-secondary-prevention-2019.json index ceef4c44..c2147818 100644 --- a/data/guidelines/eso-af-secondary-prevention-2019.json +++ b/data/guidelines/eso-af-secondary-prevention-2019.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-af-secondary-prevention-2019.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-anticoagulant-reversal-ich-2019.json b/data/guidelines/eso-anticoagulant-reversal-ich-2019.json index 5cee5013..40c0e02f 100644 --- a/data/guidelines/eso-anticoagulant-reversal-ich-2019.json +++ b/data/guidelines/eso-anticoagulant-reversal-ich-2019.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-anticoagulant-reversal-ich-2019.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-aphasia-rehab-2025.json b/data/guidelines/eso-aphasia-rehab-2025.json index e5584c85..6e6a48a4 100644 --- a/data/guidelines/eso-aphasia-rehab-2025.json +++ b/data/guidelines/eso-aphasia-rehab-2025.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-aphasia-rehab-2025.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-artery-dissection-2021.json b/data/guidelines/eso-artery-dissection-2021.json index a732aa90..bf2a3ed2 100644 --- a/data/guidelines/eso-artery-dissection-2021.json +++ b/data/guidelines/eso-artery-dissection-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-artery-dissection-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-bao-2024.json b/data/guidelines/eso-bao-2024.json index ac6deb54..8829a2df 100644 --- a/data/guidelines/eso-bao-2024.json +++ b/data/guidelines/eso-bao-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-bao-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-bp-2025.json b/data/guidelines/eso-bp-2025.json index 77507ab6..dfb5ce8e 100644 --- a/data/guidelines/eso-bp-2025.json +++ b/data/guidelines/eso-bp-2025.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-bp-2025.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-carotid-stenosis-2021.json b/data/guidelines/eso-carotid-stenosis-2021.json index 7bc41167..cf4ccc42 100644 --- a/data/guidelines/eso-carotid-stenosis-2021.json +++ b/data/guidelines/eso-carotid-stenosis-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-carotid-stenosis-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-covert-csvd-2021.json b/data/guidelines/eso-covert-csvd-2021.json index 4447b8bc..367e220f 100644 --- a/data/guidelines/eso-covert-csvd-2021.json +++ b/data/guidelines/eso-covert-csvd-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-covert-csvd-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-cvt-2017.json b/data/guidelines/eso-cvt-2017.json index addc4b70..9e89d4e9 100644 --- a/data/guidelines/eso-cvt-2017.json +++ b/data/guidelines/eso-cvt-2017.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-cvt-2017.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-dysphagia-2021.json b/data/guidelines/eso-dysphagia-2021.json index 1e706e41..b8d5a71c 100644 --- a/data/guidelines/eso-dysphagia-2021.json +++ b/data/guidelines/eso-dysphagia-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-dysphagia-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-ean-poststroke-cognition-2021.json b/data/guidelines/eso-ean-poststroke-cognition-2021.json index ae955dd3..9c606cb2 100644 --- a/data/guidelines/eso-ean-poststroke-cognition-2021.json +++ b/data/guidelines/eso-ean-poststroke-cognition-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-ean-poststroke-cognition-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-esmint-mechanical-thrombectomy-2019.json b/data/guidelines/eso-esmint-mechanical-thrombectomy-2019.json index 45985d7c..817edba3 100644 --- a/data/guidelines/eso-esmint-mechanical-thrombectomy-2019.json +++ b/data/guidelines/eso-esmint-mechanical-thrombectomy-2019.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-esmint-mechanical-thrombectomy-2019.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-esmint-thrombectomy-2022.json b/data/guidelines/eso-esmint-thrombectomy-2022.json index 0cff502c..b034176d 100644 --- a/data/guidelines/eso-esmint-thrombectomy-2022.json +++ b/data/guidelines/eso-esmint-thrombectomy-2022.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-esmint-thrombectomy-2022.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-glycaemia-2018.json b/data/guidelines/eso-glycaemia-2018.json index e9d26f47..b08bac7e 100644 --- a/data/guidelines/eso-glycaemia-2018.json +++ b/data/guidelines/eso-glycaemia-2018.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-glycaemia-2018.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-ich-2025.json b/data/guidelines/eso-ich-2025.json index a0d7c5f0..ae969bf8 100644 --- a/data/guidelines/eso-ich-2025.json +++ b/data/guidelines/eso-ich-2025.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-ich-2025.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-intracranial-atherosclerosis-2022.json b/data/guidelines/eso-intracranial-atherosclerosis-2022.json index 131beaa6..893c7ea1 100644 --- a/data/guidelines/eso-intracranial-atherosclerosis-2022.json +++ b/data/guidelines/eso-intracranial-atherosclerosis-2022.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-intracranial-atherosclerosis-2022.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-ivt-2021.json b/data/guidelines/eso-ivt-2021.json index 2b2ed6b0..1080ed6b 100644 --- a/data/guidelines/eso-ivt-2021.json +++ b/data/guidelines/eso-ivt-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-ivt-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-lacunar-2024.json b/data/guidelines/eso-lacunar-2024.json index 0fe5a1cf..2a79fc7d 100644 --- a/data/guidelines/eso-lacunar-2024.json +++ b/data/guidelines/eso-lacunar-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-lacunar-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-mobile-stroke-units-2022.json b/data/guidelines/eso-mobile-stroke-units-2022.json index c1f309fa..176ce670 100644 --- a/data/guidelines/eso-mobile-stroke-units-2022.json +++ b/data/guidelines/eso-mobile-stroke-units-2022.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-mobile-stroke-units-2022.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-motor-rehab-2025.json b/data/guidelines/eso-motor-rehab-2025.json index 6735c443..33f40db7 100644 --- a/data/guidelines/eso-motor-rehab-2025.json +++ b/data/guidelines/eso-motor-rehab-2025.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-motor-rehab-2025.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-moyamoya-2023.json b/data/guidelines/eso-moyamoya-2023.json index 8ffb3cce..aa4e8ecc 100644 --- a/data/guidelines/eso-moyamoya-2023.json +++ b/data/guidelines/eso-moyamoya-2023.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-moyamoya-2023.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-pacns-2023.json b/data/guidelines/eso-pacns-2023.json index c648a434..c7332980 100644 --- a/data/guidelines/eso-pacns-2023.json +++ b/data/guidelines/eso-pacns-2023.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-pacns-2023.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-pfo-2024.json b/data/guidelines/eso-pfo-2024.json index 778ffa63..90671409 100644 --- a/data/guidelines/eso-pfo-2024.json +++ b/data/guidelines/eso-pfo-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-pfo-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-poststroke-seizures-2017.json b/data/guidelines/eso-poststroke-seizures-2017.json index 46f76d70..429d6df8 100644 --- a/data/guidelines/eso-poststroke-seizures-2017.json +++ b/data/guidelines/eso-poststroke-seizures-2017.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-poststroke-seizures-2017.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-sah-2026.json b/data/guidelines/eso-sah-2026.json index 5ac99b3e..89f479cf 100644 --- a/data/guidelines/eso-sah-2026.json +++ b/data/guidelines/eso-sah-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-sah-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-sap-2026.json b/data/guidelines/eso-sap-2026.json index e34b8e54..4ae28912 100644 --- a/data/guidelines/eso-sap-2026.json +++ b/data/guidelines/eso-sap-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-sap-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-secondary-prevention-2022.json b/data/guidelines/eso-secondary-prevention-2022.json index 8f886d44..4f794ffb 100644 --- a/data/guidelines/eso-secondary-prevention-2022.json +++ b/data/guidelines/eso-secondary-prevention-2022.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-secondary-prevention-2022.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-short-term-dapt-2021.json b/data/guidelines/eso-short-term-dapt-2021.json index 22c546cb..33054eae 100644 --- a/data/guidelines/eso-short-term-dapt-2021.json +++ b/data/guidelines/eso-short-term-dapt-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-short-term-dapt-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-space-occupying-infarction-2021.json b/data/guidelines/eso-space-occupying-infarction-2021.json index 168ad740..6fcf5ee7 100644 --- a/data/guidelines/eso-space-occupying-infarction-2021.json +++ b/data/guidelines/eso-space-occupying-infarction-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-space-occupying-infarction-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-stroke-in-women-2022.json b/data/guidelines/eso-stroke-in-women-2022.json index e345eb05..3494f76e 100644 --- a/data/guidelines/eso-stroke-in-women-2022.json +++ b/data/guidelines/eso-stroke-in-women-2022.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-stroke-in-women-2022.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-subclinical-af-screening-2022.json b/data/guidelines/eso-subclinical-af-screening-2022.json index 23d56002..d3c80ec8 100644 --- a/data/guidelines/eso-subclinical-af-screening-2022.json +++ b/data/guidelines/eso-subclinical-af-screening-2022.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-subclinical-af-screening-2022.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-temperature-2015.json b/data/guidelines/eso-temperature-2015.json index 0c04cc88..c5b90961 100644 --- a/data/guidelines/eso-temperature-2015.json +++ b/data/guidelines/eso-temperature-2015.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-temperature-2015.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-tenecteplase-2023.json b/data/guidelines/eso-tenecteplase-2023.json index 8c2a23c6..3083b44f 100644 --- a/data/guidelines/eso-tenecteplase-2023.json +++ b/data/guidelines/eso-tenecteplase-2023.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-tenecteplase-2023.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-tia-2021.json b/data/guidelines/eso-tia-2021.json index 6d14e640..c18ec827 100644 --- a/data/guidelines/eso-tia-2021.json +++ b/data/guidelines/eso-tia-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-tia-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-unruptured-aneurysms-2022.json b/data/guidelines/eso-unruptured-aneurysms-2022.json index e9721d56..6ec47379 100644 --- a/data/guidelines/eso-unruptured-aneurysms-2022.json +++ b/data/guidelines/eso-unruptured-aneurysms-2022.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-unruptured-aneurysms-2022.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-visual-2025.json b/data/guidelines/eso-visual-2025.json index bf964f45..3a32c680 100644 --- a/data/guidelines/eso-visual-2025.json +++ b/data/guidelines/eso-visual-2025.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-visual-2025.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/eso-vte-prophylaxis-2016.json b/data/guidelines/eso-vte-prophylaxis-2016.json index f986c51c..d2c1b6fc 100644 --- a/data/guidelines/eso-vte-prophylaxis-2016.json +++ b/data/guidelines/eso-vte-prophylaxis-2016.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/eso-vte-prophylaxis-2016.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/ich-2022.json b/data/guidelines/ich-2022.json index bd23f534..d651d9a1 100644 --- a/data/guidelines/ich-2022.json +++ b/data/guidelines/ich-2022.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/ich-2022.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/index.json b/data/guidelines/index.json index 1222e9f9..13f9ee07 100644 --- a/data/guidelines/index.json +++ b/data/guidelines/index.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/index.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/landmark-trials.json b/data/guidelines/landmark-trials.json index 52fddcbc..1d7116a4 100644 --- a/data/guidelines/landmark-trials.json +++ b/data/guidelines/landmark-trials.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/landmark-trials.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/maternal-stroke-2026.json b/data/guidelines/maternal-stroke-2026.json index ead51b47..1e5cf437 100644 --- a/data/guidelines/maternal-stroke-2026.json +++ b/data/guidelines/maternal-stroke-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/maternal-stroke-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/ncs-ich-seizure-prophylaxis-2024.json b/data/guidelines/ncs-ich-seizure-prophylaxis-2024.json index 1cdce521..2245f5b6 100644 --- a/data/guidelines/ncs-ich-seizure-prophylaxis-2024.json +++ b/data/guidelines/ncs-ich-seizure-prophylaxis-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/ncs-ich-seizure-prophylaxis-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/ncs-neuroprognostication-ais-2026.json b/data/guidelines/ncs-neuroprognostication-ais-2026.json index f5c3bf0c..11bfc441 100644 --- a/data/guidelines/ncs-neuroprognostication-ais-2026.json +++ b/data/guidelines/ncs-neuroprognostication-ais-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/ncs-neuroprognostication-ais-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/ncs-neuroprognostication-ich-2023.json b/data/guidelines/ncs-neuroprognostication-ich-2023.json index bf4864bc..40cd1ebe 100644 --- a/data/guidelines/ncs-neuroprognostication-ich-2023.json +++ b/data/guidelines/ncs-neuroprognostication-ich-2023.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/ncs-neuroprognostication-ich-2023.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/ncs-reversal-2026.json b/data/guidelines/ncs-reversal-2026.json index 968f859b..3d9089b7 100644 --- a/data/guidelines/ncs-reversal-2026.json +++ b/data/guidelines/ncs-reversal-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/ncs-reversal-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/ncs-sah-seizure-prophylaxis-2026.json b/data/guidelines/ncs-sah-seizure-prophylaxis-2026.json index a16dd0d7..984a39d0 100644 --- a/data/guidelines/ncs-sah-seizure-prophylaxis-2026.json +++ b/data/guidelines/ncs-sah-seizure-prophylaxis-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/ncs-sah-seizure-prophylaxis-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/ncs-sccm-antithrombotic-reversal-2016.json b/data/guidelines/ncs-sccm-antithrombotic-reversal-2016.json index ddf01798..4e0937f3 100644 --- a/data/guidelines/ncs-sccm-antithrombotic-reversal-2016.json +++ b/data/guidelines/ncs-sccm-antithrombotic-reversal-2016.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/ncs-sccm-antithrombotic-reversal-2016.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/perioperative-stroke-2021.json b/data/guidelines/perioperative-stroke-2021.json index 48917d5c..21d5bc03 100644 --- a/data/guidelines/perioperative-stroke-2021.json +++ b/data/guidelines/perioperative-stroke-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/perioperative-stroke-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/poststroke-cognitive-2023.json b/data/guidelines/poststroke-cognitive-2023.json index f686bf0b..6ca3b147 100644 --- a/data/guidelines/poststroke-cognitive-2023.json +++ b/data/guidelines/poststroke-cognitive-2023.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/poststroke-cognitive-2023.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/poststroke-primary-care-2021.json b/data/guidelines/poststroke-primary-care-2021.json index ee442315..bd076b5c 100644 --- a/data/guidelines/poststroke-primary-care-2021.json +++ b/data/guidelines/poststroke-primary-care-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/poststroke-primary-care-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/poststroke-spasticity-2026.json b/data/guidelines/poststroke-spasticity-2026.json index 47ffacae..d2732373 100644 --- a/data/guidelines/poststroke-spasticity-2026.json +++ b/data/guidelines/poststroke-spasticity-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/poststroke-spasticity-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/premorbid-disability-2022.json b/data/guidelines/premorbid-disability-2022.json index 0237a5d0..465d082d 100644 --- a/data/guidelines/premorbid-disability-2022.json +++ b/data/guidelines/premorbid-disability-2022.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/premorbid-disability-2022.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/primary-prevention-2024.json b/data/guidelines/primary-prevention-2024.json index 6077b536..372f9a12 100644 --- a/data/guidelines/primary-prevention-2024.json +++ b/data/guidelines/primary-prevention-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/primary-prevention-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/sah-2023.json b/data/guidelines/sah-2023.json index b7536462..e55427ee 100644 --- a/data/guidelines/sah-2023.json +++ b/data/guidelines/sah-2023.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/sah-2023.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/secondary-prevention-2021.json b/data/guidelines/secondary-prevention-2021.json index bcfb22ab..de2b7d42 100644 --- a/data/guidelines/secondary-prevention-2021.json +++ b/data/guidelines/secondary-prevention-2021.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/secondary-prevention-2021.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/svin-dsa-collaterals-2025.json b/data/guidelines/svin-dsa-collaterals-2025.json index 1b8a88b8..41e8da36 100644 --- a/data/guidelines/svin-dsa-collaterals-2025.json +++ b/data/guidelines/svin-dsa-collaterals-2025.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/svin-dsa-collaterals-2025.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/svin-lab-consensus-2025.json b/data/guidelines/svin-lab-consensus-2025.json index 3e38901d..e96480bb 100644 --- a/data/guidelines/svin-lab-consensus-2025.json +++ b/data/guidelines/svin-lab-consensus-2025.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/svin-lab-consensus-2025.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/svin-large-core-2025.json b/data/guidelines/svin-large-core-2025.json index cbb2cc12..a636dd01 100644 --- a/data/guidelines/svin-large-core-2025.json +++ b/data/guidelines/svin-large-core-2025.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/svin-large-core-2025.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/svin-mevo-dvo-evt-2026.json b/data/guidelines/svin-mevo-dvo-evt-2026.json index dd3d5bb7..1debdfcc 100644 --- a/data/guidelines/svin-mevo-dvo-evt-2026.json +++ b/data/guidelines/svin-mevo-dvo-evt-2026.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/svin-mevo-dvo-evt-2026.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/systemic-complications-2024.json b/data/guidelines/systemic-complications-2024.json index 25d457fd..6eba5352 100644 --- a/data/guidelines/systemic-complications-2024.json +++ b/data/guidelines/systemic-complications-2024.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/systemic-complications-2024.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/guidelines/tia-ed-2023.json b/data/guidelines/tia-ed-2023.json index b13651e4..c6b38118 100644 --- a/data/guidelines/tia-ed-2023.json +++ b/data/guidelines/tia-ed-2023.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "data/guidelines/tia-ed-2023.json", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:74234e98afe7498fb5daf1f36ac2d78a", "count": 0, "source": "Retired historical portal endpoint", diff --git a/data/index.json b/data/index.json index 7ab75778..ca672174 100644 --- a/data/index.json +++ b/data/index.json @@ -1,7 +1,7 @@ { "_meta": { "name": "stroke", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "schemaVersion": "2.0.0", "baseUrl": "https://rkalani1.github.io/stroke", "license": "Synthetic educational reference content for qualified review. No warranty.", diff --git a/data/management-cards.json b/data/management-cards.json index 50b9ab32..68c25996 100644 --- a/data/management-cards.json +++ b/data/management-cards.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "management-cards", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:a25b7a3690110c4d74ef70c888ea60db", "count": 4, "source": "Protected public protocol reference bundle", diff --git a/data/sources.json b/data/sources.json index 7746c155..21cc9ded 100644 --- a/data/sources.json +++ b/data/sources.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "sources", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:1f9a9dbcc57ddda4a6e6d846b61d9ddd", "count": 4, "source": "Canonical clinical claims, source identities and retained primary-source projections", diff --git a/data/trials.json b/data/trials.json index a753d911..ebd38e35 100644 --- a/data/trials.json +++ b/data/trials.json @@ -2,7 +2,7 @@ "_meta": { "endpoint": "trials", "schemaVersion": "2.0.0", - "appVersion": "7.10.4", + "appVersion": "7.11.0", "checksum": "sha256:d4920f603911fb67eb9b7facff45c5fb", "count": 15, "source": "Trial screener and table summaries with per-profile registry check dates", diff --git a/docs/review-2026-11-07.md b/docs/review-2026-11-07.md new file mode 100644 index 00000000..52c4d4bb --- /dev/null +++ b/docs/review-2026-11-07.md @@ -0,0 +1,37 @@ +# Review 2026-11-07 — accessibility, layout and performance (outside the Protocols tab) + +Owner instruction: "skip the protocols section, but perfect the rest". The Protocols tab was not reviewed or changed; every fix below is scoped away from it, and the Protocols source lock, the Example Protocols snapshot and the rendered locks (desktop and phone) are the guard. + +## Method + +Read-only auditors worked against a built copy of 7.10.4 in headless Chromium 141 with synthetic entries only: + +- **Accessibility (WCAG 2.2 AA):** axe-core 4.11.0 on 34 states × 390×844 and 1440×900 × light and dark (136 scans), plus keyboard traversal (5,218 Tab stops), reflow at 320 px, 200–400% zoom approximated with CSS-pixel viewports, text spacing, target size, reduced motion and forced colors. +- **Layout and interaction:** 690 states at 360, 390, 768, 1024, 1280 and 1440 px in both themes (about 1,300 screenshots; about 70 inspected by eye, the rest by automated probes for overflow, clipping, CLS and contrast). +- **Performance:** an esbuild metafile with the production options, 4× CPU-throttled runtime traces at 390×844, and Lighthouse 12.8.2 (desktop 98, mobile 69 on an uncompressed local server; accessibility, best practices and SEO 100). + +Not completed in this round (stopped at the owner's deadline): clinical-logic boundary testing, offline/PWA behaviour, evidence currency since 2026-10-31, the trial-registry recheck, CI and dependency hygiene, and a copy and link sweep. + +## Fixed in 7.11.0 + +| Finding | Fix | +|---|---| +| Trials: "View N possible candidates" (below 1024 px) opened the Retired destination page, because `#trial-results` was read as a route | In-page button that scrolls to the results and focuses the result summary | +| Short screens (≤ 440 px tall): header, case bar and docked nav covered 62–100% of the screen; focus hidden (1.4.10, 2.4.11) | Header and case bar scroll with the page at ≤ 440 px tall on every surface except Protocols | +| Case bar offered the thrombolytic "Dose table" in ICH, SAH, TIA and other encounters | Shown only for acute ischemic stroke, a recorded administration, or before a diagnosis is chosen | +| More panel stayed open over the focused control; a press in the install sheet closed it; Escape always moved focus to More | Closes when focus leaves it (dialogs it opened excepted); Escape returns focus only from inside | +| Global search field: no focus indicator (2.4.7); placeholder 2.54:1 (1.4.3) | Focus ring on the field; placeholder uses the muted token (passes in both themes) | +| Forced colors erased selected, pressed and current states, link markers and the Copy button boundary | `@media (forced-colors: active)` rules scoped to Encounter, Trials, the nav and the wide indexes | +| Trial-criteria dialog: Close scrolled out of view on phones | Sticky title row with Close on screens taller than 440 px | +| Evidence search: 79–154 ms long task per keystroke at 4× throttling | Per-record memoization; identical results for 2,061 queries × 4 settings; 229 → 2.5 ms per typed word unthrottled | +| Registry links showed two arrow markers; database search name did not start with its visible label (2.5.3) | One CSS marker (also in the dialog); label-first accessible name | +| Wide Evidence index headings ran into their counts ("ACUTE ISCHEMIC STROKE19") | Count set apart, spoken as ", 19 topics" | +| Evidence and Calculators failure states unstyled; reference tiles teal in dark mode; checklist selects misaligned at 481–768 px | Styled like the retired-page card, opt-in per boundary so the Protocols and Quick reference fallbacks are unchanged; tiles keep ink; alignment from 481 px | +| qa-smoke compared `--case-bar-h` before the ResizeObserver could run | Waits for a rendering opportunity (fails after 2 s if still stale) | + +## Deferred (recorded for the next round) + +- **Out-of-range number entries (3.3.1):** Encounter and calculator number fields drop out-of-range values (age 250, weight 900 kg, SBP 500) without an on-screen error; the generated note does flag them. The fix needs each field's message to use the same bounds as the note (for example weight must be greater than 0 while the field's `min` is 0), so it was not rushed. +- **iOS splash images in the precache** (367,861 B, 17% of the precache, used only by iOS home-screen launches): could move to runtime caching. +- **Initial-graph headroom:** about 40 KB raw of the initial graph runs only after data entry; the JavaScript budgets are at 99–100%. +- **Low:** search and filter rows shift on the first keystroke; three elapsed-time formats; the pinned two-pane card can toggle; short pages scroll by the dock height; retired-page wording; status regions inserted with their text; the bare "/" shortcut (2.1.4); the phone "Jump to" select navigates on change (3.2.2); search-dialog footer clipping under text-spacing overrides. diff --git a/index.html b/index.html index cb6e16ab..6923f848 100644 --- a/index.html +++ b/index.html @@ -6,7 +6,7 @@ - + @@ -35,7 +35,7 @@ Stroke · Encounter workspace - + @@ -48,12 +48,12 @@ - + - + diff --git a/llms-full.txt b/llms-full.txt index 9f5208db..15e28c8e 100644 --- a/llms-full.txt +++ b/llms-full.txt @@ -1,6 +1,6 @@ # Stroke Encounter Educational Demo -> v7.10.4: deterministic synthetic Encounter workflow with embedded retained tools, protected example protocols, a trial screener/reference database, curated Evidence topics and completed primary-study summaries. +> v7.11.0: deterministic synthetic Encounter workflow with embedded retained tools, protected example protocols, a trial screener/reference database, curated Evidence topics and completed primary-study summaries. Synthetic educational demo only - NOT medical advice, NOT an approved clinical tool, and NOT local clinical policy. Do not enter, transmit, or infer PHI or real encounter details. Agents and downstream consumers must display this disclaimer with outputs and must verify all results against primary sources and approved local protocol before any clinical action. diff --git a/llms.txt b/llms.txt index d0ace78b..e64256e6 100644 --- a/llms.txt +++ b/llms.txt @@ -1,6 +1,6 @@ # Stroke Encounter Educational Demo -> v7.10.4: deterministic synthetic Encounter workflow with embedded retained tools, protected example protocols, a trial screener/reference database, curated Evidence topics and completed primary-study summaries. +> v7.11.0: deterministic synthetic Encounter workflow with embedded retained tools, protected example protocols, a trial screener/reference database, curated Evidence topics and completed primary-study summaries. Synthetic educational demo only - NOT medical advice, NOT an approved clinical tool, and NOT local clinical policy. Do not enter, transmit, or infer PHI or real encounter details. Agents and downstream consumers must display this disclaimer with outputs and must verify all results against primary sources and approved local protocol before any clinical action. diff --git a/package-lock.json b/package-lock.json index 9a8efb25..3d426947 100644 --- a/package-lock.json +++ b/package-lock.json @@ -1,12 +1,12 @@ { "name": "stroke", - "version": "7.10.4", + "version": "7.11.0", "lockfileVersion": 3, "requires": true, "packages": { "": { "name": "stroke", - "version": "7.10.4", + "version": "7.11.0", "license": "ISC", "dependencies": { "@capacitor/android": "^8.3.1", diff --git a/package.json b/package.json index a7410e33..78f5d05e 100644 --- a/package.json +++ b/package.json @@ -1,6 +1,6 @@ { "name": "stroke", - "version": "7.10.4", + "version": "7.11.0", "description": "Encounter workspace with embedded calculations, protocols, Pulsara summaries and Epic note templates.", "main": "service-worker.js", "scripts": { diff --git a/scripts/qa-smoke.mjs b/scripts/qa-smoke.mjs index b60befe6..be4f4e8c 100644 --- a/scripts/qa-smoke.mjs +++ b/scripts/qa-smoke.mjs @@ -368,7 +368,7 @@ async function main() { await tables.getByRole('button', { name: 'Ischemic stroke', exact: true }).waitFor({ state: 'visible' }); await page.getByRole('tab', { name: 'Database', exact: true }).click(); const database = page.getByRole('tabpanel', { name: 'Database', exact: true }); - await database.getByRole('searchbox', { name: 'Search the study database by acronym, name or NCT number', exact: true }).fill('STEP'); + await database.getByRole('searchbox', { name: 'Search acronym, name or NCT number in the study database', exact: true }).fill('STEP'); assert((await database.innerText()).includes('STEP')); assert(!(await database.innerText()).includes('PICASSO')); await page.screenshot({ path: path.join(outDir, 'trials-desktop.png'), fullPage: true }); @@ -669,6 +669,8 @@ async function main() { // The sticky bar wraps instead of clipping, keeps the 4.5 h pill uncovered and publishes its height. for(const [width,height] of [[360,844],[390,844],[667,375],[600,900],[834,900],[1180,900],[1232,900],[1280,900],[1440,900]]) { await page.setViewportSize({width,height});await page.evaluate(()=>window.scrollTo(0,0));await page.waitForTimeout(150); + // The bar republishes its height from a ResizeObserver; read after a rendering opportunity (a stale value still fails after 2 s). + await page.waitForFunction(()=>{const bar=document.querySelector('.case-bar');return Math.abs(Math.ceil(bar.getBoundingClientRect().height)-parseInt(getComputedStyle(document.documentElement).getPropertyValue('--case-bar-h'),10))<=1;},null,{polling:'raf',timeout:2000}).catch(()=>{}); const fit=await page.evaluate(()=>{const pill=document.querySelector('.case-bar__window'),r=pill.getBoundingClientRect(),hit=document.elementFromPoint(r.left+r.width/2,r.top+r.height/2),items=document.querySelector('.case-bar__items');return {overflow:document.documentElement.scrollWidth>innerWidth+1,pill:Boolean(hit&&pill.contains(hit)),clipped:items.scrollWidth>items.clientWidth+1,bar:Math.ceil(document.querySelector('.case-bar').getBoundingClientRect().height),published:parseInt(getComputedStyle(document.documentElement).getPropertyValue('--case-bar-h'),10)};}); assert.equal(fit.overflow,false,`case bar overflows at ${width}px`);assert(fit.pill,`4.5 h pill covered at ${width}px`);assert.equal(fit.clipped,false,`case bar items clipped at ${width}px`);assert(Math.abs(fit.bar-fit.published)<=1,`--case-bar-h ${fit.published} vs bar ${fit.bar} at ${width}px`); } @@ -864,7 +866,7 @@ async function main() { assert.deepEqual(cache.reference, { appVersion: await p.locator('.app-shell').getAttribute('data-version'), schemaVersion: '2.0.0', topics: reference.data.topics.length, studies: reference.data.studies.length, calculators: reference.data.calculators.length }); assert.equal(cache.reference.appVersion, reference._meta.appVersion); await offline.setOffline(true);await p.reload({waitUntil:'domcontentloaded'});await setupIschemic(p);await p.getByLabel('Manual rationale / recommendations',{exact:true}).fill('Synthetic offline encounter; specialist review pending.');const items=nihssRows(p);await openDetails(items.first());for(let i=0;i<15;i++) await scoreNihssZero(items.nth(i));assert((await p.locator('#calc-tnk').innerText()).includes('TNK 20.75 mg'));assert((await(await generate(p)).inputValue()).includes('NIHSS score: 0/42')); - await p.getByRole('link',{name:'Trials',exact:true}).click();await p.getByRole('heading',{name:'Trials',exact:true}).waitFor();await p.getByRole('tab',{name:'Database',exact:true}).click();await p.getByRole('searchbox',{name:'Search the study database by acronym, name or NCT number',exact:true}).fill('STEP');assert((await p.getByRole('tabpanel',{name:'Database',exact:true}).innerText()).includes('STEP'));await p.screenshot({path:path.join(outDir,'trials-offline-mobile.png'),fullPage:true}); + await p.getByRole('link',{name:'Trials',exact:true}).click();await p.getByRole('heading',{name:'Trials',exact:true}).waitFor();await p.getByRole('tab',{name:'Database',exact:true}).click();await p.getByRole('searchbox',{name:'Search acronym, name or NCT number in the study database',exact:true}).fill('STEP');assert((await p.getByRole('tabpanel',{name:'Database',exact:true}).innerText()).includes('STEP'));await p.screenshot({path:path.join(outDir,'trials-offline-mobile.png'),fullPage:true}); assert.equal(await p.evaluate(() => navigator.onLine), false); await p.getByRole('link', { name: 'Calculators', exact: true }).click(); await p.getByRole('heading', { name: 'Calculators', exact: true }).waitFor(); diff --git a/service-worker.js b/service-worker.js index e8e18a80..e9215b80 100644 --- a/service-worker.js +++ b/service-worker.js @@ -6,9 +6,9 @@ Old app caches are retired only on activation. Fetch policy is independent. */ -const APP_VERSION = '7.10.4'; +const APP_VERSION = '7.11.0'; const CACHE_PREFIX = 'stroke-cache-v'; -const CACHE_NAME = 'stroke-cache-v7-10-4-utility-review-20261001'; +const CACHE_NAME = 'stroke-cache-v7-11-0-utility-review-20261001'; // Retired teaching figures must not be served from a stale browser cache or // a bookmarked URL after this worker takes control. Paths are scope-relative @@ -92,28 +92,28 @@ const APP_CHUNKS = [ "./chunks/chunk-BVAA575E.js", "./chunks/chunk-CCC5QWPU.js", "./chunks/chunk-DXV6LRZM.js", + "./chunks/chunk-FI3I7QSW.js", "./chunks/chunk-FPW5WEWF.js", "./chunks/chunk-HOFJI2PN.js", "./chunks/chunk-HXREWURP.js", "./chunks/chunk-MXOIE5XZ.js", - "./chunks/chunk-NIDKKCR2.js", "./chunks/chunk-QPJ3MHXX.js", "./chunks/chunk-RKNMGIFI.js", "./chunks/chunk-ROKRUQE4.js", "./chunks/chunk-SQ3QWPC3.js", - "./chunks/chunk-WQJWBHBV.js", + "./chunks/chunk-X3EP23JS.js", "./chunks/InstallAppButton-NWUBLKJU.js", "./chunks/ProtectedProtocols-6MFHWK7D.js", "./chunks/QuickReference-UKRUSEBK.js", - "./chunks/QuickSearch-4PP7N7HQ.js", - "./chunks/Reference-7WXJYWKM.js", - "./chunks/Tools-JDNJXZ5B.js", - "./chunks/Trials-G5OA3FQU.js" + "./chunks/QuickSearch-ZDBPYRCR.js", + "./chunks/Reference-G5TQRGNK.js", + "./chunks/Tools-GTTP3WWZ.js", + "./chunks/Trials-U2GWQ2GP.js" ]; // END GENERATED APP CHUNKS // BEGIN GENERATED REFERENCE VALIDATION -var ReferenceValidation=(()=>{var l=Object.defineProperty;var g=Object.getOwnPropertyDescriptor;var h=Object.getOwnPropertyNames;var y=Object.prototype.hasOwnProperty;var b=(t,s)=>{for(var e in s)l(t,e,{get:s[e],enumerable:!0})},$=(t,s,e,a)=>{if(s&&typeof s=="object"||typeof s=="function")for(let n of h(s))!y.call(t,n)&&n!==e&&l(t,n,{get:()=>s[n],enumerable:!(a=g(s,n))||a.enumerable});return t};var f=t=>$(l({},"__esModule",{value:!0}),t);var v={};b(v,{validReferenceData:()=>m});var i=t=>typeof t=="string"&&t.trim().length>0,r=t=>Array.isArray(t)&&t.every(i),c=t=>i(t)&&/^[a-z0-9-]+$/.test(t),p=t=>typeof t=="string"&&/^https:\/\/[^\s]+$/.test(t),d=t=>t===void 0||Array.isArray(t)&&t.length>0&&t.every(s=>s&&["text","cor","loe","source","id"].every(e=>i(s[e])))&&new Set(t.map(s=>s.id)).size===t.length;function A(t){return Array.isArray(t)&&t.length>0&&new Set(t.map(s=>s?.id)).size===t.length&&t.every(s=>s&&c(s.id)&&["name","category","limits","sourceLabel","reviewScope"].every(e=>i(s[e]))&&p(s.sourceUrl)&&(!s.verificationUrl||p(s.verificationUrl))&&Array.isArray(s.fields)&&s.fields.every(e=>e&&i(e.key)&&i(e.label)&&["truth","select","number"].includes(e.type)&&(e.type!=="select"?e.options===void 0:Array.isArray(e.options)&&e.options.length>0&&e.options.every(a=>Array.isArray(a)&&a.length===2&&a.every(i))))&&(!s.shared||Array.isArray(s.shared)&&s.shared.every(e=>["age","sex","bp","mrs","gcs","weight","height","mtici","sahCause"].includes(e)))&&(!s.regions||Array.isArray(s.regions)&&s.regions.every(e=>e&&i(e.key)&&i(e.label)&&[1,2].includes(e.weight))))}function m(t,s){let e=t?.data;return t?._meta?.appVersion===s&&t?._meta?.schemaVersion==="2.0.0"&&A(e?.calculators)&&["topics","studies"].every(a=>Array.isArray(e?.[a])&&e[a].length>0&&new Set(e[a].map(n=>n?.id)).size===e[a].length&&e[a].every(n=>n&&c(n.id)&&i(n.title)&&r(n.keywords)&&r(n.settings)&&n.settings.length&&n.settings.every(o=>["on-call","hospital","clinic"].includes(o))&&Array.isArray(n.sources)&&n.sources.length&&n.sources.every(o=>o&&["title","type","checkedAt","access"].every(u=>i(o[u]))&&Number.isInteger(o.year)&&typeof o.url=="string"&&/^https:\/\/[^\s]+$/.test(o.url))&&(a==="topics"?i(n.category)&&["summary","caution"].every(o=>i(n[o]))&&r(n.consider)&&n.consider.length&&d(n.recommendations)&&Array.isArray(n.related)&&n.related.every(o=>i(o.label)&&/^#\/(?:encounter|tools|protocols|evidence|trials)(?:\/[a-z0-9-]+){0,2}$/.test(o.href)):["question","population","comparison","result","limits"].every(o=>i(n[o]))&&(n.headline===void 0||i(n.headline))&&Number.isInteger(n.year)&&(n.relatedTopic===""||c(n.relatedTopic)))))&&e.studies.every(a=>!e.topics.some(n=>n.id===a.id))&&e.studies.every(a=>a.relatedTopic===""||e.topics.some(n=>n.id===a.relatedTopic))}return f(v);})(); +var ReferenceValidation=(()=>{var l=Object.defineProperty;var g=Object.getOwnPropertyDescriptor;var h=Object.getOwnPropertyNames;var y=Object.prototype.hasOwnProperty;var b=(t,s)=>{for(var e in s)l(t,e,{get:s[e],enumerable:!0})},$=(t,s,e,a)=>{if(s&&typeof s=="object"||typeof s=="function")for(let n of h(s))!y.call(t,n)&&n!==e&&l(t,n,{get:()=>s[n],enumerable:!(a=g(s,n))||a.enumerable});return t};var f=t=>$(l({},"__esModule",{value:!0}),t);var x={};b(x,{validReferenceData:()=>m});var i=t=>typeof t=="string"&&t.trim().length>0,r=t=>Array.isArray(t)&&t.every(i),c=t=>i(t)&&/^[a-z0-9-]+$/.test(t),p=t=>typeof t=="string"&&/^https:\/\/[^\s]+$/.test(t),d=t=>t===void 0||Array.isArray(t)&&t.length>0&&t.every(s=>s&&["text","cor","loe","source","id"].every(e=>i(s[e])))&&new Set(t.map(s=>s.id)).size===t.length;function A(t){return Array.isArray(t)&&t.length>0&&new Set(t.map(s=>s?.id)).size===t.length&&t.every(s=>s&&c(s.id)&&["name","category","limits","sourceLabel","reviewScope"].every(e=>i(s[e]))&&p(s.sourceUrl)&&(!s.verificationUrl||p(s.verificationUrl))&&Array.isArray(s.fields)&&s.fields.every(e=>e&&i(e.key)&&i(e.label)&&["truth","select","number"].includes(e.type)&&(e.type!=="select"?e.options===void 0:Array.isArray(e.options)&&e.options.length>0&&e.options.every(a=>Array.isArray(a)&&a.length===2&&a.every(i))))&&(!s.shared||Array.isArray(s.shared)&&s.shared.every(e=>["age","sex","bp","mrs","gcs","weight","height","mtici","sahCause"].includes(e)))&&(!s.regions||Array.isArray(s.regions)&&s.regions.every(e=>e&&i(e.key)&&i(e.label)&&[1,2].includes(e.weight))))}function m(t,s){let e=t?.data;return t?._meta?.appVersion===s&&t?._meta?.schemaVersion==="2.0.0"&&A(e?.calculators)&&["topics","studies"].every(a=>Array.isArray(e?.[a])&&e[a].length>0&&new Set(e[a].map(n=>n?.id)).size===e[a].length&&e[a].every(n=>n&&c(n.id)&&i(n.title)&&r(n.keywords)&&r(n.settings)&&n.settings.length&&n.settings.every(o=>["on-call","hospital","clinic"].includes(o))&&Array.isArray(n.sources)&&n.sources.length&&n.sources.every(o=>o&&["title","type","checkedAt","access"].every(u=>i(o[u]))&&Number.isInteger(o.year)&&typeof o.url=="string"&&/^https:\/\/[^\s]+$/.test(o.url))&&(a==="topics"?i(n.category)&&["summary","caution"].every(o=>i(n[o]))&&r(n.consider)&&n.consider.length&&d(n.recommendations)&&Array.isArray(n.related)&&n.related.every(o=>i(o.label)&&/^#\/(?:encounter|tools|protocols|evidence|trials)(?:\/[a-z0-9-]+){0,2}$/.test(o.href)):["question","population","comparison","result","limits"].every(o=>i(n[o]))&&(n.headline===void 0||i(n.headline))&&Number.isInteger(n.year)&&(n.relatedTopic===""||c(n.relatedTopic)))))&&e.studies.every(a=>!e.topics.some(n=>n.id===a.id))&&e.studies.every(a=>a.relatedTopic===""||e.topics.some(n=>n.id===a.relatedTopic))}return f(x);})(); // END GENERATED REFERENCE VALIDATION const validReferenceEnvelope = reference => ReferenceValidation.validReferenceData(reference, APP_VERSION); diff --git a/src/Reference.jsx b/src/Reference.jsx index 883ebc72..9fa336a0 100644 --- a/src/Reference.jsx +++ b/src/Reference.jsx @@ -48,7 +48,7 @@ export default function Reference({ version, focusId, active = true }) { try { await navigator.clipboard.writeText(text); if (epoch.current === request) setCopy({ id: record.id, failed: false }); } catch { if (epoch.current === request) setCopy({ id: record.id, text, failed: true }); } }; - if (failed) return

Evidence unavailable

The reference download failed or is out of date, and this browser has no offline copy of this version. If offline, reconnect, then retry; Encounter entries stay in this session.

; + if (failed) return

Evidence unavailable

The reference download failed or is out of date, and this browser has no offline copy of this version. If offline, reconnect, then retry; Encounter entries stay in this session.

; if (!data) return

Loading evidence…

; const categories = [...new Set(data.topics.map(record => record.category))]; const matchingStudies = searchReference(data.studies, query, setting); @@ -110,7 +110,7 @@ export default function Reference({ version, focusId, active = true }) { Below 1024 px the index scrolls sideways, and Chrome leaves a focused button that is barely in view where it is, so keyboard focus brings the whole button into view (a click does not, so it never moves under the pointer). */} - {widePane ?
{chosen && renderCard(chosen)}
: <> + {widePane ?
{chosen && renderCard(chosen)}
: <> {groups.length > 1 && } {groups.map(([name, entries]) =>

{name}{entries.length}

{entries.map(renderCard)}
)}}

Summaries work offline; source links need internet.

diff --git a/src/Tools.jsx b/src/Tools.jsx index 8ea2d08e..3aa0df5c 100644 --- a/src/Tools.jsx +++ b/src/Tools.jsx @@ -5,7 +5,7 @@ import { ENCOUNTER_TOOLS, matchesCalculatorSearch } from './calculator-utilities export default function Tools(props) { const { data, failed, retry } = useReferenceData(props.version); - if (failed) return

Calculators unavailable

The calculator download failed or is out of date, and this browser has no offline copy of this version. If offline, reconnect, then retry; Encounter entries stay in this session.

; + if (failed) return

Calculators unavailable

The calculator download failed or is out of date, and this browser has no offline copy of this version. If offline, reconnect, then retry; Encounter entries stay in this session.

; if (!data) return

Loading calculators…

; return ; } diff --git a/src/app.jsx b/src/app.jsx index 2ada8dcb..eb6cae77 100644 --- a/src/app.jsx +++ b/src/app.jsx @@ -23,7 +23,7 @@ const Reference = lazy(() => import('./Reference.jsx').then(module => ({ default const Tools = lazy(() => import('./Tools.jsx')); const QuickSearch = lazy(() => import('./components/QuickSearch.jsx')); const QuickReference = lazy(() => import('./components/QuickReference.jsx')); -const APP_VERSION = '7.10.4'; +const APP_VERSION = '7.11.0'; const getPublicDemoMode = () => { if (BUILD_PUBLIC_DEMO) return true; return /(^|\.)github\.io$/i.test(window.location.hostname || ''); @@ -53,6 +53,7 @@ class SurfaceBoundary extends React.Component { state = { failed: false }; static getDerivedStateFromError() { return { failed: true }; } render() { + if (this.state.failed && this.props.styled) return

{this.props.label} unavailable

The {this.props.label.toLowerCase()} download failed. Your Encounter entries remain in this session. Return to Encounter, or explicitly reload when connected to retry; reloading clears the session.

Return to Encounter

; return this.state.failed ?

{this.props.label || 'Protocols'} unavailable

The {(this.props.label || 'Protocols').toLowerCase()} download failed. Your Encounter entries remain in this session. Return to Encounter, or explicitly reload when connected to retry; reloading clears the session.

Return to Encounter
: this.props.children; } } @@ -100,15 +101,26 @@ function App() { window.addEventListener('online', sync); window.addEventListener('offline', sync); return () => { window.removeEventListener('online', sync); window.removeEventListener('offline', sync); }; }, []); - // The More panel closes on Escape or a click outside it. + // The More panel closes on Escape, a press outside it, or focus moving outside it, so it never covers + // the focused control (WCAG 2.4.11). A dialog it opened (the install sheet is portalled) is not outside. useEffect(() => { const close = event => { const panel = utilitiesRef.current; if (!panel?.open) return; - if (event.type === 'keydown' ? event.key === 'Escape' : !panel.contains(event.target)) { panel.open = false; if (event.type === 'keydown') panel.querySelector('summary')?.focus(); } + if (event.type === 'keydown') { + // An open dialog (the install sheet) handles its own Escape and restores focus. + if (event.key !== 'Escape' || document.activeElement?.closest?.('[role="dialog"]')) return; + const inside = panel.contains(document.activeElement); + panel.open = false; + if (inside) panel.querySelector('summary')?.focus(); + return; + } + const target = event.target; + if (!(target instanceof Node) || panel.contains(target) || (target instanceof Element && target.closest('[role="dialog"]'))) return; + panel.open = false; }; - document.addEventListener('keydown', close); document.addEventListener('pointerdown', close); - return () => { document.removeEventListener('keydown', close); document.removeEventListener('pointerdown', close); }; + document.addEventListener('keydown', close); document.addEventListener('pointerdown', close); document.addEventListener('focusin', close); + return () => { document.removeEventListener('keydown', close); document.removeEventListener('pointerdown', close); document.removeEventListener('focusin', close); }; }, []); useLayoutEffect(() => { const header = document.querySelector('.workspace-header'); @@ -317,7 +329,7 @@ function App() { const protocolSub = ['ich', 'sah'].includes(state.note.diagnosisCategory) ? 'ich' : 'ischemic'; const primaryNav = ; const failedUpdate = () => setUpdateReady({ message: 'Update failed. Current encounter remains open; try again when connected.' }); - const utilities =
{ if (event.currentTarget.open) setUtilitiesVisited(true); }}>More{updateDeferred && }
{updateDeferred && }{utilitiesVisited && Loading install options…

}> { if (!installPrompt) return; try { await installPrompt.prompt(); const choice = await installPrompt.userChoice; if (choice.outcome === 'accepted') setInstalled(true); setInstallPrompt(null); } catch { setInstallPrompt(null); } }} />}

Ctrl/⌘ K or / search

Version {APP_VERSION}

{offlineStatus}

; + const utilities =
{ if (event.currentTarget.open) setUtilitiesVisited(true); }}>More{updateDeferred && }
{updateDeferred && }{utilitiesVisited && Loading install options…

}> { if (!installPrompt) return; try { await installPrompt.prompt(); const choice = await installPrompt.userChoice; if (choice.outcome === 'accepted') setInstalled(true); setInstallPrompt(null); } catch { setInstallPrompt(null); } }} />}

Ctrl/⌘ K or / search

Version {APP_VERSION}

{offlineStatus}

; const externalReferences = ; // NIHSS, mRS, renal and GCS tools always render; ICH volume and severity need an ICH encounter, the rest acute ischemic stroke (DAPT also TIA). const ichTool = ['ich-volume', 'ich-score'].includes(route.tool); @@ -336,16 +348,16 @@ function App() { service worker) the banner repeats the More panel's status, which says this tab needs internet. */}

{online ? '' : `Offline · ${navigator.serviceWorker?.controller ? 'the workspace still works; external and source links need internet' : offlineStatus}`}

- {searchVisited && setSearchOpen(false)} onFocusEncounter={goToEncounter} version={APP_VERSION} protocolSub={route.surface === 'protocols' && route.sub ? route.sub : protocolSub} />} + {searchVisited && setSearchOpen(false)} onFocusEncounter={goToEncounter} version={APP_VERSION} protocolSub={route.surface === 'protocols' && route.sub ? route.sub : protocolSub} />} {/* Always rendered, so screen readers hear the update notice when it appears; a live region inserted together with its text often is not announced. */}

{updateReady ? updateReady.message || UPDATE_READY_TEXT : ''}

{updateReady && }
{protocolVisited && } - {trialsVisited && } - {evidenceVisited && } - {route.surface === 'tools' && Loading calculators…

}>} + {trialsVisited && } + {evidenceVisited && } + {route.surface === 'tools' && Loading calculators…

}>} {route.surface === 'retired' &&

Retired destination

This route is no longer maintained in the lean Stroke workspace.

Return to Encounter · Calculators

}
; diff --git a/src/components/CaseBar.jsx b/src/components/CaseBar.jsx index 45523672..bc45f95a 100644 --- a/src/components/CaseBar.jsx +++ b/src/components/CaseBar.jsx @@ -181,7 +181,8 @@ export default function CaseBar({ state, documentLabel, blocked, onCopy, copySta {(acuteIschemic || c.administered) && }
- Dose table + {/* Thrombolytic dosing only where it can apply: acute ischemic stroke, a recorded administration, or no diagnosis yet. */} + {(acuteIschemic || c.administered || !state.note.diagnosisCategory) && Dose table} {bpLink && BP targets} {c.administered && Post-lytic bleed} {c.administered && c.aceInhibitor && Angioedema} diff --git a/src/components/EligibilityTables.jsx b/src/components/EligibilityTables.jsx index c4084271..81a3caed 100644 --- a/src/components/EligibilityTables.jsx +++ b/src/components/EligibilityTables.jsx @@ -19,7 +19,7 @@ export function buildTableHtml(table) { } function StudyIdentity({ trial }) { - return <>

{trial.acronym}

{trial.nct && {trial.nct} ↗}

{sourceRecord(trial)}

; + return <>

{trial.acronym}

{trial.nct && {trial.nct}}

{sourceRecord(trial)}

; } function StudySummary({ trial }) { diff --git a/src/components/TrialScreener.jsx b/src/components/TrialScreener.jsx index ad9140f0..33c1e5ed 100644 --- a/src/components/TrialScreener.jsx +++ b/src/components/TrialScreener.jsx @@ -45,12 +45,12 @@ export function TrialSourceContext({ trial, now = null }) { function TrialDetailsModal({ trial, onClose, now = null }) { const dialogRef = useRef(null), closeRef = useRef(null); useDialogChrome({ dialogRef, initialFocusRef: closeRef, onClose }); - return createPortal(<>