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Background: Neurological deterioration (ND) after mechanical thrombectomy (MT) of acute ischemic stroke (AIS) in anterior circulation is an important complication associated with a poor outcome. Moreover, evident causes of ND may remain unexplained (UnND). Objective: We sought to evaluate the association of the systolic blood pressure (SBP) parameters before MT, during MT, and during a 24-h period after MT with UnND. Methods: We analyzed 382 MT-treated AIS patients in two stroke centers from 2017 to 2019. The patients with unsuccessful recanalization and/or with symptomatic intracerebral hemorrhage after MT were excluded. Multivariate logistic regression analysis was used to identify the SBP parameters that predict UnND. Results: There were 5.9% patients with UnND within 24 h after MT among patients with successful recanalization what comprises 4.9% of all patients who had undergone MT. SBP > 180 mmHg on admission (odds ratio (OR): 4, 95% confidence interval (CI): 1.6–10, p = 0.004) and a drop of SBP below100 mmHg during MT (OR: 4.7, 95% CI: 1.3–17, p = 0.019) were associated with UnND occurrence within 7 days without a significant association with UnND within 24 h. UnND within 7 days was predicted by the episodes of SBP exceeding the level of SBP observed before the groin puncture and occurring over the first 2 h following recanalization (OR: 5, 95% CI: 1.3–19, p = 0.021), an increase of SBP of more than 20% within 2–24 h after MT (OR: 3.4, 95% CI: 1.1–10, p = 0.035), and a drop of SBP below 100 mmHg after MT (OR: 3.2, 95% CI: 1.1–9, p = 0.039). Conclusion: The association between the SBP parameters and UnND depends on the treatment period and the time of UnND occurrence. The J/U resembling relationship between SBP and UnEND was established during a 24-h period after MT.

Background and Objectives: Contralateral A1 and AComA aplasia/hypoplasia are critically important in distal ICA T occlusion as the protective collateral blood supply from the circle of Willis via the anterior communicating artery is compromised. Although the terms aplasia/hypoplasia are used broadly in the literature, the need for concrete measurements and data on their clinical significance is apparent. Features of the individual anatomy of the circle of Willis may determine patient outcomes. We aim to determine the cut-off values of contralateral A1 and AComA segments that determine worse outcomes for patients with acute ischemic stroke with T occlusion of the terminal internal carotid artery. Material and Methods: Retrospective patient data from 2015 to 2020 and prospective data from 2021 to 2022 of 482 patients with diagnosed acute ischemic stroke that underwent mechanical thrombectomy at the Republican Vilnius University Hospital (Vilnius, Lithuania) were obtained. Of these patients, 70 were selected with occlusion of internal carotid artery bifurcation and extension to M1 or A1 segments. For statistically significant interactions, patient data were analyzed using two statistical methods (logistic regression and Multivariate Adaptive Regression Splines (MARS)). Results: The narrowest segment of contralateral A1 and/or AComA was statistically significant for 7-day NIHSS, and the optimal cut-off points for this variable were 1.1 mm (MARS model) and 1.2 mm (logistic regression, p = 0.0079, sensitivity 66.7%, specificity 67.9%). The other considered variables (age, gender, time from last seen well to groin puncture, intravenous recombinant tissue plasminogen activator, admission NIHSS, and ASPECT score) and their interactions were not statistically significant. Conclusions: A negative correlation was found between the narrowest segment and seven days of NIHSS. A larger diameter of contralateral A1 and AComA appears to be essential for better patient outcomes at 7-day evaluation post mechanical thrombectomy.

Background and Objectives: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with a five-fold increased risk for acute ischemic stroke (AIS). We aimed to estimate the prevalence of AF in a Lithuanian cohort of stroke patients, and its impact on patients regarding case fatality, functional outcome, and health-related quality of life (HRQoL) at 90 days. Materials and Methods: A single-center prospective study was carried out for four non-consecutive months between December 2018 and July 2019 in one of the two comprehensive stroke centers in Eastern Lithuania. A telephone-based follow-up was conveyed at 90 days using the modified Rankin Scale (mRS) and EuroQoL five-dimensional three-level descriptive system (EQ-5D-3L) with a self-rated visual analog scale (EQ-VAS). One-year case fatality was investigated. Results: We included 238 AIS patients with a mean age of 71.4 ± 11.9 years of whom 45.0% were female. A striking 97 (40.8%) AIS patients had a concomitant AF, in 68 (70.1%) of whom the AF was pre-existing. The AIS patients with AF were at a significantly higher risk for a large vessel occlusion (LVO; odds ratio 2.72 [95% CI 1.38–5.49], p = 0.004), and had a more severe neurological impairment at presentation (median NIHSS score (interquartile range): 9 (6–16) vs. 6 (3–9), p < 0.001). The LVO status was only detected in those who had received computed tomography angiography. Fifty-five (80.9%) patients with pre-existing AF received insufficient anticoagulation at stroke onset. All patients received a 12-lead ECG, however, in-hospital 24-h Holter monitoring was only performed in 3.4% of AIS patients without pre-existing AF. Although multivariate analyses found no statistically significant difference in one-year stroke patient survival and favorable functional status (mRS 0–2) at 90 days, when adjusted for age, gender, reperfusion treatment, baseline functional status, and baseline NIHSS, stroke patients with AF had a significantly poorer self-perceived HRQoL, indicated by a lower EQ-VAS score (regression coefficient ± standard error: β = −11.776 ± 4.850, p = 0.017). Conclusions: In our single-center prospective observational study in Lithuania, we found that 40.8% of AIS patients had a concomitant AF, were at a higher risk for an LVO, and had a significantly poorer self-perceived HRQoL at 90 days. Despite the high AF prevalence, diagnostic tools for subclinical AF were greatly underutilized.

Abstract Background and aims The Stroke Action Plan for Europe (SAP-E) 2018–2030 targets >90% of stroke patients receiving first-line care in dedicated stroke units. By law, Lithuanian suspected stroke patients are transported to the nearest stroke-ready hospital for diagnostic confirmation. We compared long-term survival between acute ischemic stroke (AIS) patients subsequently hospitalized at Vilnius University Hospital (VUH) and those transferred to non-stroke centers (NCs). Methods We retrospectively identified AIS patients, diagnosed between October 2020 and October 2025 at VUH, one of six Lithuanian comprehensive stroke centers (CSCs), and linked clinical data to the Lithuanian Death Registry. Patients were grouped according to treatment location (CSC vs NC). Survival time was defined from stroke onset to death or administrative censoring, with follow-up truncated at 5 years. Survival was compared using Kaplan–Meier curves and the log-rank test. Cox proportional hazards models were used to estimate adjusted mortality risk. Results A total of 5,589 patients were included. Survival was significantly higher in the CSC group compared to NCs both at 90 days (80.6% vs 71.9%) and 5 years (58.4% vs 45.9%, P<0.0001). Kaplan-Meier curves diverged early after stroke onset and remained almost parallel throughout the 5-year follow-up. After adjustment for age, sex, baseline NIHSS, and reperfusion therapy, treatment at the CSC was associated with significantly lower mortality compared with transfer to NCs (HR 0.88, 95% CI 0.80–0.98). Conclusions AIS patients treated at a CSC demonstrated significantly better long-term survival than those transferred to NCs, supporting SAP-E goals and underscoring the benefits of stroke unit care. Conflict of interest All authors: nothing to disclose. Figure 1 - belongs to Methods Figure 2 - belongs to Results Figure 3 - belongs to Conclusions

Background Stroke remains a major public health challenge in Europe with regional disparities. Although the Baltic states share similar demographic and socioeconomic profiles, they differ in stroke care networks and treatment infrastructure. To date, no direct cross‐country comparison of stroke care has been published. Methods We conducted a multicenter cross‐sectional analysis of ischemic stroke patients, prospectively recorded in the Registry of Stroke Care Quality (RES‐Q) by 23 of 26 primary and comprehensive stroke centers across the Baltic states during at least 1 month of the first quarter of 2022. Data on demographic characteristics, stroke risk factors, acute management, and discharge destinations were compared with assess intercountry differences. Results A total of 897 ischemic stroke patients were analyzed: 479 from Lithuania, 294 from Latvia, and 124 from Estonia. Although atrial fibrillation (AF) rates were uniformly high (overall 37.2%), anticoagulant use at stroke onset among patients with known AF was significantly higher in Estonia (72.7%) compared with Latvia (34.9%) and Lithuania (48.8%, p = 0.032). Estonia reported the highest intravenous thrombolysis (IVT) rates (44.4%), whereas Lithuania achieved the highest endovascular treatment (EVT) rates (17.7%). In contrast, Latvia had the lowest recanalization therapy rates (IVT 21.1%, EVT 5.1%). Rehabilitation access varied strikingly: Only 2.7% of Latvian patients were transferred to inpatient rehabilitation compared with 30.5% in Lithuania and 20.2% in Estonia (p < 0.001). Conclusions This first comprehensive comparison of stroke care in the Baltic states highlights a high AF burden and important disparities in recanalization therapy and poststroke rehabilitation pathways. Data Access Statement The data supporting this study′s findings are available from the corresponding author upon reasonable request.

Introduction: Reperfusion therapy (RT) is a mainstay treatment for acute ischemic stroke (AIS). We aimed to evaluate the impact of a comprehensive national policy (CNP) to improve access to RT for AIS patients across Lithuania. Patients and methods: Aggregated anonymized data on AIS cases treated in Lithuanian hospitals between 2006 and 2019 were retrospectively obtained from the Institute of Hygiene and the Stroke Integrated Care Management Committee. Through an interrupted time series analysis, we examined the trends in AIS hospital admissions, RT, and in-hospital case fatality rates prior to the enactment of CNP in 2014, changes immediately after the intervention, and differences in trends between the pre- and post-intervention periods. Mean yearly door-to-needle times were calculated post-intervention. Results: 114,436 cases were treated for AIS in Lithuanian hospitals before, and 65,084 after the government intervention. We observed a significant decreasing post-intervention trend change in AIS hospital admission rate per 100,000 population (regression coefficient ± standard error: β = –16.47 ± 3.95, p = 0.002) and an increasing trend change in the proportion of AIS patients who received reperfusion treatment: intravenous thrombolysis (β = 1.42 ± 0.96, p < 0.001) and endovascular therapy (β = 0.85 ± 0.05, p < 0.001). The proportion of patients treated in stroke centers increased immediately after the intervention (β = 4.95 ± 1.14, p = 0.001), but the long-term post-intervention trend did not change. In addition, there was a significant decreasing trend in all cause in-hospital case fatality rate within primary and comprehensive stroke centers after the intervention (β = –0.60 ± 0.18, p = 0.008) despite its prompt initial immediate increase (β = 1.68 ± 0.73, p = 0.043). The mean countrywide door-to-needle time decreased from 68 min in 2014 to 43 min in 2019. Conclusion: The comprehensive national stroke patient care policy could be associated with an immediate increase in stroke center treatment rate, increased access to RT, and improved stroke care performance measures. Graphical abstract

Introduction: Endovascular treatment (EVT) improves outcomes for basilar artery occlusion (BAO) with moderate-to-severe symptoms. However, the best treatment for mild symptoms (NIHSS score 0–10 and 0–5) remains unclear. This study compared EVT ± IVT to IVT alone in BAO patients with mild symptoms. Patients and Methods: From the SITS-International Stroke Treatment Register, we included BAO patients with available baseline NIHSS score, treated by EVT, IVT, or both within 6 h of symptom onset from 2013 to 2021. Using the Doubly Robust approach (propensity score matching plus multivariable logistic regression), we analyzed efficacy (3-month mRS) and safety (SICH and 3-month death) outcomes for EVT ± IVT versus IVT alone in BAO patients with NIHSS scores 0–10 and 0–5. Results: 1426 patients were included. For NIHSS scores 0–10 (180 matched, 1:1 ratio), outcomes were similar between EVT ± IVT and IVT alone groups. For NIHSS scores 0–5 (89 matched, 1:1 ratio), EVT ± IVT was associated with worse outcomes compared to IVT alone (mRS 0–2, aOR 0.20 [95% CI 0.06–0.61]; p = 0.005; mRS 0–3, aOR 0.27 [95% CI 0.08–0.89]; p = 0.031), but safety outcomes were similar. Discussion: In early-treated BAO patients with mild symptoms, defined as NIHSS 0–10, there were no significant differences in outcomes between EVT ± IVT and IVT alone. However, for very mild symptoms, defined as NIHSS 0–5, IVT alone was associated with better outcomes compared to EVT ± IVT.Conclusion: Randomized trials are crucial to determine the optimal reperfusion therapy for BAO patients with mild symptoms. Graphical abstract

Organised stroke care and reperfusion therapies are key components of modern stroke treatment. We assessed accessibility of organised stroke care and reperfusion therapies in Europe and explored its association with key organisational indicators. Stroke Action Plan for Europe (SAP-E) Stroke Service Tracker data from 2023 reported by 47 European countries was assessed. Accessibility indicators included stroke unit (SU) admission proportions, intravenous thrombolysis (IVT) and EVT treatment proportions. Organisational indicators included the facility density of SU, IVT-capable centres and EVT-capable centres per capita (number of centres per 100,000 population), presence of national stroke plans and quality programmes. Across Europe, marked variations were observed in facility density of SU (0.21-0.48), IVT-capable centres (0.19-0.45) and EVT-capable centres (0.06-0.15). SU admission proportions ranked from 0.8% to 96.7%, IVT treatment proportions from 1.3% to 34.7% and EVT treatment proportions from 0.2% to 14.3%. Stroke unit admission proportions were associated with SU density (r = 0.42, P = .03). Density of reperfusion-capable centres showed a possible trending association with IVT treatment proportions (r = 0.34, P = .08), but no association with EVT treatment proportions (r = 0.22, P = .23). Neither the presence of a national stroke plan nor a quality programme were associated with accessibility of SU care, IVT or EVT. Large inequities in access to organised stroke care and reperfusion therapies persist across Europe. At the country level, national stroke plans and quality programmes have not yet translated into effect on accessibility indicators, suggesting that achieving effective implementation takes time or could primarily manifest as within-country improvements.

As there are scarce data regarding the outcomes of acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT) within 60 min from symptom onset (“golden hour”), we sought to compare outcomes between AIS patients treated within [GH(+)] and outside [GH(−)] the “golden hour” by analyzing propensity score matched data from the SITS-EAST registry. Clinical recovery (CR) at 2 and 24 h was defined as a reduction of ≥10 points on NIHSS-score or a total NIHSS-score of ≤3 at 2 and 24 h, respectively. A relative reduction in NIHSS-score of ≥40% at 2 h was considered predictive of complete recanalization (CREC). Symptomatic intracranial hemorrhage (sICH) was defined using SITS-MOST criteria. Favorable functional outcome (FFO) was defined as a mRS-score of 0–1 at 3 months. Out of 19,077 IVT-treated AIS patients, 71 GH(+) patients were matched to 6882 GH(−) patients, with no differences in baseline characteristics ( p  > 0.1). GH(+) had higher rates of CR at 2 (31.0 vs. 12.4%; p  < 0.001) and 24 h (41 vs. 27%; p  = 0.010), CREC at 2 h (39 vs. 21%; p  < 0.001) and FFO (46.5 vs. 34.0%; p  = 0.028) at 3 months. The rates of sICH and 3-month mortality did not differ ( p  > 0.2) between the two groups. GH(+) was associated with 2-h CR (OR: 5.34; 95% CI 2.53–11.03) and CREC (OR: 2.38; 95% CI 1.38–4.09), 24-h CR (OR: 1.88; 95% CI 1.08–3.26) and 3-month FFO (OR: 2.02; 95% CI 1.15–3.54) in multivariable logistic regression models adjusting for potential confounders. In conclusion, AIS treated with IVT within the GH seems to have substantially higher odds of early neurological recovery, CREC, 3-month FFO and functional improvement.

Introduction: Data is limited on the safety of early initiation of direct oral anticoagulation (DOAC) treatment after acute ischemic stroke (AIS) receiving reperfusion therapy in patients with atrial fibrillation (AF). We investigated the timing of DOAC initiation and its association with safety and outcomes. Materials and methods: We included AIS patients receiving reperfusion therapy with AF diagnosis (prevalent or new) registered in the Safe Implementation of Treatments in Stroke international registry during 2013–2024. Safety outcomes were hemorrhage and death. Secondary outcomes were recurrent AIS, any embolism and functional independence (modified Rankin Scale [mRS] 0–2) at 3 months. We performed descriptive statistics and multivariable analysis for DOAC initiation time as an ordinal variable (0–3, 4–7, and 8–100 days after stroke onset) and its association with outcomes. Explorative analyses were performed to investigate factors associated with DOAC initiation time, as a continuous or ordinal variable. Results: In total, 13,389 patients had data on DOAC initiation time, and 7861 patients had new event data by 3-month follow-up. We observed 0.1% intracranial hemorrhage, 0.4% major extracranial hemorrhage, 1.1% recurrent ischemic stroke, and 0.2% systemic embolism. At 3 months, 4.8% patients had died, and functional independence was seen in 60.9%. In multivariable analyses, DOAC initiation after stroke onset was not associated with any outcomes. Higher 24 h NIHSS and lower pre-stroke mRS score were associated with delayed DOAC initiation. Conclusion: DOAC initiation time was not associated with any outcomes in AIS patients who received reperfusion therapy. Severe stroke symptoms at 24 h were associated with delayed DOAC initiation. The low incidence of safety outcomes and missing data in this study should lead to cautious interpretations of these results. Graphical abstract