Intracerebral Haemorrhage – From Blood Pressure Control to Secondary Brain Injury

Embolic stroke of undetermined source (ESUS) accounts for a substantial proportion of ischaemic strokes. But could new imaging techniques help uncover the causes that conventional investigations have missed? In the latest Voice of Stroke podcast episode, we explore three recent studies examining how advanced imaging, carotid plaque assessment and thrombus composition may help identify the underlying mechanisms of cryptogenic stroke. This episode discusses: A novel PET imaging technique that may directly identify the source of thrombosis in patients with ischaemic stroke Whether CT angiography and Plaque-RADS can identify high-risk non-stenotic carotid plaques associated with ESUS How the composition of thrombi retrieved during thrombectomy may reveal distinct stroke mechanisms Featuring discussion of recent research published in Circulation, Neurology, and Neurological Sciences. Written by: Voice of Stroke Podcast Editor Robert Hurford from University of Oxford, and Voice of Stroke Editor-in-Chief Linxin Li from University of Oxford. Read the full transcript: https://eso-stroke.org/wp-content/uploads/ESOPodacst_EP9_Transcript.pdf ____ This podcast series is supported by an unrestricted educational grant from Bayer

Medium or distal vessel occlusions account for up to a third of ischaemic stroke, but recent randomised trials have raised important questions about the role of thrombectomy in these patients. In the latest Voice of Stroke podcast episode, we explore new evidence searching for the "green flags" that could help identify patients with medium or distal vessel occlusion who may benefit from thrombectomy. This episode discusses: • The ORIENTAL-MeVO trial and thrombectomy in patients with moderate-to-severe neurological deficits • Whether baseline imaging and collateral status may help identify differences in treatment response • Evidence from DISTAL examining whether thrombectomy can preserve threatened brain tissue Featuring discussion of recent research published in: · New England Journal of Medicine · Radiology · JAMA Neurology Written by: Umberto Pensato, Voice of Stroke Podcast Editor, and Linxin Li, Voice of Stroke Editor-in-Chief. Read the full transcript. References 1. Liu J, Cui T, Wen J, et al. Endovascular Treatment of Medium-Vessel-Occlusion Strokes. N Engl J Med. 2026;394:1894-1904. 2. Ospel JM, Diprose WK, Uchida K, et al. Reperfusion Therapy in ESCAPE-MeVO Trial Participants: Imaging Characteristics and Clinical Outcomes. Radiology. 2026;319:e251769. 3. Anastasiou A, Corbaz H, Christodoulou E, et al. Mechanical Thrombectomy and Final Infarct Volume in Medium or Distal Vessel Occlusion Stroke: A Post Hoc Analysis of a Randomized Clinical Trial. JAMA Neurol. 2026;83:537-543. 4. Goyal M, Ospel JM, Ganesh A, et al. Endovascular Treatment of Stroke Due to Medium-Vessel Occlusion. N Engl J Med. 2025;392:1385-1395. 5. Psychogios M, Brehm A, Ribo M, et al. Endovascular Treatment for Stroke Due to Occlusion of Medium or Distal Vessels. N Engl J Med. 2025;392:1374-1384. 6. Clarençon F, Bala F, Baptiste A, et al. Mechanical Thrombectomy in Ischemic Stroke With a Medium or Distal Arterial Occlusion: The DISCOUNT Randomized Clinical Trial. JAMA. 2026;336:755–764. 7. Prabhakaran S, et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke. Stroke. 2026;57:e316–e436.

Endovascular thrombectomy has transformed the treatment of large vessel occlusion stroke. But as its use expands, important questions remain about where its boundaries lie. In this episode of Voice of Stroke, we explore three recent studies examining patient selection and treatment intensity at the margins of thrombectomy practice. This episode discusses: • The CHOICE-2 trial and adjunctive intra-arterial alteplase after successful thrombectomy • Whether ischaemic core volume may refine patient selection beyond ASPECTS in large-core stroke • The AURORA pooled analysis examining the role of time in imaging-selected patients treated in the extended 6–24-hour window Featuring discussion of recent research published in JAMA, Stroke, and Neurology. Written by: Robert Hurford, Voice of Stroke Podcast Editor, and Linxin Li, Voice of Stroke Editor-in-Chief. Read the full transcript here References · Renú A, Fernández-Couto MD, de la Riva P, et al. Adjunctive Intra-Arterial Alteplase After Successful Thrombectomy for Acute Ischemic Stroke: The CHOICE-2 Randomized Clinical Trial. JAMA. 2026. · Jiang X, Zhao Z, Zhang Y, et al. Intra-arterial thrombolysis following endovascular recanalization for large vessel occlusion stroke: a systematic review and meta-analysis. Neurology. 2025. · Kim H, Ryu WS, Inoue M, et al. Defining the Therapeutic Ceiling of Endovascular Thrombectomy in Large-Core Stroke: Beyond the Limits of ASPECTS. Stroke. 2026. · Sarraj A, Hassan AE, Abraham MG, et al. Endovascular thrombectomy for large ischemic stroke across ischemic injury and penumbra profiles. JAMA. 2024. · Sarraj A, Thomalla G, Yoshimura S, et al. Endovascular thrombectomy for patients with large-core ischaemic stroke presenting up to 24 h after onset (ATLAS). Lancet. 2026. · Nogueira RG, Jovin TG, Lansberg MG, et al. Time to Treatment in Stroke Thrombectomy and Outcomes in the Extended Time Window: A Meta-Analysis. Neurology. 2026.

Cerebral small vessel disease is increasingly recognised as one of the leading causes of stroke, cognitive impairment and dementia worldwide. Despite its enormous clinical impact, disease-modifying therapies remain limited. In this episode of Voice of Stroke, we explore how advances in biomarker discovery and cerebrovascular physiology are reshaping our understanding of cSVD and identifying promising new therapeutic targets. This episode discusses: The global burden of cerebral small vessel disease Cerebrospinal fluid and blood biomarkers for disease characterisation and progression Cerebral autoregulation as an emerging physiological biomarker The potential role of phosphodiesterase-5 inhibitors and other therapies targeting cerebral vascular function Featuring discussion of recent research published in: International Journal of Stroke Nature Aging Alzheimer's Research & Therapy Frontiers in Neurology Written by: Annemijn Algra, Voice of Stroke Podcast Editor, and Linxin Li, Voice of Stroke Editor-in-Chief. Read the full transcript References 1. Lam BYK, et al. Global burden of cerebral small vessel disease determined from large MRI studies: A systematic review and meta-analysis. International Journal of Stroke. 2026. 2. Hristovska I, et al. Identification of distinct and shared biomarker panels in different manifestations of cerebral small-vessel disease through proteomic profiling. Nature Aging. 2026. 3. Yang D, et al. Plasma extracellular vesicle proteins biomarker for cerebral small vessel disease related cognitive impairment. Alzheimer's Research & Therapy. 2026. 4. Webb AJS, et al. The role of impaired autoregulation in cerebral small vessel disease and vascular cognitive impairment. International Journal of Stroke. 2026. 5. Yan L, et al. Phosphodiesterase-5 inhibitors for cerebral small vessel disease-related ischemic stroke and cognitive decline: Systematic review and meta-analysis. Frontiers in Neurology. 2026.

How should clinicians think about hypertension in 2026? In this episode of Voice of Stroke, we explore recent evidence addressing one of the most important questions in vascular prevention: not simply whether to lower blood pressure, but which treatments work best, who should be treated, and how hypertension-related vascular disease may influence stroke mechanisms and secondary prevention. This episode discusses: Meta-analyses evaluating the efficacy and tolerability of antihypertensive drugs and combinations Blood pressure lowering in isolated diastolic hypertension An exploratory analysis of the ARCADIA trial examining high-risk hypertension features and recurrent stroke prevention Featuring discussion of recent studies published in The Lancet, JAMA, European Heart Journal and JAMA Neurology. Written by Voice of Stroke Podcast Editor-In-Chief Linxin Li and Co-Editor Maria Magdalena Gabriel. Read the full transcript here. References Ridha M et al. Hypertension With High-Risk Features in Cryptogenic Stroke: An Exploratory Analysis of the ARCADIA Randomized Clinical Trial. JAMA Neurology. 2026. Bidel Z et al. Blood pressure lowering in isolated diastolic hypertension and cardiovascular risk: an individual patient data meta-analysis. European Heart Journal. 2026. Wang N et al. Blood pressure-lowering efficacy of antihypertensive drugs and their combinations. The Lancet. 2025. Wang N et al. Adverse Effects and Treatment Discontinuation of Blood Pressure-Lowering Drugs and Combinations. JAMA. 2026. Blood Pressure Treatment Efficacy Calculator: https://www.bpmodel.org/blood-pressure-treatment-efficacy-calculator/