Introduction

The 12th European Stroke Organisation Conference (ESOC), held May 6–8, 2026, delivered important advances across acute stroke intervention, secondary prevention, and rehabilitation. Building on this meeting, the VJNeurology Post-ESOC 2026 Highlights webinar, chaired by Diana Aguiar de Sousa, MD, PhD, Central Lisbon University Hospital Center, Lisbon, Portugal, and moderated by Michele Romoli, MD, PhD, Bufalini Hospital, Cesena, Italy, and Thalia Field, MD, The University of British Columbia, Vancouver, Canada, brought together leading investigators to discuss selected abstracts from the congress program. We have selected our top five practice-changing abstracts from the webinar.

ATLAS study: Meta-analysis demonstrates mechanical thrombectomy benefit in large-core ischemic stroke

Mechanical thrombectomy for large-core ischemic stroke has been an important paradigm shift in stroke care in recent years. At ESOC 2026 and the Post-ESOC 2026 Highlights webinar, Amrou Sarraj, MD, University Hospitals, Cleveland, OH, presented the ATLAS individual patient-level meta-analysis, combining data from six randomized trials and 1,886 patients. The analysis aimed to clarify treatment effects across imaging-defined subgroups following central adjudication and reprocessing of imaging data.¹

Approximately half of patients were treated beyond six hours after symptom onset, and nearly 20% had an ASPECTS score of 0–2. In the pooled analysis, thrombectomy was associated with a shift towards improved functional outcomes, with an estimated number needed to treat of four for a one-point improvement on the modified Rankin Scale.¹

In addition to the overall shift in disability outcomes, thrombectomy was also associated with improvements in several clinically relevant measures. Approximately 20% of patients achieved functional independence, representing a three-fold increase over medical management, while rates of independent ambulation approached 40%, and were approximately doubled compared with medical therapy alone. Thrombectomy was also associated with lower mortality, suggesting that its effects extended beyond disability reduction alone.¹

Presenting the findings during the webinar, Dr Sarraj emphasized the consistent benefit observed across patient subgroups:
“The ATLAS individual patient-level data analysis demonstrated an overwhelming benefit of thrombectomy in an important population [of patients] with large-core stroke”

Benefit was maintained regardless of age, timing, ASPECTS score, mismatch status, and ischemic core volume across treatment windows extending up to 24 hours from stroke onset, although evidence was limited in patients with core volumes ≥150 ml treated in the late time window.¹

The ATLAS analysis provides additional evidence supporting the use of endovascular thrombectomy in patients with large-core ischemic stroke, with treatment benefit observed across a broad range of clinical and imaging subgroups.¹

CASES trial: Immediate carotid artery stenting during thrombectomy demonstrates favorable safety and patency outcomes 

The optimal management of tandem lesions in patients undergoing endovascular thrombectomy for acute ischemic stroke remains uncertain. At ESOC 2026 and the Post-ESOC 2026 Highlights webinar, Maarten Uyttenboogaart, MD, University Medical Center Groningen, Groningen, The Netherlands, presented the key findings from the CASES trial (NCT06511089), which investigated whether immediate carotid artery stenting (CAS) during thrombectomy was non-inferior to a deferred treatment strategy. Deferred treatment included carotid endarterectomy (CEA), delayed CAS, and/or best medical management.²

The open-label, international, multi-center, randomized controlled trial enrolled 633 patients with ischemic stroke due to a tandem lesion from 27 centers in the Netherlands and Belgium.²

In the full analysis set, immediate stenting did not meet the pre-specified criteria for non-inferiority compared with deferred treatment. However, in the per-protocol analysis, non-inferiority was demonstrated.²

Immediate CAS was associated with substantially higher carotid artery patency. At 24 hours, patency rates were 90% in the immediate CAS group compared with 45% in the deferred treatment group. These findings persisted at 90 days, with patency rates of 90% and 39%, respectively.² 

Immediate stenting was not associated with an increase in safety events. Symptomatic intracranial hemorrhage (sICH) occurred in 2.1% of patients who received immediate CAS, and 3.8% of patients who received deferred treatment. Mortality rates were similar between both treatment groups.²

Although the primary endpoint was only met in the per-protocol population, immediate CAS during thrombectomy was associated with higher carotid artery patency and was not accompanied by an increase in sICH or mortality.²

DISTALS trial: Supports the safety and technical effectiveness of a novel stent-retriever for clot removal in DMVO patients

The role of endovascular thrombectomy in distal medium vessel occlusions (DMVOs) remains an area of ongoing investigation. At ESOC 2026 and the Post-ESOC 2026 Highlights webinar, the final results of the DISTALS (distal ischemic stroke treatment with adjustable low-profile stentriever) randomized trial of Tigertriever 13-EVT for DMVO (NCT05152524) were presented by Jeffrey Saver, MD, UCLA Comprehensive Stroke Center, Los Angeles, CA.³

The multicenter, prospective, randomized trial with blinded endpoint assessment evaluated the safety and effectiveness of the Tigertriever13 revascularization device in patients with DMVOs who were ineligible for thrombolysis.³

149 patients were enrolled, including 31 patients in the lead-in phase. In the randomized phase, 118 patients were allocated to thrombectomy plus best medical management or medical therapy alone. The primary endpoint, successful reperfusion at 24 hours without sICH was achieved in 86.3% of patients receiving thrombectomy compared with 27.7% receiving medical management (p<0.001). No sICHs occurred in randomized patients treated with the device.³

The study was not powered for clinical efficacy, and rates of excellent functional outcomes (mRS 0–1) at three months were comparable between the thrombectomy and medical management groups (41% versus 38%, respectively). However, exploratory analyses suggested potential benefit among patients presenting with more severe neurological deficits, and among those treated under general anesthesia.³

Overall, the findings from the DISTALS study support the technical effectiveness and safety of thrombectomy using the TIGERTRIEVER13 stent-retriever device in patients with DMVO, while highlighting the need for improved patient selection to better determine the clinical benefit.³

TAILSWITCH study: Individualized DOAC monitoring may improve secondary prevention

Despite anticoagulation, recurrent stroke remains a major problem in patients with atrial fibrillation. At ESOC 2026 and the Post-ESOC 2026 Highlights webinar, Michele Romoli presented findings from the TAILSWITCH study, which investigated whether tailoring direct oral anticoagulant (DOAC) therapy according to plasma drug levels could improve outcomes^.4

The prospective, multicenter cluster-level intervention study enrolled 616 patients with breakthrough stroke while receiving anticoagulation, including 502 patients who received standard of care and 114 patients who underwent DOAC plasma level monitoring (data shown during webinar presentation).⁴

In the monitoring group, 23 of 114 patients (20%) required a change in anticoagulant as plasma drug levels indicated inadequate anticoagulation (data shown during webinar presentation).⁴

Functional outcomes were comparable between the two groups, with similar rates of modified Rankin scale scores of 0–2 at 90 days. Importantly, this monitoring strategy did not prolong hospitalization, with a median length of stay of 7 days in both groups (data shown during webinar presentation).⁴

Although the study was non-randomized and did not demonstrate statistically significant differences in clinical outcomes, a consistent signal towards lower rates of major cardiovascular events and recurrent stroke was observed in the DOAC monitoring group.⁴

The findings provide the rationale for a future cluster-randomized trial and suggest that precision anticoagulation strategies may represent a promising avenue in secondary prevention.⁴

AVERT DOSE trial: Identifies optimal early mobilization after ischemic stroke

Early mobilization after stroke has long been viewed as beneficial, but findings from the Phase III AVERT trial reported poorer functional outcomes among patients who received a higher dose of very early mobilization initiated within 24 hours of stroke onset compared with usual care.⁵ Building on these findings, the AVERT DOSE trial sought to identify optimal early mobility training regimens for patients with ischemic stroke.⁶

At ESOC 2026 and the Post-ESOC 2026 Highlights webinar, Julie Bernhardt, MD, PhD, The Florey Institute of Neuroscience and Mental Health, Melbourne, Australia presented findings from the AVERT DOSE trial (U1111-1221-2442).⁶

The international, Phase III, multi-arm, adaptive, randomized trial recruited 1000 patients with ischemic stroke (mild [NIHSS<7] n=637; moderate (NIHSS 8–16) n=363) across seven countries,⁶ with 60% coming from low- and middle-income settings (data shown during webinar presentation).

Four different mobility-training regimens were initiated within 48 hours of stroke onset across two strata: mild and moderate ischemic stroke. The mobility-based interventions were standing, task-specific training delivered by on-ward physiotherapists and nurses. On average, participants were recruited into the trial at about 33 hours after stroke and began their mobility-based training approximately 38 hours after stroke onset (data shown during webinar presentation).⁶

No significant differences in functional outcomes (modified Rankin scale scores of 0–2) were observed among patients with mild stroke three months post stroke. However, Bayesian analysis suggested that among patients with moderate stroke, two 10-minute daily sessions, combined with nursing-supported activities, represented the most effective regimen. Importantly, no safety concerns were identified across the intervention regimens (data shown during webinar presentation).⁶

Prof. Bernhardt highlighted the practical implications and feasibility, even in resource-limited environments:
“We can provide actionable mobility training guidance for people with mild and moderate ischemic stroke…The intervention can start within 48 hours of stroke onset. It can be delivered by routine staff and is very important, especially for people in low-resource settings.”

Looking ahead

The VJNeurology Post-ESOC 2026 Highlights webinar showcased the breadth of innovation currently transforming stroke care, from expanding thrombectomy indications and optimizing procedural strategies, to tailoring secondary prevention and improving rehabilitation.

Selected by webinar chair Diana Aguiar de Sousa, these studies underline how advances across the stroke pathway continue to refine patient management. While several findings require further validation, many provide important insights that are likely to shape future research and clinical practice.

References