New Trends in Acute Ischemic Stroke

Dear Colleagues,

Stroke is the second leading cause of death and a major contributor to disability worldwide, with ischemic stroke being the most common type.

Acute stroke treatment has had two major breakthroughs over the past 30 years, both involving early reperfusion of an ischemic brain. Treatment is focused on restoring blood flow and rescuing penumbra using thrombolytic agents alteplase or tenecteplase alone, or in combination with mechanical thrombectomy. Reperfusion stroke treatment is limited to causal vessel recanalization and only a limited number of patients are eligible for these time-sensitive treatments. The currently available therapy is unable to limit secondary brain injury associated with inflammation and oxidative damage during reperfusion. In an attempt to prevent ischemic neurons from irreversible injury, neuroprotective agents are under investigation for use alone or as an add-on therapy in standard care. While endovascular treatment helps restore blood flow through an occluded vessel, neuroprotective agents are important for maintaining the function of neurons surrounding dead brain tissue. Numerous agents showed promising neuroprotective potential in preclinical studies; however, none have succeeded in translation into clinical practice.

The role of immunity at all stages of stroke is recognized, from the pathogenesis of risk factors to neurotoxicity, tissue remodeling and repair. The brain and immune system interaction is complex, bidirectional and multifaceted.  It is characterized by the activation of brain resident immune cells: microglia and astrocytes, as well as infiltration of peripheral immune cells that release pro-inflammatory cytokines, chemokines and reactive oxygen species. Interestingly, while neuroinflammation contributes to brain damage during the early phase of ischemic stroke, the inflammatory response could facilitate recovery at late stages by promoting neurogenesis, angiogenesis and neuronal plasticity. Understanding the transition of neuroinflammatory response from injury to repair is essential for developing novel stroke therapies. Despite promising results of experimental studies, successful bench-to-bedside translations are still lacking.

Although considerable progress in our understanding of the pathophysiology of stroke and the underlying mechanisms leading to ischemic insult has been made in recent years, numerous gaps remain. Improvements in the imaging techniques and endovascular management with modern devices, along with novelties in the field of neuroprotection and immunomodulation will bring new insights for understanding stroke.

Looking into the future, advances in precision medicine will enable tailored prevention and individualized stroke treatment in order to reduce mortality, achieve better stroke outcomes, lessen disability and improve the quality of life after stroke.

Dr. Marina Bralić
Guest Editor

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• acute ischemic stroke
• endovascular treatment
• stroke management
• neuroprotection
• inflammation
• immunomodulation
• mechanical thrombectomy
• intravenous thrombolysis
• reperfusion therapy