Editorial: Advances and controversies in ischemic stroke management: from prevention to diagnosis and acute treatment

Ischemic stroke remains a leading cause of death and long-term disability worldwide. The clinical and scientific landscape is rapidly evolving, with ongoing advances in prevention, diagnosis, acute treatment, and prognostication. The articles collected in this Research Topic address multiple aspects of stroke care, providing novel evidence across the continuum of management. In terms of diagnosis and early recognition, several studies focused on improving the accuracy and timeliness of ischemic stroke detection. Jin et al. combined clinical examination with diffusion-weighted imaging to differentiate posterior circulation infarctions from mimics, underscoring the role of integrated clinical–radiological assessment. Schaefer et al. explored plasma biomarkers for pre-hospital stroke identification, supporting the feasibility of biochemical triage tools. Quantitative imaging approaches were also investigated, including the evaluation of the RAPID non-contrast CT stroke platform for large vessel occlusion and intracranial haemorrhage detection, and dual-phase CT angiography for rapid prognostic stratification in patients with large ischemic regions. Additional contributions examined the predictive value of the modified Prehospital Acute Stroke Severity scale in posterior circulation occlusion and the role of advanced MRI signatures in distinguishing posterior circulation infarction from vestibular neuritis in acute vestibular syndrome. Regarding acute treatment, multiple articles addressed refinements in reperfusion strategies. Lin et al. demonstrated the prognostic relevance of the Prominent Cortical Vein sign on post-thrombectomy outcomes. Pei et al. identified clinical and imaging factors linked to poor prognosis after thrombectomy, while Sun et al. developed a nomogram to predict futile recanalisation. Comparative effectiveness research included analyses of combined stent retriever plus aspiration versus stent retriever alone, and meta-analyses comparing general anaesthesia to conscious sedation during thrombectomy. The efficacy of endovascular treatment beyond 24 hours, guided by CT perfusion, was examined, as well as treatment of anterior cerebral artery occlusion and basilar artery occlusion. Pharmacological adjuncts were also explored, including PCSK9 inhibitors in mechanical thrombectomy patients, tirofiban in non-thrombectomy cases, and low-dose or no heparinisation during cerebral angiography. Workflow optimisation studies assessed time-saving models for acute treatment in China and strategies for reducing onset-to-door and onset-to-groin times. With respect to secondary prevention, research emphasised risk factor stratification and targeted therapy. Jie et al. reported that the ApoB/ApoA-I ratio predicts recurrent stroke, while Hu et al. used Mendelian randomisation to investigate links between chronic rhinosinusitis and stroke risk. Other genetic epidemiology studies examined causal associations between inflammatory bowel disease and ischemic stroke, bone mineral density and stroke outcomes, and fatigue as a mediator of post-stroke prognosis. Several contributions focused on lipid-related indices, such as the triglyceride–glucose index and triglyceride-to-HDL ratio, as predictors of early neurological deterioration. Antiplatelet therapy optimisation was addressed in propensity-matched analyses of cilostazol-based dual therapy and systematic reviews comparing clopidogrel plus aspirin for varying treatment durations in symptomatic intracranial stenosis. Trials and cohort studies also evaluated secondary prevention strategies in atrial fibrillation, including the ACE2L score for predicting AF in cryptogenic stroke and the ATIS-NVAF protocol for optimal antithrombotic therapy. In the area of biomarkers and prognosis, a substantial number of studies investigated circulating and imaging markers to refine prognostic assessment. Chaiwisitkun et al. identified the platelet-to-neutrophil ratio as a predictor of haemorrhagic transformation after intravenous thrombolysis, while Chen et al. evaluated multiple biomarkers in thrombectomy patients to guide prognostication. Sun et al. reported an association between higher baseline bilirubin and favourable outcomes, and other studies linked the eosinophil-to-neutrophil ratio, fibrinogen levels, and the haemoglobin-to-red cell distribution width ratio to functional recovery. Imaging biomarkers included lesion core extent, ASPECTS progression, and vascular hyperintensity– DWI mismatch for late-window thrombectomy selection. Prognostic models were developed for specific complications such as ventilator-associated pneumonia and malignant cerebral oedema, and for predicting symptomatic intracranial haemorrhage based on admission glucose or the total cholesterol-to-HDL ratio after successful thrombectomy. Finally, at the level of public health and systems of care, several contributions extended the focus beyond individual patient management to healthcare systems and population-level interventions. Sese et al. highlighted the importance of public awareness campaigns for stroke recognition, particularly in underserved communities. Lee et al. provided a systematic review of registered prevention programmes, mapping global strategies. Other studies addressed disparities in access to endovascular therapy, including geographic, socioeconomic, and temporal ("weekend effect") factors. Workflow and organisational improvements were explored in telestroke networks, including evaluations from Colombia and rural healthcare systems. Further work examined the integration of artificial intelligence into stroke pathways to improve diagnostic accuracy and streamline acute care delivery. In summary, the studies collected in this Research Topic provide a broad and multifaceted overview of current advances and ongoing debates in ischemic stroke management. The evidence spans early diagnosis, acute treatment optimisation, targeted secondary prevention, biomarker discovery, and system-level strategies, reflecting the complexity of improving outcomes in this heterogeneous condition. The integration of translational research, clinical trials, and real-world data offers a rich foundation for future investigation and implementation in diverse healthcare settings.