From cells to vesicles: mechanisms and therapeutic promise of cell- and exosome-based interventions in ischemic stroke

With the growing burden of ischemic stroke as a leading cause of mortality and long-term disability worldwide, the demand for innovative and effective therapeutic strategies has become increasingly urgent. Traditional interventions offer limited neurorestorative potential, prompting a shift toward regenerative approaches. Cell-based and exosome-based therapies have attracted significant interest due to their potential to regulate inflammation, safeguard neural tissue, and support recovery following ischemic injury. Mesenchymal stem cells (MSCs) exert neuroprotective effects through paracrine signaling, immune modulation, and intercellular mitochondrial transfer. In parallel, exosomes - nano-sized extracellular vesicles derived from various cell types - have emerged as a potent cell-free alternative, capable of delivering bioactive molecules such as microRNAs, proteins, and lipids to target cells, thereby mimicking many of the therapeutic functions of stem cells. Their favorable safety profile, ease of storage and handling, and potential for customization make them highly promising for clinical translation. This review aims to provide a comparative evaluation of cell-based and exosome-based therapies in the treatment of ischemic stroke. By analyzing key molecular mechanisms, therapeutic benefits, limitations, and translational challenges, we seek to highlight the relative strengths of each approach and offer insights that may guide future strategies for optimizing stroke recovery.