Acupuncture for ischemic stroke: where are we now?

Ischemic stroke is one of the leading causes of death and disability worldwide, accounting for approximately 70% of all stroke cases. This comprehensive narrative review systematically examines the scientific evidence on the use of acupuncture in the treatment and rehabilitation of ischemic stroke, analyzing both clinical and experimental studies published between 2013 and 2023. The methodology involved systematic searches in PubMed and Web of Science databases, resulting in the analysis of 118 relevant publications — 56 clinical studies and 62 experimental animal studies. Clinical results demonstrate that acupuncture offers significant benefits across multiple post-stroke complications.

For motor function, which affects approximately 70% of stroke survivors, several randomized clinical trials showed that both electroacupuncture and manual acupuncture significantly improve NIHSS scores and activities of daily living. Studies indicate that early treatment, initiated within 48 hours after stroke, may provide greater clinical benefits. For dysphagia, which occurs in 37-78% of post-stroke patients, recent meta-analyses confirmed the efficacy and safety of acupuncture compared with conventional treatment, with cohort studies showing reduced dysphagia risk in treated patients. In the cognitive domain, although some early studies had conflicting results due to methodological limitations, more recent evidence from multicenter trials demonstrates efficacy comparable or superior to acupuncture relative to medications such as citicoline in improving cognition and performance in daily activities.

The review also identified significant benefits in treating post-stroke depression, which affects more than one-third of patients. Cohort studies with more than 13,000 patients showed that those who received acupuncture had a significantly lower incidence of depression compared with those untreated. For sleep disturbances and insomnia, affecting 56-58% of post-stroke patients, randomized clinical trials demonstrated that acupuncture effectively improves sleep quality and reduces affective symptoms. The mechanisms of action identified through experimental studies reveal that acupuncture exerts neuroprotective effects through multiple pathways: neuroplasticity (neurogenesis and synaptogenesis), angiogenesis, regulation of cell proliferation and apoptosis, and modulation of oxidative stress, inflammation, and immune response.

Functional neuroimaging studies show that acupuncture alters functional connectivity between different brain regions, activating compensatory mechanisms and strengthening connections related to motor, cognitive, and language functions. At the molecular level, acupuncture modulates important signaling pathways such as PI3K/Akt, NF-κB, mTOR, JAK2/STAT3, and Wnt/β-catenin, regulating neurotrophic factors such as BDNF and GDNF. It also promotes angiogenesis through the HIF-1α/VEGF/Notch1 pathway, enhances neuroplasticity via neurotransmitter regulation such as GABA, and reduces inflammation through modulation of pro-inflammatory cytokines. Identified limitations include heterogeneity in acupuncture protocols, lack of standardization in point selection, insufficient sample sizes in some studies, and the need for greater methodological rigor in clinical trials.

Quality of evidence varies, with a need for more multicenter, randomized studies with long-term follow-up. Clinical implications are significant, as acupuncture emerges as a safe and effective complementary therapy for multiple ischemic stroke complications. The World Health Organization already recommends acupuncture as a complementary strategy for stroke treatment, and 2018 Chinese guidelines include acupuncture for post-stroke motor dysfunction. This review provides a robust scientific basis for clinical implementation of acupuncture in post-stroke rehabilitation programs, highlighting the need for standardized protocols and adequate provider training to optimize therapeutic outcomes.