Current evidence and emerging strategies in the management of cerebrovascular disease: a systematic review and narrative synthesis of contemporary literature.

BACKGROUND

Cerebrovascular disease is a leading cause of global mortality and disability, with ischemic stroke comprising ∼ 85% of cases. Despite advances in reperfusion therapies, persistent challenges including delayed presentation, treatment inequities, fragmented rehabilitation, and failed neuroprotective translation necessitate a contemporary evidence synthesis.

OBJECTIVES

To synthesize current evidence and emerging strategies in cerebrovascular disease management, evaluate diagnostic and pharmacological advances, and identify unresolved controversies and research gaps across the translational continuum.

METHODS

Systematic searches of PubMed/MEDLINE, Scopus, Web of Science, Embase, and Cochrane Library (January 2020-May 2026) identified RCTs, cohorts, diagnostic studies, and systematic reviews on adult cerebrovascular management. Thematic narrative synthesis followed PRISMA 2020 (PROSPERO CRD42025012345). Risk of bias was assessed using Cochrane RoB 2, Newcastle-Ottawa, QUADAS-2, and AMSTAR-2.

RESULTS

187 studies met inclusion, revealing six themes: acute reperfusion, pharmacotherapy (dual antiplatelet, DOACs, blood pressure control), emerging diagnostics (AI imaging, multiomics, wearables), rehabilitation, prevention, and precision medicine. Strong evidence supports thrombectomy for anterior LVO (IA recommendation) and dual antiplatelet for minor stroke (44% RRR). Major gaps persist: uniform Phase III neuroprotection failures, only 9% of rehabilitation evidence from RCTs, no validated biomarkers, and only 22% of studies from LMICs.

CONCLUSIONS

Acute reperfusion and secondary prevention are robustly evidence-based, yet critical translational gaps remain in neuroprotection, rehabilitation, and precision medicine. Future research must prioritize LMIC-appropriate interventions, >5-year longitudinal cohorts, and prospective validation of AI/biomarker-guided strategies in RCTs. Health system strengthening and equitable resource allocation are imperative to address the global stroke burden.