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Microcirculatory failure after successful recanalization in ischemic stroke: insights into mechanisms; imaging; and therapeutic strategies
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DOI：10.3389/fphar.2026.1884183.png)
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Abstract
En 中文
Early; effective reopening of an occluded large artery is a cornerstone of modern ischemic stroke care. Yet angiographic success does not consistently translate into tissue level reperfusion; nor does it reliably forecast good neurological recovery. Futile recanalization is multifactorial; and in many patients poor outcome may also reflect extensive irreversible injury already present at the time of recanalization because reopening is achieved too late to rescue substantial tissue. A growing body of work suggests that persistent microcirculatory dysfunction after recanalization may represent one important contributor to this discordance. In the post-recanalization setting; microvascular failure reflects intertwined ischemia-reperfusion processes: oxidative stress; inflammatory activation; endothelial injury; microthrombosis; and pericyte-driven capillary constriction; that together degrade capillary perfusion and exchange. As a result; tissue hypoxia can persist and the infarct core may continue to expand even when large-vessel patency has been restored. Experimental studies and emerging clinical observations; including trials of adjunct intra-arterial thrombolysis; increasingly support the idea that resolving residual microvascular obstruction can yield functional benefits beyond macrorecanalization alone. In parallel; progress in microcirculation imaging and monitoring; ranging from high-resolution optical tools in experimental models to angiography- and perfusion-derived metrics in patients; has strengthened in vivo evaluation of microvascular reperfusion and treatment effects. This review integrates current detection approaches; mechanistic drivers across microvascular segments; and translational therapeutic strategies; and it outlines priorities for clinically practical microcirculatory readouts and imaging-guided precision trials to speed development of microvascular-targeted adjunct therapies for ischemic stroke.
Keywords:
ischemic stroke
therapeutic strategy
pathomechanism
microcirculation dysfunction
imaging readouts
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