Acupuncture modulates the gut–brain axis in ischemic stroke: A narrative review of mechanisms and therapeutic potential

Abstract: Ischemic stroke not only causes localized cerebral injury but also triggers systemic disturbances across multiple organs, most prominently within the gastrointestinal tract. Emerging evidence underscores the gut–brain axis (GBA) as a key determinant of stroke pathogenesis, recovery, and prognosis. Acupuncture—a core modality of traditional Chinese medicine—has demonstrated reproducible clinical efficacy in stroke rehabilitation; however, its mechanistic basis within the GBA framework remains incompletely defined. This narrative review synthesizes findings from preclinical and clinical studies retrieved from PubMed and Web of Science up to October 2025. This review integrates current experimental and clinical findings to elucidate how acupuncture mitigates ischemic stroke through multilevel modulation of the GBA. Specifically, acupuncture (1) rectifies gut dysbiosis by restraining pathogenic taxa and enriching commensal microbiota, thereby reinforcing intestinal barrier integrity through upregulation of tight junction proteins (ZO-1, occludin); (2) rebalances neuroendocrine activity by inhibiting hypothalamic–pituitary–adrenal axis hyperactivation while enhancing vagus-mediated cholinergic anti-inflammatory signaling; (3) reprograms gut-derived metabolic profiles by increasing neuroprotective short-chain fatty acids and reducing neurotoxic trimethylamine N-oxide; and (4) restores immune homeostasis by modulating peripheral–central immune crosstalk and promoting neurorepair. Collectively, these insights establish acupuncture as a system-level regulator capable of restoring GBA homeostasis after stroke, providing a mechanistic framework for precision-targeted and translational interventions. The synthesized framework not only elucidates acupuncture’s system-level mechanisms but also highlights its potential as a precision neuromodulatory therapy, guiding future translational research in integrative stroke care.