Revolution in Stroke Treatment Over 50 Years and Predicting Stroke Care in 2050

This article describes the remarkable progress over the past 50 years in acute stroke therapy, stroke prevention, and, to a lesser extent, stroke recovery, and forecasts advances in stroke care for 2050. Stroke has gone from an untreatable and unpreventable disease to a disease with effective medical and interventional treatments for acute ischemic and hemorrhagic stroke, many new medical, surgical, and interventional treatments for primary and secondary stroke prevention, and the beginnings of a revolution in our understanding of the neural code that portends a great future for stroke recovery. Progress in management of stroke risk factors has been mixed, with a major increase in obesity but a decrease in the prevalence of smoking, as well as better control of hypertension and hyperlipidemia in the United States and other high-income countries. The incidence rate of stroke in the US population studies has decreased, but with recent increases in younger segments of the population. Because age remains the most important risk factor for stroke, the burden of stroke is likely to continue to increase as the population ages. In 2050, we will use artificial intelligence to pull clinical trial data from multiple trials in the context of a patient’s demographics, medical history, and biometric, imaging, and laboratory data to recommend the best treatment for that patient—true precision medicine. Making these precision treatments in the hospital, clinic, and home settings available to everyone, regardless of geographic, social, and economic situation, is one of our challenges of the next century. As we make greater progress in stroke prevention, acute treatment, and stroke recovery, we will need larger trials and more efficient trial designs. Large trials will require global efforts. The last 50 years have been about advances in stroke prevention and acute treatment. The next century will be about advances in recovery and rehabilitation after stroke and addressing current global disparities in access to proven therapies. Until we can mitigate mechanisms associated with aging, stroke will remain common and a tremendous societal and financial burden. We have made a significant dent in this burden over the past 50 years; the best is yet to come.