Beyond recanalization: protecting the lungs in the era of stroke reperfusion therapy

Stroke-associated pneumonia remains a frequent obstacle to recovery after acute stroke. A new review in the Chinese Medical Journal examines how dysphagia, aspiration, stroke-induced immunodepression, brain–lung and gut–lung signaling, and periprocedural care may converge to shape pneumonia risk in patients receiving reperfusion therapy. It also assesses prediction tools, explains why routine prophylactic antibiotics are not recommended, and highlights coordinated preventive care and research priorities for clinicians and researchers worldwide in the reperfusion era.

Intravenous thrombolysis and endovascular therapy have transformed acute ischemic stroke care by restoring blood flow to threatened brain tissue. Yet recovery after reperfusion can still be affected by early medical complications. Stroke-associated pneumonia (SAP), generally defined as a lower respiratory tract infection occurring within seven days after stroke, is among the most frequent and clinically important. It is associated with longer hospitalization, greater costs, disability, and death.

A new review led by corresponding author Professor Penglian Wang of Beijing Tiantan Hospital, Capital Medical University, and published in the Chinese Medical Journal on  August 17, 2026, under the title Advances in stroke-associated pneumonia in the era of revascularization therapy, synthesizes current evidence on SAP in the setting of modern reperfusion care. The authors examine its epidemiology, risk factors, prediction models, biological mechanisms, prevention, and treatment, while emphasizing the additional clinical complexities introduced by thrombectomy, anesthesia, airway management, and intensive care.

Understanding risk without overstating causality

Several observational studies have reported a higher incidence of SAP among patients undergoing endovascular therapy. This association should not be interpreted as evidence that the procedure itself causes pneumonia. Patients selected for thrombectomy generally have more severe strokes and may be more likely to have impaired consciousness, dysphagia, general anesthesia, endotracheal intubation, or mechanical ventilation. SAP after reperfusion may therefore reflect the combined effects of baseline illness and periprocedural factors. Whether treatment modality independently influences risk remains uncertain and requires better-designed prospective studies.

SAP is more than aspiration

Aspiration is an important trigger, but it does not fully explain SAP. Stroke may also activate sympathetic, hypothalamic–pituitary–adrenal, and cholinergic pathways, resulting in stroke-induced immunodepression and altered antimicrobial defenses. Brain–lung signaling may increase pulmonary inflammation and vascular permeability, while intestinal dysbiosis and disruption of the gut barrier may influence lung immunity through the gut–lung axis. These interacting pathways help explain why patients with similar aspiration exposure can have different outcomes.

Current risk assessment relies on factors such as age, neurological severity, impaired consciousness, dysphagia, atrial fibrillation, and comorbidities. Established scores, including A²DS², AIS-APS, and ISAN, can support early screening, although their performance varies across populations and care settings. The review argues that future models should incorporate dynamic information, including inflammatory biomarkers, imaging, anesthesia and airway data, postprocedural neurological status, and reperfusion results, followed by prospective multicenter validation.

Coordinated prevention across the stroke pathway

Prevention should focus on coordinated care rather than routine prophylactic antibiotics. Large randomized trials, including PASS, STROKE-INF, and PRECIOUS, did not show that preventive antibiotics reduce pneumonia or improve functional outcomes after stroke. In the absence of suspected or confirmed infection, routine antibiotic prophylaxis is therefore not recommended. Practical measures include early dysphagia and aspiration-risk screening, standardized oral care, appropriate nutrition and positioning, individualized anesthesia, avoidance of unnecessary intubation and ventilation, timely extubation when safe, respiratory care, and early mobilization. When SAP is suspected or established, antimicrobial treatment should be individualized using clinical, imaging, microbiological, and local resistance information.

What comes next?

The authors call for standardized SAP definitions, prospective databases designed specifically for thrombolysis and thrombectomy populations, interpretable dynamic prediction tools, and randomized evaluation of multidisciplinary prevention bundles. Emerging host-directed, immunomodulatory, and microbiota-targeted strategies remain research priorities, but are not yet ready for routine use. Protecting the lungs throughout the acute stroke pathway may help preserve the neurological benefits made possible by reperfusion therapy.

***

Reference

DOI:  10.1097/ CM9.0000000000004224

About Penglian Wang from Beijing Tiantan Hospital, Capital Medical University

Penglian Wang, MD, PhD, is a chief physician, professor, and doctoral supervisor at the Center of Neurology, Beijing Tiantan Hospital, Capital Medical University. She received her PhD in neuroscience from The University of Manchester and has more than 25 years of experience in clinical neurology, research, and medical education. Her principal interests include cerebrovascular disease, intracerebral hemorrhage, and secondary prevention of stroke.

Funding information

This work was supported by the National Key Research and Development Program of China (No. 2018YFC1312402).