For more than 40 years as a researcher and clinician, Joseph Broderick has actively contributed to improvements in stroke care, occupying a front row seat to seismic innovations: the clinical trials that proved tPA as the first effective treatment for acute ischemic stroke in the 1990s, the seminal trials leading to mechanical removal of clots within the artery in the 2000s and most recently the FASTEST trial today testing what could be the first treatment to slow bleeding for spontaneous acute intracerebral hemorrhage (ICH).
Looking back shows how far the field has come, but what does the future hold? Broderick sought to answer that question by making predictions for what stroke care will look like in 2050 in a new article published in the journal Stroke . The article is a follow-up to a 2003 article where Broderick made predictions about 2025 in the areas of acute treatment, stroke prevention and stroke recovery.
"The last 50 years have been about advances in stroke prevention and acute treatment," wrote Broderick, MD, professor in the University of Cincinnati's College of Medicine, senior adviser at the UC Gardner Neuroscience Institute and director of the NIH StrokeNet National Coordinating Center.
Acute stroke
Past predictions: Until the mid-1990s, there was no scientifically proven treatment for acute stroke. By 2000, there were five proven scientific treatments or expanded indications, including the first medical treatment for ischemic stroke, t-PA.
In 2003, Broderick predicted that novel mechanical devices would remove blood clots blocking brain arteries, with and without t-PA, improving outcomes by restoring blood flow to the brain. However, his prediction that neuroprotection techniques like rapid hypothermia would play a role during blood flow restoration has not yet come to fruition.
"All these predictions proved to be pretty accurate, except for neuroprotection, which has been a very hard nut to crack and still has defied our best efforts," wrote Broderick. "Regardless, we now have 20 scientifically proven treatments or expanded indications, including additional thrombolytic agents, various catheter devices, mobile stroke units, surgical treatment for selected patients with brain hemorrhage and drugs to slow bleeding in patients with brain hemorrhage.
"The largest advance has been mechanical clot removal for ischemic stroke, first within six hours of onset and then out to 24 hours with appropriate imaging selection."
In 2050? Patient wearables will help begin stroke diagnosis at home, leading to specific treatments for ischemic and hemorrhagic stroke starting before arrival at the hospital for more patients. But treatment of ischemic stroke may reach the limits of biology and technology, as it has for myocardial infarction, which has not seen a major advance for a number of years.
Clot removal devices will become smaller and safer, and researchers will solve the challenge of neuroprotection that has not been solved yet. Treatment of ICH will continue to advance but remain the most challenging stroke to treat.
"We are going to need larger global trials to find much smaller benefits as our success in acute stroke has dramatically increased," Broderick said. "Artificial intelligence (AI) and telemedicine will play an even more important part in clinical decision-making worldwide and will help to deliver the best care to locations that currently lack expertise and resources. Finally, physiological time will remain the most important variable for success for all types of strokes."
Stroke prevention
Past predictions: In 1975, researchers had just identified the effectiveness of treating hypertension to prevent a first stroke and preventing a second stroke with aspirin. By 2000, the medical community had 14 proven primary and secondary prevention treatments.
In 2003, Broderick predicted stroke would remain a great burden if at-risk behaviors and the high cost of therapies were not addressed and no treatments were available to delay or halt aging. Over the past years, the U.S. population has become much more obese.
Reductions in U.S. cigarette smoking rates and better managed hypertension have led to a decrease in the overall incidence of stroke in the Greater Cincinnati/Northern Kentucky region, but strokes have numerically increased among younger people. In 2025, we now have 35 proven prevention treatments and expanded indications.
"We know that the Mediterranean diet decreases the risk of recurrent stroke," Broderick said of current stroke prevention advances. "We have four novel anticoagulants for primary and secondary prevention, primarily in patients with atrial fibrillation; more antiplatelet agents; genetic and medical treatments for sickle cell disease and other genetic diseases associated with stroke; stents for carotid arteries; mechanical devices to close holes between the upper chambers of the heart; and devices that close off chambers in the left atrium of the heart that can harbor blood clots for appropriately selected patients.
"The newest entrees for prevention have been GLP-1 and GIP receptor medications, which not only improve diabetic control and weight loss but also improve cardiovascular outcomes."
In 2050? Lifestyle changes will remain the greatest challenge and opportunity for primary and secondary stroke prevention, particularly focused on diet, sleep, exercise, weight and blood pressure control, smoking cessation, and a patient's metabolic state.
"Weight control medications will be integral to primary and secondary stroke prevention and cardiovascular health as much as lipid medications. Biomarkers will provide greater precision for the use of antithrombotic drugs and devices, and we will have new treatments for genetic causes of stroke," Broderick said. "But again, unless we have treatments that slow aging, the overall stroke burden will only decrease a little."
Stroke recovery
Past predictions: With no scientifically proven treatments in 2003, Broderick predicted a number of approaches, including growth factors, stimulant medications and new physical therapy methods, could play a role in stroke recovery. In 2025, two treatments have been scientifically proven to be effective: modified constraint therapy and vagal nerve stimulation paired with modified constraint therapy.
"Even more impressive is the AI revolution in understanding the neural code," Broderick wrote. "Patients without the ability to move or to speak have been able with AI-driven brain-device interfaces to train their brains to move devices, to write words on the screen and even to speak. We've also developed techniques for decoding what the brain is visualizing."
In 2050? Additional higher-intensity physical, occupational and speech therapies will be proven effective to enhance recovery. AI will accelerate connection between the brain and related organs with machines and the digital web to enhance daily function, though limited by cost.
"Recovery approaches will be limited by the initial damage and physiological age of the recovering brain," Broderick said. "Implanting new brain cells to replace damaged brain tissue that make new connections throughout the nervous system to enhance function may still require science beyond 2050."
Big picture
Broderick said advances in stroke treatment, prevention and recovery have occurred primarily in developed countries with more economic resources, and even current treatments still need to be implemented worldwide in many regions of the world.
"The next century will be about advances in recovery and rehabilitation after stroke and addressing current global disparities in stroke incidence, outcomes and access to proven therapies," Broderick said. "But until we solve aging, stroke will remain common and a tremendous societal and financial burden. We have made a significant dent in the burden of stroke over the past 50 years, and I think that the best is yet to come."
