Sleep and Stroke-An Overlooked Bidirectional Influence: Why Should Sleep and Vascular Neurologists Work Closer?

Since the earliest investigations into the impact of sleep-related breathing disorders on cardiovascular risk, the association between sleep-wake disorders and major cerebrovascular events has been increasingly and robustly established. Recent international joint statements-endorsed by leading scientific societies (e.g., American Heart Association, American Stroke Association, European Academy of Neurology, European Stroke Organization, European Sleep Research Society, and European Respiratory Society)-represent a milestone in stroke prevention and rehabilitation by formally recognizing sleep disorders as both risk factors for ischemic stroke and determinants of poor short- and long-term outcomes. Nevertheless, despite these strong epidemiological and mechanistic associations, the therapeutic evidence supporting sleep-wake interventions (e.g., positive airway pressure therapy, GABA-receptor agonists, melatonin) for stroke prevention remains limited and requires further validation through well-designed clinical trials. In this perspective article, we review recent advances in understanding the bidirectional relationship between sleep disorders and stroke, discuss the proposed pathophysiological mechanisms underpinning this complex interplay-with particular emphasis on arousal-related activation of the autonomic nervous system-and provide a critical appraisal of current research directions and future perspectives. Finally, we underscore the need for closer collaboration between sleep and stroke specialists to bridge existing knowledge gaps and optimize patient care.