Acupuncture in ischemic stroke: from local neuromodulation to metabolic reprogramming

Ischemic stroke remains a leading cause of death and long-term disability worldwide, and its management extends far beyond hyperacute reperfusion to include rehabilitation and secondary prevention. Acupuncture has long been used as an adjunctive intervention in stroke rehabilitation, yet its clinical role remains unsettled because benefit signals vary across outcomes, study designs, and control conditions. In recent years, a more informative framework has emerged: ischemic stroke is not only a focal vascular event but also an evolving metabolic crisis involving mitochondrial dysfunction, altered glucose utilization, lactate imbalance, lipid peroxidation, ferroptosis, and systemic metabolic dysregulation. Against this background, the present narrative review examines acupuncture in ischemic stroke through the lens of metabolic reprogramming. Current clinical evidence suggests that acupuncture may show more consistent signals in selected domains such as dysphagia, depressive symptoms, and possibly cognitive impairment than in global disability as a whole. Mechanistic studies increasingly indicate that acupuncture may influence mitochondrial bioenergetics, lactate signaling, ferroptosis-related lipid injury, and microbiota-derived metabolic pathways, although most evidence remains preclinical. We further argue that post-stroke phenotypes differ in their metabolic sensitivity and that this heterogeneity may partly explain the persistent inconsistency of the field. Future research should move beyond undifferentiated efficacy claims and adopt biomarker-anchored, phenotype-specific, and rigorously controlled trial designs. A metabolism-centered framework may therefore help generate testable hypotheses for clarifying the potential adjunctive role of acupuncture in ischemic stroke recovery.