Pharmacological Strategies to Prevent Hemorrhagic Transformation of Ischemic Stroke

Abstract

This review summerize evidence on pharmacological approaches to prevent HT, with emphasis on interventions that stabilise the neurovascular unit, modulate inflammatory injury, and support risk-informed treatment decisions. Pharmacological prevention can be conceptualised in three tiers: (i) BBB-directed therapies that reinforce endothelial barrier programmes; (ii) optimised reperfusion pharmacology, where thrombolytic selection and protocolised physiological management reduce avoidable bleeding risk; and (iii) adjunct neuroprotective and immunomodulatory strategies, including PSD-95 pathway modulation and antioxidant or anti-inflammatory. Precision frameworks are advancing through biomarkers that reflect proteolytic vulnerability (e.g., MMP-9), BBB structural injury (tight-junction proteins), and thromboinflammatory markers (e.g., clot S100B), supporting pathway-tailored monitoring. Overall, integrating BBB-stabilising pharmacology with optimised acute pathways and biomarker-guided strategies represents a promissing breakthrough to reduce HT without decreasing reperfusion efficacy.