Immunoinflammatory biomarkers as predictors of hemorrhagic transformation in acute ischemic stroke patients after endovascular thrombectomy

What is your competent? doctor's EXACT PROTOCOL to prevent hemorrhagic transformation? Oh, doesn't have one? So, you DON'T have a functioning stroke doctor, do you?

 Immunoinflammatory biomarkers as predictors of hemorrhagic transformation in acute ischemic stroke patients after endovascular thrombectomy

Li BaoYuhang WangShuang He^*

• Department of Stroke Center, Affiliated Hospital of Nantong University, Nantong, China

Background: Hemorrhagic transformation (HT) and symptomatic intracranial hemorrhage (sICH) are common complications of endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) patients. The role of peripheral immune inflammation in HT after EVT is unclear. This study aimed to evaluate the relationship between immune inflammatory factor levels and HT and sICH occurrence, and to develop predictive models.

Methods: We included 81 AIS patients who underwent EVT. Peripheral blood samples were collected immediately post-EVT to measure immunoinflammatory markers. Least absolute shrinkage and selection operator (LASSO) regression was used to select variables, and backward stepwise multivariable logistic regression identified independent predictors and predictive models for HT and sICH. The models’ discrimination was assessed using the area under the receiver operating characteristic curve (AUC), and calibration was evaluated using the Hosmer–Lemeshow test. Logistic regression models were used to evaluate the impact of HT or sICH on 90-day functional outcomes and mortality.

Results: The HT rate was 39.51% (32/81), and the sICH rate was 17.07% (14/81). Multivariate analysis revealed that HT after EVT was significantly associated with collateral score [OR 0.27 (95% CI 0.13–0.52), p < 0.001], arteriosclerosis etiology [OR 0.11 (95% CI 0.02–0.46), p = 0.006], puncture to recanalization time [OR 3.72 (95% CI 1.07–14.59), p = 0.04], and levels of IL-6 [OR 7.33 (95% CI 2.1–31.07), p = 0.003; AUC 0.696 (95% CI 0.593–0.799)]. sICH was independently related to direct aspiration (DA) techniques [OR 0.07 (95% CI 0.09–0.35), p = 0.004] and neutrophil-to-albumin ratio (NAR) values [OR 5.69 (95% CI 1.16–37.24), p = 0.044; 0.676 (95% CI 0.550–0.803)]. Both predictive models for HT [AUC 0.898 (95% CI 0.831–0.965)] and sICH [AUC 0.925 (0.853–0.997)] exhibited good discrimination and calibration.

Conclusion: IL-6 and NAR are potential biomarkers for predicting HT and sICH in AIS patients after EVT. This study developed simple and effective predictive models for HT and sICH based on immunoinflammatory factors. Future research should explore the spatiotemporal effects of immune inflammation on prognosis in AIS patients undergoing EVT.

Introduction

Acute ischemic stroke (AIS) is characterized by high incidence, disability, and mortality rates, thereby imposing a significant burden on healthcare systems globally (1, 2). Endovascular thrombectomy (EVT) has emerged as an effective and widely adopted reperfusion therapy for AIS due to large vessel occlusion (LVO) (3–5). Nonetheless, the common and serious complication of EVT, hemorrhagic transformation (HT), is strongly correlated with poor clinical outcomes and can substantially undermine the therapeutic advantages of EVT (6, 7). Consequently, HT is frequently employed as a safety outcome in clinical research. Therefore, identifying risk factors for HT is crucial for optimizing clinical decision-making and enhancing postoperative management strategies.

Recent studies have identified several risk factors for HT following EVT, including the National Institutes of Health Stroke Scale (NIHSS) score, admission blood glucose levels, hyperdense middle cerebral artery sign, and symptom onset to puncture time (8–11). Furthermore, HT f post-EVT is strongly linked to blood-brain barrier (BBB) disruption, which is induced by reperfusion-related inflammation (12). Reperfusion increases reactive oxygen species (ROS) generation and heightens BBB permeability, facilitating the recruitment and activation of resident brain immune cells, such as microglia and astrocytes, as well as infiltrating blood-derived immune cells, including neutrophils and lymphocytes (13, 14). These immune cells release a diverse array of immunoinflammatory cytokines that modulate the balance between pro-inflammatory and anti-inflammatory responses, which is essential for maintaining BBB integrity (15, 16). However, there is a paucity of evidence regarding the relationship between peripheral blood immunoinflammatory cytokine levels and HT following EVT. This prospective study aimed to investigate the impact of immediate post-EVT peripheral blood immunoinflammatory cytokine levels on HT and symptomatic intracranial hemorrhage (sICH) in AIS patients, with the goal of facilitating early prediction of HT and sICH, thereby guiding treatment strategies.

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