Systemic inflammation and endothelial dysfunction influence the risk and severity of hemorrhagic transformation after endovascular treatment for acute ischemic stroke
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2026
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Frontiers Media SA
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Background – Hemorrhagic transformation (HT) is a frequent and serious complication, occurring in up to 40% of cases after endovascular treatment (EVT) for acute ischemic stroke (AIS). Inflammation has been increasingly recognized as a key factor influencing both stroke pathophysiology and post-treatment complications (such as HT) interacting with endothelial dysfunction to exacerbate vascular injury after EVT. The objective of this study is to evaluate whether systemic inflammatory status predicts HT in AIS patients, and its relationship with endothelial biomarkers in the setting of this complication. Methods – We retrospectively reviewed a prospective cohort of 229 AIS patients treated with EVT. Demographic, clinical, imaging, and laboratory data were collected. Inflammatory markers included white blood cell subsets and indices such as neutrophil-to-lymphocyte ratio (NLR), neutrophil-to-platelet ratio (NPR), systemic immune-inflammation index (SII), and systemic inflammation response index (SIRI). Endothelial function was assessed by flow-mediated dilation (FMD) and circulating homoarginine (HArg), asymmetric dimethylarginine (ADMA), and symmetric dimethylarginine (SDMA). The main outcome was radiological or symptomatic HT, classified according to ECASS criteria. Results – HT was observed in 92 patients (40.2%), of whom 35 (36.1% of HT and 15.3% of the total) were symptomatic. In multivariate analysis, independent predictors of HT included higher NIHSS at admission, higher plasma glucose at admission, the use of non-aspiration devices, lower pre-recanalization lymphocyte count, higher pre-recanalization SII and higher NLR levels. Among endothelial function markers, HArg correlated with inflammatory markers, ANC (r = −0.2) and WBC (r = −0.19), and was associated to PH and symptomatic HT, but not with any radiologic HT after AIS. Conclusion – An altered inflammatory status prior to EVT in AIS patients is associated with an increased risk of developing HT after EVT. Additionally, endothelial dysfunction could participate in the more aggressive forms of this complication.
Palabras clave
Acute ischemic stroke (AIS)
Biomarkers
Endothelial dysfunction
Endovascular treatment (EVT)
Flow-mediated dilation (FMD)
Hemorrhagic transformation (HT)
Homoarginine (Harg)
Neutrophil-to-lymphocyte ratio (NLR)
Biomarkers
Endothelial dysfunction
Endovascular treatment (EVT)
Flow-mediated dilation (FMD)
Hemorrhagic transformation (HT)
Homoarginine (Harg)
Neutrophil-to-lymphocyte ratio (NLR)
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Álvarez-Agoues, K., de la Riva, P., Rodríguez-Antigüedad, J., Gomez, V., Arenaza-Choperena, G., Gorostidi, A., Díez, N., de Arce, A., Martínez-Zabaleta, M., Garmendia, E., Lüttich, A., Anabitarte, M., Larrea, J. A., Bergareche, A., Lopez de Munain, A., & Marta-Enguita, J. (2026). Systemic inflammation and endothelial dysfunction influence the risk and severity of hemorrhagic transformation after endovascular treatment for acute ischemic stroke. Frontiers in Neurology, 17. https://doi.org/10.3389/FNEUR.2026.1913218