Impact of Stress Hyperglycemia Ratio on Parenchymal Hemorrhage Risk Following Bridging Thrombolysis and Endovascular Therapy in Large Vessel Occlusion Stroke

Introduction: Elevated glucose levels in patients with large vessel occlusion stroke (LVOS) have been associated with an increased risk of intracranial hemorrhage and poor outcomes following thrombolysis. Traditionally, single measurements of glucose upon admission have been used as a surrogate biomarker to identify patients at risk. However, the stress hyperglycemia ratio (SHR), which incorporates both acute and baseline glucose levels, may offer a more accurate reflection of the body's physiological response to acute stress. This study investigated the association of SHR and the risk of parenchymal hemorrhage (PH) in LVOS patients receiving bridging thrombolysis and endovascular treatment (EVT).

Methods: SHR was calculated as the ratio of admission glucose (mmol/L) to the estimated average glucose derived from HbA1c (1.59 x HbA1c – 2.59). SHR values were categorized into < median and ≥ median for multivariable logistic regression analysis. In the study period 01/2020 – 05/2024, 280 LVOS patients underwent intravenous thrombolysis (IVT) followed by EVT. The primary endpoint was the occurrence of PH type 1 or 2.

Results: Among the 280 patients, 99 received TPA, and 181 received TNK, with 12.9% developing PH type 1 or 2. The median SHR was 1.04 (IQR 0.93 – 1.24), showing no significant difference between TPA and TNK groups (p=0.706). In univariable analysis, a higher SHR, female sex, elevated baseline NIHSS, lower platelet count, the number of thrombectomy passes, and stent-retriever use were associated with an increased likelihood of PH type 1 or 2. Multivariable logistic regression indicated that SHR (adjusted odds ratio [aOR] 2.762, 95% CI 1.244 – 6.131, p=0.013) and number of thrombectomy passes independently predicted PH.

Conclusion : Higher SHR was independently associated with an elevated risk of parenchymal hemorrhage in LVOS patients treated with bridging thrombolysis and thrombectomy, highlighting SHR’s potential role as a predictive biomarker for hemorrhagic complications in this cohort.