Complications of reperfusion therapy of acute ischemic stroke (scientific review)

Reperfusion therapy using intravenous thrombolysis and mechanical thrombectomy is the main type of specific treatment for ischemic stroke. However, restoration of cerebral blood flow may paradoxically lead to reperfusion injury of brain tissue. The main causes of complications of reperfusion therapy are considered in this scientific review. The scientific search was carried out using the PubMed (https://pubmed.ncbi.nlm.nih.gov), ClinicalKey Elsevier (https://www.clinicalkey.com), Cochrane Library (https://www.cochranelibrary.com) and Google Scholar (https://scholar.google.com) databases for publications of 2008–2024. Intracranial hemorrhage is one of the most dangerous complications of thrombolytic therapy for ischemic stroke, which is associated with poor prognosis. Risk factors for the development of reperfusion complications, including hemorrhagic transformation of a brain infarction, can be age, pre-stroke treatment and conditions, infarct volume. The risk and frequency may depend on the reperfusion technique in the acute phase of stroke and various reperfusion strategies like intravenous thrombolysis with alteplase, tenecteplase, mechanical thrombectomy, etc. Reperfusion injuries of the brain have complex pathophysiological cellular and biochemical mechanisms of development, and one of the main factors is damage to the blood-brain barrier. Its increased permeability is mediated by the activation of matrix metalloproteinases. A number of laboratory biomarkers are being investigated to assess the permeability of the blood-brain barrier and the risk of hemorrhagic transformation. Several studies prove that an increase in the level of matrix metalloproteinase 9 is associated with increased brain infarct size and the development of hemorrhagic transformation. Another encouraging laboratory marker is caveolin-1, whose reduced levels are associated with intracranial hemorrhage and poor functional outcome after endovascular therapy. Various neuroprotective strategies are being investigated to reduce the risk of complications of reperfusion therapy. Modern approaches to revascularization have become very successful and continue to improve, and perhaps the concept of reperfusion injury will develop further.