Atherogenic Index of Plasma Predicts Futile Reperfusion and Early Deterioration After Successful Recanalization: A Multicenter Study of EVT-Treated LAA Stroke

<b>Background:</b> Futile reperfusion (FR), which is defined as successful revascularization without a favorable functional outcome, is a major limitation of endovascular treatment (EVT) for acute ischemic stroke. Although clinical and imaging predictors of FR have been studied, the role of systemic metabolic markers, such as the atherogenic index of plasma (AIP), remains unclear. No prior studies have examined the use of AIP in patients with large artery atherosclerosis (LAA)-related stroke. <b>Methods:</b> We analyzed data from four university-affiliated, prospectively maintained registries in the Republic of Korea (2015-2024). We included patients with anterior-circulation LVO who underwent EVT and achieved successful reperfusion. AIP was calculated as log(triglyceride/HDL-C) in mmol/L. The primary outcome was FR, defined as modified Rankin Scale (mRS) 3-6 at 3 months. The secondary outcome was early neurological deterioration (END). Multivariable logistic regression and ROC analysis were used. <b>Results:</b> Among the 406 LAA patients, 227 (55.9%) experienced FR, while 82 (20.2%) had END. Higher AIP quartiles were significantly associated with an increased risk of both FR and END (<i>p</i> for trend < 0.01). The highest AIP quartile (Q4 ≥ 0.26) had adjusted odds ratios of 4.34 (95% CI: 2.18-8.65) for FR and 9.62 (95% CI: 3.66-25.26) for END. The AUCs were 0.775 for FR and 0.726 for END. <b>Conclusions:</b> In a multicenter cohort of EVT-treated LAA stroke with successful reperfusion, elevated AIP independently predicted FR and END. AIP is a simple, widely available biomarker that may support pre-procedural risk stratification and inform post-reperfusion management after EVT.