Analysis of risk factors for early neurological deterioration after intravenous thrombolysis in acute ischemic stroke

Early Neurological Deterioration (END) after intravenous thrombolysis (IVT) in Acute Ischemic Stroke (AIS) increases disability, death, and healthcare burden. Its mechanisms, possibly involving reperfusion injury and hemorrhagic transformation, are not fully understood, and current risk factors lack detailed pathophysiological explanations. Identifying reliable predictors for END is essential for early intervention. In a single-center retrospective cohort study, a retrospective cohort study was conducted on 198 AIS patients who received IVT with recombinant tissue plasminogen activator (rt-PA) at Hunan Provincial Brain Hospital between October 2022 and December 2024. END was defined as an increase of ≥ 4 points in the National Institutes of Health Stroke Scale (NIHSS) score or death within 24 h after thrombolysis. We collected and compared demographic, clinical, laboratory (including inflammatory/thrombotic ratios: neutrophil-to-lymphocyte ratio (NLR), fibrinogen-to-albumin ratio (FAR), lactate dehydrogenase-to-albumin ratio (LAR), D-dimer-to-fibrinogen ratio (DFR)), and imaging data between the END and non-END groups. Univariate analyses, multivariate logistic regression, and ROC curve analysis were performed to identify independent risk factors and assess their predictive power. Of note, neurological status after 24 h was not routinely assessed with NIHSS in our stroke-unit protocol; Therefore we cannot report the incidence of deterioration beyond 24 h. This may have overestimated END frequency compared with studies using 48- or 72-h definitions. END occurred in 50 patients (25.2%). Multivariate logistic regression identified five independent risk factors for END: history of atrial fibrillation (AF) (OR = 2.558, P = 0.003), higher pre-thrombolysis NIHSS score (OR = 1.118, P = 0.001), elevated lactate dehydrogenase (LDH) (OR = 1.087, P = 0.035), higher Fibrinogen-to-Albumin Ratio (FAR) (OR = 1.031, P = 0.008), and higher Lactate Dehydrogenase-to-Albumin Ratio (LAR) (OR = 2.129, P = 0.012). ROC analysis showed that LAR had the highest individual predictive value (AUC = 0.801, Sensitivity = 76.1%, Specificity = 76.3%). Combining NIHSS, LDH, FAR, and LAR provided the best prediction (AUC = 0.922, Sensitivity = 94.0%, Specificity = 74.3%). Of note, this high AUC reflects exploratory performance within a single retrospective cohort; the composite model is not intended for immediate clinical use and must be prospectively validated. Our study identifies LAR and FAR as new and important predictors of END after IVT, based on the pathophysiology involving hypoxic injury and the interplay of inflammation and coagulation, LAR and FAR are new and important predictors of END after IVT, which may aid in the early identification of high-risk patients for intensified monitoring.