ABSTRACT NUMBER: ESOC2026LB216 HIGHER HDL CHOLESTEROL IS ASSOCIATED WITH REDUCED HEMORRHAGIC REPERFUSION INJURY AND IMPROVED FUNCTIONAL OUTCOME AFTER THROMBECTOMY FOR ISCHEMIC STROKE: RESULTS FROM THE MULTICENTER SHIELD-EVT STUDY

Abstract Background and aims We hypothesized that higher HDL-C levels provide neuroprotection and mitigate hemorrhagic reperfusion injury in patients undergoing thrombectomy for anterior circulation large vessel occlusion (acLVO). Methods The prospective SHIELD-EVT registry study evaluated patients treated with thrombectomy for acLVO at 15 German centers between 1/2017 and 1/2025. We utilized inverse probability weighted regression and ordered logistic shift analysis to assess the impact of HDL-C levels on imaging-defined hemorrhagic injury (intracerebral or subarachnoid bleeding per Heidelberg classification) and 90-day functional outcomes. Results In our cohort of 7085 thrombectomy patients (51.9% women; median age, 76 years [IQR, 65–83], median HDL-C 43.4 mg/dL [IQR, 35-53]), those in the lowest HDL-C quintile (4-33 mg/dL) had a 32.9% risk of hemorrhagic reperfusion injury. Compared with this group, hemorrhage risk decreased by 6.2% in quintile 2 (34-40 mg/dL; P=0.02), by 6.0% in quintile 3 (40-47 mg/dL; P=0.04), by 6.2% in quintile 4 (47-56 mg/dL; P=0.03), and by 5.9% in quintile 5 (56-205 mg/dL; P=0.04). The dose response plot showed a threshold effect above 33 mg/dL with sustained protection across normal-to-high HDL ranges. (Figure A) We observed a significant shift in the overall distribution of 90-day mRS scores in favor of a HDL-C level above the median (adjusted OR 0.61; 95CI% [0.55; 0.69]; p<0.001). (Figure B) Conclusions Higher HDL-C levels above a 33 mg/dL threshold are independently associated with a significant reduction in hemorrhagic reperfusion injury and superior 90-day functional recovery following thrombectomy for acLVO. Conflict of interest Figure 1 - belongs to Conclusions