Impact of insulin resistance partially mediating symptomatic intracranial hemorrhage on futile recanalization in large vessel occlusion patients

Insulin resistance (IR) contributes to the development of the no-reflow phenomenon in acute myocardial infarction patients following coronary revascularization. However, the impact of IR on futile recanalization for anterior circulation large vessel occlusion (LVO) patients following endovascular treatment (EVT) remains unclear. This study was based on a multicenter cohort. Acute ischemic stroke patients with LVO who underwent successful EVT within 24 h of symptom onset were enrolled. IR was assessed by the triglyceride-glucose (TyG) index, obtained as ln [fasting TG (mg/dl) × FBG (mg/dl)/2]. The primary outcome was futile recanalization (90-day modified Rankin Scale [mRS] score 3–6 despite successful recanalization). Symptomatic intracranial hemorrhage was assessed as an independent short-term outcome and evaluated as a potential mediator between TyG and futile recanalization. Of 860 patients screened for eligibility, 608 patients who achieved recanalization were included. Enrolled patients were divided into three groups based on the TyG index levels (tertile [T] 1: 5.45–8.41; T2: 8.41–8.95; T3: 8.95–10.97). After adjustment for confounders, the T3 group had a higher proportion of futile recanalization than the T1 and T2 groups (T3 vs. T1: adjusted OR: 2.08, 95% CI 1.30–3.33, P = 0.002; T3 vs. T2: adjusted OR: 1.89, 95% CI 1.18–3.02, P = 0.008). The restricted cubic splines regression model revealed that the risk of futile recanalization and symptomatic intracranial hemorrhage (sICH) increased linearly with elevated TyG index. Mediation analysis showed that sICH partially mediated an estimated 17.4% (95% CI 1.3–58.0%) of the association between a higher TyG index and futile recanalization. The TyG index is a robust risk factor for symptomatic intracranial hemorrhage and futile recanalization in acute LVO patients who achieved successful recanalization.