Dynamic alterations of novel thrombotic molecular markers in acute ischemic stroke patients after intravenous thrombolysis: a retrospective cohort study

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These molecular markers facilitate the early assessment of coagulation and fibrinolysis system functions, as well as vascular endothelial injury; however, their clinical application following intravenous thrombolysis for acute ischemic stroke (AIS) remains unclear. Therefore, our study aims to evaluate the dynamic levels of these novel thrombosis-related molecular markers within 24 hours after intravenous thrombolysis in patients with AIS and analyze their relationship with patients outcome. Methods: We conducted a retrospective cohort study based on the data of 77 patients with AIS who underwent alteplase intravenous thrombolysis between November 2022 and February 2024. Novel thrombotic markers were evaluated at four time points: prior to thrombolysis, 1 hour after thrombolysis, 6 hours after thrombolysis, and 24 hours after thrombolysis. Based on the modified Rankin scale (mRS) score at day 90 post-discharge, patients were categorized into the good outcome group (mRS ≤ 1) and the poor outcome group (mRS > 1). Stepwise multivariate logistic regression was employed to analyze the association between 90-day functional outcomes and the measured variables. The area under the receiver operating characteristic curve (AUC) was utilized to assess the predictive ability of novel thrombotic markers. Results: Our study demonstrated that, compared to the poor outcome group, the good outcome group exhibited significant lower serum TAT levels both prior to thrombolysis and at 6 hours post-thrombolysis (all p < 0.05), and serum TM and t-PAIC levels were also significantly elevated in the good outcome group at 1 hour, 6 hours, and 24 hours following thrombolysis (all p < 0.05). Stepwise logistic regression analysis indicated that increased serum TM and t-PAIC levels at 24 hours post-thrombolysis were protective factors for a good 90-day outcome. The AUC values of TM, t-PAIC, and TM combined with t-PAIC for predicting 90-day functional outcomes were 0.918 (sensitivity 80.0%; specificity 85.7%), 0.658 (sensitivity 91.4%; specificity: 45.2%), and 0.984 (sensitivity: 97.1%; specificity 97.6%), respectively. Conclusion: Novel thrombotic molecular markers might serve as indicators for the early monitoring of dysfunction in the coagulation-fibrinolysis system and endothelial injury following intravenous thrombolysis for AIS. TM and t-PAIC exhibit predictive value regarding the outcome of intravenous thrombolysis in AIS, providing insights for future research on the protective role of TM in AIS. acute ischemic stroke intravenous thrombolysis coagulation-fibrinolysis system endothelial injury thrombomodulin Figures Figure 1 Figure 2 Background Acute ischemic stroke (AIS) is associated with high mortality and disability. Recanalization therapies, such as intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT), represent effective treatments for AIS. Nevertheless, despite aggressive reperfusion therapy, some patients may experience poor outcomes or deteriorate [ 1 , 2 ]. Imbalance in the coagulation and fibrinolysis systems, along with endothelial injury, are pivotal factors in the occurrence and progression of ischemic stroke, exerting influence on its outcome[ 3 – 5 ]. Novel thrombotic molecular markers include Thrombin-antithrombin complex (TAT), Plasmin inhibitor-plasmin complex (PIC), Thrombomodulin (TM), and Tissue Plasminogen Activator-Plasminogen Activator Inhibitor-1 Complex (t-PAIC). These molecular markers facilitate early assessment of coagulation, fibrinolysis system function, and vascular endothelial injury in the body [ 6 , 7 ].The novel thrombotic molecular markers have been extensively investigated in the context of ischemic stroke. Studies have suggested that elevated serum TM levels are associated with a favorable outcome for cerebral infarction [ 6 , 8 – 10 ], while increased TAT and PIC levels may indicate an elevated risk of post-thrombectomy bleeding [ 11 ]. However, the clinical significance of these molecular markers remains debated due to variations in stroke etiology, treatment modalities, and timing of detection among patients, leading to substantial heterogeneity across different patient cohorts [ 12 ]. Therefore, our study aims to assess the dynamic levels of novel thrombotic molecular markers within 24 hours following intravenous thrombolysis in patients with AIS and analyze their correlation with patients outcomes. Methods Study design and participants We conducted a retrospective cohort study using a prospectively maintained clinical database and biobank. Between November 2022 and February 2024, we screened patients with AIS who underwent intravenous thrombolysis at our stroke center. The inclusion criteria were: (1) age ≥ 18 years; (2) first-time AIS meeting the emergency intravenous thrombolysis criteria according to the American Heart Association/American Stroke Association guidelines and receiving alteplase intravenous thrombolysis. The exclusion criteria were: (1) baseline modified Rankin Scale score ≥ 2; (2) severe heart (New York Heart Association classification system, class III-IV), hepatic (serum alanine aminotransferase or aspartate aminotransferase >2 times of the upper limit of normal), or renal (serum creatinine >1.5 times of the upper limit of normal) failure; and (3) lack of blood samples, clinical data, or follow-up information. This study was approved by the Ethics Committee of Ganzhou Hospital-Nanfang Hospital, Southern Medical University (TY-ZKY2023-053-01) and adhered to the principles outlined in the Helsinki Declaration. Written consent was obtained from the patients or their legal representatives for this study. Clinical data collection We collected the following clinical data: (1) age and gender; (2) medical history; (3) parameters of intravenous thrombolytic treatment, including onset to thrombolysis time (OTT), door to needle time (DNT); (4) location of the infarcted lesion in the responsible vessel, divided into anterior circulation and posterior circulation; (5) stroke severity assessed using the National Institutes of Health Stroke Scale (NIHSS), with assessments conducted before and 24 hours after thrombolysis; (6) stroke etiology defined using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria, categorized as atherosclerotic large artery disease, cardiac embolism, small vessel disease, or other causes; and (7) 90-day functional outcome evaluated using the modified Rankin scale (mRS), with scores ranging from 2 to 6 indicating poor outcome. All study results were validated by certified neurovascular specialists and radiologists through blinded verification of clinical data. Blood sample collection and measurements The blood samples were collected at four time points: 0 hour (on admission, before thrombolysis), 1 hour, 6 hours, and 24 hours after thrombolysis. Heparin-coated blood collection tubes were used for sample collection. Subsequently, the blood samples underwent centrifugation at 1500g for 15 minutes followed by a second centrifugation at 13000g for 3 minutes to isolate plasma. The obtained plasma was aliquoted and stored at -80°C until use, with thawing conducted at 37°C prior to analysis. Levels of TAT, PIC, t-PAIC, and sTM were quantified using an automatic chemiluminescence analyzer (MI600; Yingkai Biotech, Shenzhen, China) in conjunction with specific reagent kits as per the manufacturer's instructions. The normal reference ranges provided by the manufacturer are as follows: TAT ≤ 4 ng/mL, PIC ≤ 0.8 µg/mL, t-PAIC (male: ≤17.0ng/mL; female: ≤10.5 ng/mL), sTM (3.8–13.3 TU/mL), and D-dimer ≤ 0.5 µg/mL. Statistical analysis In our study, a two-tailed P value of less than 0.05 was considered statistically significant. Statistical analyses were conducted using R (version 3.6.3, R Foundation for Statistical Computing, Vienna, Austria). Noncontinuous variables and continuous variables that deviated from the normal distribution were explored with non-parametric approaches (Mann–Whitney–Wilcoxon for two groups and Kruskal–Wallis for multigroups) and are presented as the median and interquartile range. Continuous variables following the normal distribution are presented as the mean and standard deviation; for these variables, the t test was adopted. Categorical variables are expressed as counts (percentages) and analyzed with the chi-square test. According to the 90-day mRS score, we divided patients into two groups: a good outcome group (mRS: 0–1) and a poor outcome group (mRS: 2–6). The association of measured variables with 90-day functional outcome was analyzed with stepwise multivariate logistic regression analysis that adjusted for potential confounders. To evaluate the predictive ability of hemostatic molecular markers, we calculated the area under the receiver operating characteristic curve (AUC). Results Baseline characteristics A total of 77 patients were enrolled in this study, consisting of 50 males and 27 females, with an average age of 66.30 ± 11.00 years. Table 1 presents the baseline characteristics of the selected patients stratified by their 90-day functional outcomes. No significant differences were observed between the two groups regarding gender, age, comorbidities, DNT, OTT, pre-thrombolysis NIHSS scores, stroke location, or etiology (all p > 0.05). The incidence of intracranial hemorrhage following thrombolysis was lower in the good outcome group, while NIHSS scores at both 24 hours and one week post-thrombolysis were higher compared to those in the poor outcome group. Levels of novel thrombotic molecular markers in patients with different outcomes Our study found that compared with the poor outcome group, the serum TAT level in the good outcome group was significantly lower before [ TAT, 2.130 (0.960–5.085) ng/ml vs. 4.800 (3.405–9.162) ng/ml; p < 0.01 ] and 6 hours [ TAT, 3.300 (1.775–6.695) ng/ml vs. 4.790 (3.338–9.337) ng/ml p < 0.05 ] after thrombolysis. Moreover, the serum TM and t-PAIC levels were significantly higher at 1 hour [ TM, 17.800 (12.245–21.605) TU/ml vs. 7.725 (5.995–11.673) TU/ml; p < 0.01. t-PAIC, 17.880 (11.085–23.875) ng/ml vs. 10.542 (4.028–18.412) ng/ml; p < 0.05 ], 6 hours [ TM, 18.400 (14.830–20.900) TU/ml vs. 8.055 (5.998–11.885) TU/ml; p < 0.01. t-PAIC, 9.970 (7.710-14.085) ng/ml vs. 8.190 (3.458–12.242) ng/ml; p < 0.05 ], and 24 hours [ TM, 15.990 (13.765–19.440) TU/ml vs. 7.560 (5.315–10.828) TU/ml; p < 0.01. t-PAIC, 9.140 (6.561–11.334) ng/ml vs. 6.297 (2.460–9.518) ng/ml; p < 0.05 ] following thrombolysis (Fig. 1 ). Associations between novel thrombotic molecular markers and 90-day functional outcomes Utilizing stepwise logistic regression analysis, the elevation of serum TM and t-PAIC levels 24 hours post-thrombolysis was identified as a protective factor for good outcome at 90 days, as illustrated in Table 2 . Receiver operating characteristic analysis showed that the AUC values of TM, t-PAIC and TM combined with t-PAIC in differentiating 90-day functional outcome were 0.918 (sensitivity 80.0%; specificity 85.7%), 0.658 (sensitivity 91.4%; specificity: 45.2%), and 0.984 (sensitivity: 97.1%; specificity 97.6%), respectively (Fig. 2 ). Table 1 Characteristics of study population Variables Good outcome Poor outcome P N 35 42 Male, n (%) 23 27 0.898 Age (years), mean ± SD 64.80 ± 11.74 67.55 ± 10.33 0.278 Comorbidities Coronary artery disease, n (%) 2 (5.7) 5 (11.9) 0.587 Hypertension, n (%) 30 (85.7) 33 (78.6) 0.608 Diabetes, n (%) 8 (22.9) 16 (38.1) 0.234 Atrial fibrillation, n (%) 5 (14.3) 8 (19.0) 0.803 Dyslipidemia, n (%) 11 (31.4) 11 (26.2) 0.800 DNT (minutes), median (IQR) 27(20.5–36.5) 31.5(26–44) 0.190 OTT (minutes), median (IQR) 150(120–210) 180(120–200) 0.141 NIHSS, median (IQR) Pre-thrombolysis 6(5-8.5) 8(6–10) 0.203 Post-thrombolysis 24 hours 3(1–4) 8(5–10) <0.001 Post-thrombolysis 1 week 1(1-2.5) 6(4–9) <0.001 Stroke location n (%) 0.322 Anterior circulation 24(68.6) 34(81.0) Posterior circulation 11 (31.4) 8 ( 19.0) Etiology, n (%) 0.164 LAA 14 (40.0) 20 ( 47.6) CE 3 ( 8.6) 9 ( 21.4) SVD 15 (42.9) 9 ( 21.4) Other causes 3 ( 8.6) 4 ( 9.5) Intracranial hemorrhage after thrombolysis, n (%) 1 (2.9) 9 (21.4) 0.038 SD, standard deviation; DNT, door-to-needle time; IQR, interquartile range; OTT, onset-to-thrombolysis time; NIHSS, National Institutes of Health Stroke Scale; LAA, large artery atherosclerosis; CE, cardioembolism; SVD, small vessel disease. Table 2 The serum levels of novel thrombotic molecular markers at various time points and their association with patient clinical outcomes. Time points outcome PIC,µg/ml median (IQR) TAT,ng/ml median (IQR) TM,TU/ml median (IQR) t-PAIC,ng/ml median (IQR) 0 h Good 0.580 (0.415–0.910) 2.130 (0.960–5.085) 9.760 (6.965–12.395) 7.033 (2.397–12.350) Poor 0.845 (0.455–1.653) 4.800 (3.405–9.162) 7.700 (5.488–10.218) 4.920 (1.040–9.656) p value 0.861 0.253 0.121 0.454 1 h Good 18.400 (7.970–28.370) 6.850 (3.995–19.330) 17.800 (12.245–21.605) 17.880 (11.085–23.875) Poor 21.650 (7.428–29.803) 5.065 (3.535–8.085) 7.725 (5.995–11.673) 10.542 (4.028–18.412) p value 0.151 0.080 0.064 0.246 6 h Good 8.920 (3.195–14.785) 3.300 (1.775–6.695) 18.400 (14.830–20.900) 9.970 (7.710−14.085) Poor 4.545 (0.650–8.713) 4.790 (3.338–9.337) 8.055 (5.998–11.885) 8.190 (3.458–12.242) p value 0.877 0.121 0.087 0.167 24 h Good 0.900 (0.480–1.990) 2.32 (1.250–6.785) 15.990 (13.765–19.440) 9.140 (6.561–11.334) Poor 0.750 (0.470–5.900) 3.500 (1.958–5.985) 7.560 (5.315–10.828) 6.297 (2.460–9.518) p value 0.0797 0.312 0.002 0.029 TAT, thrombin-antithrombin complex; PIC, plasmin inhibitor-plasmin complex; TM, thrombomodulin; t-PAIC, tissue plasminogen activator-plasminogen activator inhibitor-1 complex; IQR, interquartile range. Discussion Our study observed the dynamic changes of novel thrombotic markers in serum within 24 hours after intravenous thrombolysis in AIS patients for the first time. We found that the levels of TM and t-PAIC after thrombolytic therapy were significantly higher in patients with a good outcome than in those with a poor outcome. After conducting multivariate logistic regression analysis, we discovered that the elevation of TM and t-PAIC levels at 24 hours after thrombolysis is a related factor for a good outcome. Therefore, TM and t-PAIC serve as biomarkers for predicting the outcome of AIS patients treated with intravenous thrombolysis. Novel thrombotic molecular markers, including TAT, PIC, TM, and t-PAIC, can be employed for the early assessment of the functions of the coagulation and fibrinolysis systems as well as vascular endothelial injury within the body. In the early stage of coagulation system activation, prothrombin is activated into thrombin. Under normal physiological conditions, once a tiny amount of thrombin is present in the blood, it is promptly inactivated through covalent binding with its specific inhibitor, antithrombin, to form TAT [ 13 , 14 ]. An elevated TAT level can precisely reflect the generation of thrombin and the enhancement of thrombin activity, accurately indicating early coagulation dysfunction. All thrombotic diseases involve a series of pathological processes related to thrombosis formation. Excessive activation of the coagulation system and the abundant production of thrombin are the key factors for thrombosis formation [ 15 , 16 ]. The generation of plasmin lies at the core of the fibrinolysis system, and its plasma level can reflect the activation degree of the fibrinolysis system. Immediately after its generation, plasmin combines with its specific inhibitor (α2 - plasmin inhibitor complex) to form PIC and becomes inactive. The half-life of plasmin in the body is only about 10 minutes, making it difficult to directly detect the plasma concentration of plasmin. An elevated PIC level can sensitively reflect the generation of plasmin and indicate the actual state of fibrin degradation within the body [ 17 – 19 ]. TM is a transmembrane glycoprotein mainly expressed on the surface of vascular endothelial cells. The soluble form of TM in the blood is produced by the hydrolysis of membrane-bound TM on endothelial cells. Under physiological conditions, the content of TM in the blood is extremely low. When vascular endothelial cells are damaged, TM production increases and is released into the blood, resulting in an abnormally elevated TM level in the blood, which is usually secondary to vascular endothelial injury. Hence, its plasma level can reflect the degree of endothelial cell injury [ 20 , 21 ]. When blood vessels are damaged, tPA (tissue-type plasminogen activator) is released into the blood, specifically converting plasminogen into plasmin to dissolve fibrin [ 22 ]. There are four subtypes of its inhibitor PAI, among which the PAI-1 subtype plays an crucial role in the body's fibrinolysis system [ 23 , 24 ]. t-PAIC is the product of the combination of tPA and its specific inhibitor PAI-1 and serves as a marker reflecting the amount of tPA released upon endothelial damage. The detection of plasma t-PAIC levels can be utilized to determine the activation of the body's fibrinolysis system and the repair degree of the endothelium. Novel thrombotic molecular markers have been extensively studied in the context of ischemic stroke; however, the conclusions remain controversial [ 3 ]. Previous research has indicated that increased serum levels of TM are positively correlated with the severity of atherosclerosis, suggesting a relationship with vascular injury severity as well [25; 26]. Olivot et al. proposed that elevated serum TM serves as a protective factor for patients without prior vascular disease against developing cerebral infarction; however, once cerebral infarction occurs, higher serum TM levels are associated with increased mortality [ 27 ]. A study involving 3,532 patients with ischemic stroke reported that elevated serum TM was positively associated with favorable outcome at three months post-event [ 9 ]. Subsequent investigations suggested that TM may serve as a marker for early identification and progression of cerebral infarction [ 10 ]. In animal models of ischemic stroke, neuroprotective effects attributed to TM have been confirmed. While most studies currently suggest a protective role for TM regarding outcomes in ischemic stroke, there are also reports indicating that elevated serum levels of TM in patients undergoing intravenous thrombolysis correlate with higher mortality compared to those not receiving thrombolysis [ 3 ]. The changes in serum TM following intravenous thrombolysis and their association with outcome remain unclear. Therefore, our study revealed that among patients exhibiting favorable outcomes after AIS treated via intravenous thrombolysis, the levels of both serum TM and t-PAIC at 1 hour, 6 hours, and 24 hours were significantly elevated compared to those observed in patients experiencing unfavorable outcomes. This further elucidates the dynamic alterations in thrombotic molecular markers during intravenous thrombolysis for AIS. Following multivariate logistic regression analysis, we found that elevated serum levels of both TM and t-PAIC at 24 hours post-thrombolysis were associated with good outcomes. We hypothesize that these dynamic fluctuations in serum TM could exert varying impacts on patient outcomes. Prior studies have suggested that t-PAIC can indicate sustained endothelial damage alongside fibrin thrombus progression and subsequent fibrinolytic dysfunction. Elevated concentrations of t-PA and t-PAIC correlate with an increased risk for large cerebral infractions as well as heightened future stroke risk [ 7 , 28 , 29 ]. However, our findings demonstrated significantly higher t-PAIC levels within the good outcome group when compared to those within the poor outcome group. We speculate that different subtypes of t-PAIC may play roles in repairing endothelial damage—a hypothesis warranting further investigation [ 22 , 30 ]. Previous research has shown elevations in TAT and PIC among AIS patients—suggesting their potential utility for predicting adverse outcomes along with post-endovascular thrombectomy hemorrhage events [11;16]. Our study also found that the serum TAT levels in the poor outcome group before thrombolysis and 6 hours after thrombolysis were higher than those in the good outcome group. However, after correction by multivariate logistic regression analysis, no statistical significance was observed. We analyzed the reasons for this result, which may be as follows: On the one hand, serum TAT levels in the body are in a dynamic change process and are affected by various factors; on the other hand, the sample size is small. Our study has several limitations. Firstly, it is a retrospective, single-center cohort study with a limited sample size and lacks external validation. Secondly, although we employed adjusted multivariate logistic regression analysis to account for multiple potential confounding factors, residual confounding may still influence the results. Lastly, while we observed a correlation between the levels of hemostatic molecular markers and patient outcomes, this does not necessarily imply causality; further research is required to establish such relationships. Conclusion The interaction mechanism between the coagulation-fibrinolysis system and vascular endothelial injury during the acute phase of ischemic stroke is extremely intricate. Novel thrombotic biomarkers facilitate early assessment of both coagulation-fibrinolysis system function and endothelial injury status. Our study represents the first investigation into the dynamic changes in serum levels of these novel thrombotic markers within 24 hours following intravenous thrombolysis in patients with AIS. We found that patients with good outcomes exhibited significantly higher levels of TM and t-PAIC at 24 hours post-thrombolysis compared to those with poor outcomes. These findings suggest that elevated TM and t-PAIC levels might serve as pertinent prognostic indicators for positive outcomes in this patient population, providing valuable insights for future research on the potential protective role of TM in AIS. Declarations Acknowledgements Not applicable. Authors’ contributions XL and JZ conceptualized the study and revised the manuscript. SX, FL, YX, YZ, and PW acquired the data. WS and SX analyzed and interpreted the data, drafted and revised the manuscript, and prepared the figures. All authors contributed to the writing and revisions of the paper. All authors read and approved the final manuscript. Funding This work was supported by the Bureau of Science and Technology of Ganzhou Municipality (2022-ZD1360). Data Availability The original contributions made for this study are included in the article, and further inquiries can be addressed to the corresponding author. Ethics approval and consent to participate This study was approved by the Ethics Committee of Ganzhou Hospital-Nanfang Hospital, Southern Medical University (TY-ZKY2023-053-01) and adhered to the principles outlined in the Helsinki Declaration. Written consent was obtained from the patients or their legal representatives for this study. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Author details 1 Department of Neurology and Stroke Center, Ganzhou Hospital-Nanfang Hospital, Southern Medical University, Ganzhou, China 2 Department of Neurology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China 3 Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China References Powers WJ, Rabinstein AA, Ackerson T, et al. 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Clinical and applied thrombosis/hemostasis : official journal of the International Academy of Clinical and Applied Thrombosis/Hemostasis. 2022 Jan-Dec;28:10760296221102929. eng. Epub 2022/05/24. doi:10.1177/10760296221102929. Cited in: Pubmed; PMID 35603624. Declerck PJ, Gils A. Three decades of research on plasminogen activator inhibitor-1: a multifaceted serpin. Seminars in thrombosis and hemostasis. 2013 Jun;39(4):356-64. eng. Epub 2013/03/19. doi:10.1055/s-0033-1334487. Cited in: Pubmed; PMID 23504606. Ito T, Suzuki Y, Sano H, et al. Demonstration of Three Distinct High-Molecular-Weight Complexes between Plasminogen Activator Inhibitor Type 1 and Tissue-Type Plasminogen Activator. Thrombosis and haemostasis. 2022 Mar;122(3):336-343. eng. Epub 2021/05/14. doi:10.1055/a-1508-7919. Cited in: Pubmed; PMID 33984865. Ridker PM, Brown NJ, Vaughan DE, et al. Established and emerging plasma biomarkers in the prediction of first atherothrombotic events. Circulation. 2004 Jun 29;109(25 Suppl 1):Iv6-19. eng. Epub 2004/07/01. doi:10.1161/01.Cir.0000133444.17867.56. Cited in: Pubmed; PMID 15226246. Dohi Y, Ohashi M, Sugiyama M, et al. Circulating thrombomodulin levels are related to latent progression of atherosclerosis in hypertensive patients. Hypertension research : official journal of the Japanese Society of Hypertension. 2003 Jun;26(6):479-83. eng. Epub 2003/07/17. doi:10.1291/hypres.26.479. Cited in: Pubmed; PMID 12862205. Olivot JM, Labreuche J, Aiach M, et al. Soluble thrombomodulin and brain infarction: case-control and prospective study. Stroke. 2004 Aug;35(8):1946-51. eng. Epub 2004/06/12. doi:10.1161/01.STR.0000133340.37712.9b. Cited in: Pubmed; PMID 15192246. Zhao X, Yang S, Lei R, et al. Clinical study on the feasibility of new thrombus markers in predicting massive cerebral infarction. Frontiers in Neurology. 2023;13. doi:10.3389/fneur.2022.942887. Zhao X, Yang S, Lei R, et al. Value of novel thrombotic markers for predicting occurrence of the malignant cerebral artery infarction: a prospective clinical study. Front Neurol. 2023;14:1238742. eng. Epub 2023/12/15. doi:10.3389/fneur.2023.1238742. Cited in: Pubmed; PMID 38099069. Wieczór R, Wieczór AM, Rość D. Tissue-type plasminogen activator and plasminogen activator inhibitor type 1 in patients with symptomatic lower extremity artery disease. Minerva cardiology and angiology. 2021 Apr;69(2):161-171. eng. Epub 2020/07/10. doi:10.23736/s2724-5683.20.05114-2. Cited in: Pubmed; PMID 32643893. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 17 Feb, 2026 Reviews received at journal 17 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviews received at journal 04 Feb, 2026 Reviewers agreed at journal 04 Feb, 2026 Reviews received at journal 28 Jan, 2025 Reviewers agreed at journal 23 Jan, 2025 Reviewers invited by journal 09 Jan, 2025 Editor invited by journal 27 Nov, 2024 Editor assigned by journal 25 Nov, 2024 Submission checks completed at journal 25 Nov, 2024 First submitted to journal 20 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5491763","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":384396404,"identity":"10815f96-3f04-4415-a595-82386e2d5047","order_by":0,"name":"Wei Sun","email":"","orcid":"","institution":"Ganzhou Hospital-Nanfang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Sun","suffix":""},{"id":384396405,"identity":"ece8adec-ff95-4775-baed-160f217c9168","order_by":1,"name":"Shuhua Xie","email":"","orcid":"","institution":"Ganzhou Hospital-Nanfang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shuhua","middleName":"","lastName":"Xie","suffix":""},{"id":384396406,"identity":"1e7f0719-f28b-4fbf-adb4-98327dab0812","order_by":2,"name":"Fugan Liu","email":"","orcid":"","institution":"The Affiliated Ganzhou Hospital of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Fugan","middleName":"","lastName":"Liu","suffix":""},{"id":384396407,"identity":"3f74d92c-c702-4e4e-b5ba-5522e099daba","order_by":3,"name":"Yuqing Xie","email":"","orcid":"","institution":"The Affiliated Ganzhou Hospital of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Yuqing","middleName":"","lastName":"Xie","suffix":""},{"id":384396408,"identity":"96a94ea7-595d-4928-835b-6a52d34dd1ca","order_by":4,"name":"Yunhui zhu","email":"","orcid":"","institution":"Ganzhou Hospital-Nanfang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yunhui","middleName":"","lastName":"zhu","suffix":""},{"id":384396409,"identity":"b393a8a1-e9cc-420b-837e-47c3f8e09664","order_by":5,"name":"Pengcheng Wu","email":"","orcid":"","institution":"Ganzhou Hospital-Nanfang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Pengcheng","middleName":"","lastName":"Wu","suffix":""},{"id":384396410,"identity":"a9d1fad9-b3ba-41b5-9fd2-010c91f54130","order_by":6,"name":"Jiajia Zhu","email":"","orcid":"","institution":"Nanfang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jiajia","middleName":"","lastName":"Zhu","suffix":""},{"id":384396411,"identity":"50302bfe-d0f3-43f6-8b4e-07c2e97eca13","order_by":7,"name":"Xianghong Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYJACZgSzAIjZGxsffiBeiwEQ8xxuNpYgTYtEepsADx7l8u5nD38uqDjMYM7eY/bhg4GN3YabD9sYJBjs5HQbsGsxPJOXYDzjzGEGy54zxjNnGKQlb7id2PaggCHZ2OwADi0NOQbJvG2HGQxu5Bgz8xgcTja4ndhuIMFwIHEbLi39bwwOg7XcfwPVcvNgmwQPHi3yEjmGzRBbeMBa7AxuMOLXYiABMvxMOoPBmbRiRqBfEiTPJAID2QC3X+T7c4w/81RYMxgcP7yZ4UOFjT3f8eMPH36osJPDpcUAKl7fABVIXAAWMcCuHGxLA5qAPYbIKBgFo2AUjHgAAEnkXZgm42N1AAAAAElFTkSuQmCC","orcid":"","institution":"Ganzhou Hospital-Nanfang Hospital, Southern Medical University","correspondingAuthor":true,"prefix":"","firstName":"Xianghong","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2024-11-20 14:38:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5491763/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5491763/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71893860,"identity":"60f5febb-fd09-46bf-84bf-3e882445d7ff","added_by":"auto","created_at":"2024-12-19 13:29:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":551534,"visible":true,"origin":"","legend":"\u003cp\u003eConcentrations of novel thrombotic molecular markersin patients with good and bad outcome.\u003c/p\u003e\n\u003cp\u003e*\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05, **\u003cem\u003ep\u003c/em\u003e\u0026lt;0.01, NS, not significant. TAT, thrombin-antithrombin complex; PIC, plasmin inhibitor-plasmin complex; TM, thrombomodulin; t-PAIC, tissue plasminogen activator-plasminogen activator inhibitor-1 complex.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5491763/v1/0af897a4f565ebfaf56f634d.png"},{"id":71893861,"identity":"a0c6673d-d927-4673-a480-69d7ace1a57a","added_by":"auto","created_at":"2024-12-19 13:29:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":79038,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver operator characteristic curve analyses for novel thrombotic molecular markers to predict 90-day functional outcome.\u003c/p\u003e\n\u003cp\u003eAUC, area under the receiver operating characteristic curve; TM, thrombomodulin; t-PAIC, tissue plasminogen activator-plasminogen activator inhibitor-1 complex.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5491763/v1/c310ce52d5f0ded06b3ec5c4.png"},{"id":71894891,"identity":"bfd36ec2-0def-44ab-b1d0-ad62038c56ff","added_by":"auto","created_at":"2024-12-19 13:37:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1114884,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5491763/v1/6c621482-3a46-4366-a664-5ee2ca0519d1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Dynamic alterations of novel thrombotic molecular markers in acute ischemic stroke patients after intravenous thrombolysis: a retrospective cohort study","fulltext":[{"header":"Background","content":"\u003cp\u003eAcute ischemic stroke (AIS) is associated with high mortality and disability. Recanalization therapies, such as intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT), represent effective treatments for AIS. Nevertheless, despite aggressive reperfusion therapy, some patients may experience poor outcomes or deteriorate [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Imbalance in the coagulation and fibrinolysis systems, along with endothelial injury, are pivotal factors in the occurrence and progression of ischemic stroke, exerting influence on its outcome[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Novel thrombotic molecular markers include Thrombin-antithrombin complex (TAT), Plasmin inhibitor-plasmin complex (PIC), Thrombomodulin (TM), and Tissue Plasminogen Activator-Plasminogen Activator Inhibitor-1 Complex (t-PAIC). These molecular markers facilitate early assessment of coagulation, fibrinolysis system function, and vascular endothelial injury in the body [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].The novel thrombotic molecular markers have been extensively investigated in the context of ischemic stroke. Studies have suggested that elevated serum TM levels are associated with a favorable outcome for cerebral infarction [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], while increased TAT and PIC levels may indicate an elevated risk of post-thrombectomy bleeding [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, the clinical significance of these molecular markers remains debated due to variations in stroke etiology, treatment modalities, and timing of detection among patients, leading to substantial heterogeneity across different patient cohorts [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Therefore, our study aims to assess the dynamic levels of novel thrombotic molecular markers within 24 hours following intravenous thrombolysis in patients with AIS and analyze their correlation with patients outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective cohort study using a prospectively maintained clinical database and biobank. Between November 2022 and February 2024, we screened patients with AIS who underwent intravenous thrombolysis at our stroke center. The inclusion criteria were: (1) age\u0026thinsp;\u0026ge;\u0026thinsp;18 years; (2) first-time AIS meeting the emergency intravenous thrombolysis criteria according to the American Heart Association/American Stroke Association guidelines and receiving alteplase intravenous thrombolysis. The exclusion criteria were: (1) baseline modified Rankin Scale score\u0026thinsp;\u0026ge;\u0026thinsp;2; (2) severe heart (New York Heart Association classification system, class III-IV), hepatic (serum alanine aminotransferase or aspartate aminotransferase \u0026gt;2 times of the upper limit of normal), or renal (serum creatinine \u0026gt;1.5 times of the upper limit of normal) failure; and (3) lack of blood samples, clinical data, or follow-up information. This study was approved by the Ethics Committee of Ganzhou Hospital-Nanfang Hospital, Southern Medical University (TY-ZKY2023-053-01) and adhered to the principles outlined in the Helsinki Declaration. Written consent was obtained from the patients or their legal representatives for this study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical data collection\u003c/h3\u003e\n\u003cp\u003eWe collected the following clinical data: (1) age and gender; (2) medical history; (3) parameters of intravenous thrombolytic treatment, including onset to thrombolysis time (OTT), door to needle time (DNT); (4) location of the infarcted lesion in the responsible vessel, divided into anterior circulation and posterior circulation; (5) stroke severity assessed using the National Institutes of Health Stroke Scale (NIHSS), with assessments conducted before and 24 hours after thrombolysis; (6) stroke etiology defined using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria, categorized as atherosclerotic large artery disease, cardiac embolism, small vessel disease, or other causes; and (7) 90-day functional outcome evaluated using the modified Rankin scale (mRS), with scores ranging from 2 to 6 indicating poor outcome. All study results were validated by certified neurovascular specialists and radiologists through blinded verification of clinical data.\u003c/p\u003e\n\u003ch3\u003eBlood sample collection and measurements\u003c/h3\u003e\n\u003cp\u003eThe blood samples were collected at four time points: 0 hour (on admission, before thrombolysis), 1 hour, 6 hours, and 24 hours after thrombolysis. Heparin-coated blood collection tubes were used for sample collection. Subsequently, the blood samples underwent centrifugation at 1500g for 15 minutes followed by a second centrifugation at 13000g for 3 minutes to isolate plasma. The obtained plasma was aliquoted and stored at -80\u0026deg;C until use, with thawing conducted at 37\u0026deg;C prior to analysis. Levels of TAT, PIC, t-PAIC, and sTM were quantified using an automatic chemiluminescence analyzer (MI600; Yingkai Biotech, Shenzhen, China) in conjunction with specific reagent kits as per the manufacturer's instructions. The normal reference ranges provided by the manufacturer are as follows: TAT\u0026thinsp;\u0026le;\u0026thinsp;4 ng/mL, PIC\u0026thinsp;\u0026le;\u0026thinsp;0.8 \u0026micro;g/mL, t-PAIC (male: \u0026le;17.0ng/mL; female: \u0026le;10.5 ng/mL), sTM (3.8\u0026ndash;13.3 TU/mL), and D-dimer\u0026thinsp;\u0026le;\u0026thinsp;0.5 \u0026micro;g/mL.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eIn our study, a two-tailed P value of less than 0.05 was considered statistically significant. Statistical analyses were conducted using R (version 3.6.3, R Foundation for Statistical Computing, Vienna, Austria). Noncontinuous variables and continuous variables that deviated from the normal distribution were explored with non-parametric approaches (Mann\u0026ndash;Whitney\u0026ndash;Wilcoxon for two groups and Kruskal\u0026ndash;Wallis for multigroups) and are presented as the median and interquartile range. Continuous variables following the normal distribution are presented as the mean and standard deviation; for these variables, the \u003cem\u003et\u003c/em\u003e test was adopted. Categorical variables are expressed as counts (percentages) and analyzed with the chi-square test. According to the 90-day mRS score, we divided patients into two groups: a good outcome group (mRS: 0\u0026ndash;1) and a poor outcome group (mRS: 2\u0026ndash;6). The association of measured variables with 90-day functional outcome was analyzed with stepwise multivariate logistic regression analysis that adjusted for potential confounders. To evaluate the predictive ability of hemostatic molecular markers, we calculated the area under the receiver operating characteristic curve (AUC).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eBaseline characteristics\u003c/h2\u003e\n \u003cp\u003eA total of 77 patients were enrolled in this study, consisting of 50 males and 27 females, with an average age of 66.30\u0026thinsp;\u0026plusmn;\u0026thinsp;11.00 years. Table \u003cspan\u003e1\u003c/span\u003e presents the baseline characteristics of the selected patients stratified by their 90-day functional outcomes. No significant differences were observed between the two groups regarding gender, age, comorbidities, DNT, OTT, pre-thrombolysis NIHSS scores, stroke location, or etiology (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The incidence of intracranial hemorrhage following thrombolysis was lower in the good outcome group, while NIHSS scores at both 24 hours and one week post-thrombolysis were higher compared to those in the poor outcome group.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eLevels of novel thrombotic molecular markers in patients with different outcomes\u003c/h3\u003e\n\u003cp\u003eOur study found that compared with the poor outcome group, the serum TAT level in the good outcome group was significantly lower before [ TAT, 2.130 (0.960\u0026ndash;5.085) ng/ml vs. 4.800 (3.405\u0026ndash;9.162) ng/ml; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 ] and 6 hours [ TAT, 3.300 (1.775\u0026ndash;6.695) ng/ml vs. 4.790 (3.338\u0026ndash;9.337) ng/ml p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 ] after thrombolysis. Moreover, the serum TM and t-PAIC levels were significantly higher at 1 hour [ TM, 17.800 (12.245\u0026ndash;21.605) TU/ml vs. 7.725 (5.995\u0026ndash;11.673) TU/ml; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01. t-PAIC, 17.880 (11.085\u0026ndash;23.875) ng/ml vs. 10.542 (4.028\u0026ndash;18.412) ng/ml; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 ], 6 hours [ TM, 18.400 (14.830\u0026ndash;20.900) TU/ml vs. 8.055 (5.998\u0026ndash;11.885) TU/ml; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01. t-PAIC, 9.970 (7.710-14.085) ng/ml vs. 8.190 (3.458\u0026ndash;12.242) ng/ml; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 ], and 24 hours [ TM, 15.990 (13.765\u0026ndash;19.440) TU/ml vs. 7.560 (5.315\u0026ndash;10.828) TU/ml; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01. t-PAIC, 9.140 (6.561\u0026ndash;11.334) ng/ml vs. 6.297 (2.460\u0026ndash;9.518) ng/ml; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 ] following thrombolysis (Fig. \u003cspan\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eAssociations between novel thrombotic molecular markers and 90-day functional outcomes\u003c/h3\u003e\n\u003cp\u003eUtilizing stepwise logistic regression analysis, the elevation of serum TM and t-PAIC levels 24 hours post-thrombolysis was identified as a protective factor for good outcome at 90 days, as illustrated in Table \u003cspan\u003e2\u003c/span\u003e. Receiver operating characteristic analysis showed that the AUC values of TM, t-PAIC and TM combined with t-PAIC in differentiating 90-day functional outcome were 0.918 (sensitivity 80.0%; specificity 85.7%), 0.658 (sensitivity 91.4%; specificity: 45.2%), and 0.984 (sensitivity: 97.1%; specificity 97.6%), respectively (Fig. \u003cspan\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eCharacteristics of study population\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGood outcome\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePoor outcome\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.898\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64.80\u0026thinsp;\u0026plusmn;\u0026thinsp;11.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67.55\u0026thinsp;\u0026plusmn;\u0026thinsp;10.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.278\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCoronary artery disease, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.587\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypertension, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (78.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.608\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (38.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.234\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAtrial fibrillation, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.803\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDyslipidemia, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (31.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (26.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.800\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDNT (minutes), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27(20.5\u0026ndash;36.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.5(26\u0026ndash;44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.190\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOTT (minutes), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e150(120\u0026ndash;210)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e180(120\u0026ndash;200)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.141\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNIHSS, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre-thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(5-8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8(6\u0026ndash;10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.203\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePost-thrombolysis 24 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(1\u0026ndash;4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8(5\u0026ndash;10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePost-thrombolysis 1 week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1-2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(4\u0026ndash;9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStroke location n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.322\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnterior circulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24(68.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34(81.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePosterior circulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (31.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 ( 19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEtiology, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.164\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLAA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 ( 47.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 ( 8.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 ( 21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSVD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 ( 21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther causes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 ( 8.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 ( 9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntracranial hemorrhage after thrombolysis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eSD, standard deviation; DNT, door-to-needle time; IQR, interquartile range; OTT, onset-to-thrombolysis time; NIHSS, National Institutes of Health Stroke Scale; LAA, large artery atherosclerosis; CE, cardioembolism; SVD, small vessel disease.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eThe serum levels of novel thrombotic molecular markers at various time points and their association with patient clinical outcomes.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime points\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eoutcome\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePIC,\u0026micro;g/ml\u003c/p\u003e\n \u003cp\u003emedian (IQR)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTAT,ng/ml\u003c/p\u003e\n \u003cp\u003emedian (IQR)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTM,TU/ml\u003c/p\u003e\n \u003cp\u003emedian (IQR)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003et-PAIC,ng/ml\u003c/p\u003e\n \u003cp\u003emedian (IQR)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e0 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.580\u003c/p\u003e\n \u003cp\u003e(0.415\u0026ndash;0.910)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.130\u003c/p\u003e\n \u003cp\u003e(0.960\u0026ndash;5.085)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.760\u003c/p\u003e\n \u003cp\u003e(6.965\u0026ndash;12.395)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.033\u003c/p\u003e\n \u003cp\u003e(2.397\u0026ndash;12.350)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.845\u003c/p\u003e\n \u003cp\u003e(0.455\u0026ndash;1.653)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.800\u003c/p\u003e\n \u003cp\u003e(3.405\u0026ndash;9.162)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.700\u003c/p\u003e\n \u003cp\u003e(5.488\u0026ndash;10.218)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.920\u003c/p\u003e\n \u003cp\u003e(1.040\u0026ndash;9.656)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.861\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.253\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.454\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e1 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.400\u003c/p\u003e\n \u003cp\u003e(7.970\u0026ndash;28.370)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.850\u003c/p\u003e\n \u003cp\u003e(3.995\u0026ndash;19.330)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.800\u003c/p\u003e\n \u003cp\u003e(12.245\u0026ndash;21.605)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.880\u003c/p\u003e\n \u003cp\u003e(11.085\u0026ndash;23.875)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.650\u003c/p\u003e\n \u003cp\u003e(7.428\u0026ndash;29.803)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.065\u003c/p\u003e\n \u003cp\u003e(3.535\u0026ndash;8.085)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.725\u003c/p\u003e\n \u003cp\u003e(5.995\u0026ndash;11.673)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.542\u003c/p\u003e\n \u003cp\u003e(4.028\u0026ndash;18.412)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.080\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.246\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e6 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.920\u003c/p\u003e\n \u003cp\u003e(3.195\u0026ndash;14.785)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.300\u003c/p\u003e\n \u003cp\u003e(1.775\u0026ndash;6.695)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.400\u003c/p\u003e\n \u003cp\u003e(14.830\u0026ndash;20.900)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.970\u003c/p\u003e\n \u003cp\u003e(7.710\u0026minus;14.085)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.545\u003c/p\u003e\n \u003cp\u003e(0.650\u0026ndash;8.713)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.790\u003c/p\u003e\n \u003cp\u003e(3.338\u0026ndash;9.337)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.055\u003c/p\u003e\n \u003cp\u003e(5.998\u0026ndash;11.885)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.190\u003c/p\u003e\n \u003cp\u003e(3.458\u0026ndash;12.242)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.877\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.087\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.167\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e24 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.900\u003c/p\u003e\n \u003cp\u003e(0.480\u0026ndash;1.990)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.32\u003c/p\u003e\n \u003cp\u003e(1.250\u0026ndash;6.785)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.990\u003c/p\u003e\n \u003cp\u003e(13.765\u0026ndash;19.440)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.140\u003c/p\u003e\n \u003cp\u003e(6.561\u0026ndash;11.334)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.750\u003c/p\u003e\n \u003cp\u003e(0.470\u0026ndash;5.900)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.500\u003c/p\u003e\n \u003cp\u003e(1.958\u0026ndash;5.985)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.560\u003c/p\u003e\n \u003cp\u003e(5.315\u0026ndash;10.828)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.297\u003c/p\u003e\n \u003cp\u003e(2.460\u0026ndash;9.518)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0797\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTAT, thrombin-antithrombin complex; PIC, plasmin inhibitor-plasmin complex; TM, thrombomodulin; t-PAIC, tissue plasminogen activator-plasminogen activator inhibitor-1 complex; IQR, interquartile range.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study observed the dynamic changes of novel thrombotic markers in serum within 24 hours after intravenous thrombolysis in AIS patients for the first time. We found that the levels of TM and t-PAIC after thrombolytic therapy were significantly higher in patients with a good outcome than in those with a poor outcome. After conducting multivariate logistic regression analysis, we discovered that the elevation of TM and t-PAIC levels at 24 hours after thrombolysis is a related factor for a good outcome. Therefore, TM and t-PAIC serve as biomarkers for predicting the outcome of AIS patients treated with intravenous thrombolysis.\u003c/p\u003e \u003cp\u003eNovel thrombotic molecular markers, including TAT, PIC, TM, and t-PAIC, can be employed for the early assessment of the functions of the coagulation and fibrinolysis systems as well as vascular endothelial injury within the body. In the early stage of coagulation system activation, prothrombin is activated into thrombin. Under normal physiological conditions, once a tiny amount of thrombin is present in the blood, it is promptly inactivated through covalent binding with its specific inhibitor, antithrombin, to form TAT [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. An elevated TAT level can precisely reflect the generation of thrombin and the enhancement of thrombin activity, accurately indicating early coagulation dysfunction. All thrombotic diseases involve a series of pathological processes related to thrombosis formation. Excessive activation of the coagulation system and the abundant production of thrombin are the key factors for thrombosis formation [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The generation of plasmin lies at the core of the fibrinolysis system, and its plasma level can reflect the activation degree of the fibrinolysis system. Immediately after its generation, plasmin combines with its specific inhibitor (α2 - plasmin inhibitor complex) to form PIC and becomes inactive. The half-life of plasmin in the body is only about 10 minutes, making it difficult to directly detect the plasma concentration of plasmin. An elevated PIC level can sensitively reflect the generation of plasmin and indicate the actual state of fibrin degradation within the body [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. TM is a transmembrane glycoprotein mainly expressed on the surface of vascular endothelial cells. The soluble form of TM in the blood is produced by the hydrolysis of membrane-bound TM on endothelial cells. Under physiological conditions, the content of TM in the blood is extremely low. When vascular endothelial cells are damaged, TM production increases and is released into the blood, resulting in an abnormally elevated TM level in the blood, which is usually secondary to vascular endothelial injury. Hence, its plasma level can reflect the degree of endothelial cell injury [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. When blood vessels are damaged, tPA (tissue-type plasminogen activator) is released into the blood, specifically converting plasminogen into plasmin to dissolve fibrin [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. There are four subtypes of its inhibitor PAI, among which the PAI-1 subtype plays an crucial role in the body's fibrinolysis system [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. t-PAIC is the product of the combination of tPA and its specific inhibitor PAI-1 and serves as a marker reflecting the amount of tPA released upon endothelial damage. The detection of plasma t-PAIC levels can be utilized to determine the activation of the body's fibrinolysis system and the repair degree of the endothelium.\u003c/p\u003e \u003cp\u003eNovel thrombotic molecular markers have been extensively studied in the context of ischemic stroke; however, the conclusions remain controversial [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Previous research has indicated that increased serum levels of TM are positively correlated with the severity of atherosclerosis, suggesting a relationship with vascular injury severity as well [25; 26]. Olivot et al. proposed that elevated serum TM serves as a protective factor for patients without prior vascular disease against developing cerebral infarction; however, once cerebral infarction occurs, higher serum TM levels are associated with increased mortality [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. A study involving 3,532 patients with ischemic stroke reported that elevated serum TM was positively associated with favorable outcome at three months post-event [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Subsequent investigations suggested that TM may serve as a marker for early identification and progression of cerebral infarction [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In animal models of ischemic stroke, neuroprotective effects attributed to TM have been confirmed. While most studies currently suggest a protective role for TM regarding outcomes in ischemic stroke, there are also reports indicating that elevated serum levels of TM in patients undergoing intravenous thrombolysis correlate with higher mortality compared to those not receiving thrombolysis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The changes in serum TM following intravenous thrombolysis and their association with outcome remain unclear. Therefore, our study revealed that among patients exhibiting favorable outcomes after AIS treated via intravenous thrombolysis, the levels of both serum TM and t-PAIC at 1 hour, 6 hours, and 24 hours were significantly elevated compared to those observed in patients experiencing unfavorable outcomes. This further elucidates the dynamic alterations in thrombotic molecular markers during intravenous thrombolysis for AIS. Following multivariate logistic regression analysis, we found that elevated serum levels of both TM and t-PAIC at 24 hours post-thrombolysis were associated with good outcomes. We hypothesize that these dynamic fluctuations in serum TM could exert varying impacts on patient outcomes. Prior studies have suggested that t-PAIC can indicate sustained endothelial damage alongside fibrin thrombus progression and subsequent fibrinolytic dysfunction. Elevated concentrations of t-PA and t-PAIC correlate with an increased risk for large cerebral infractions as well as heightened future stroke risk [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, our findings demonstrated significantly higher t-PAIC levels within the good outcome group when compared to those within the poor outcome group. We speculate that different subtypes of t-PAIC may play roles in repairing endothelial damage\u0026mdash;a hypothesis warranting further investigation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Previous research has shown elevations in TAT and PIC among AIS patients\u0026mdash;suggesting their potential utility for predicting adverse outcomes along with post-endovascular thrombectomy hemorrhage events [11;16]. Our study also found that the serum TAT levels in the poor outcome group before thrombolysis and 6 hours after thrombolysis were higher than those in the good outcome group. However, after correction by multivariate logistic regression analysis, no statistical significance was observed. We analyzed the reasons for this result, which may be as follows: On the one hand, serum TAT levels in the body are in a dynamic change process and are affected by various factors; on the other hand, the sample size is small.\u003c/p\u003e \u003cp\u003eOur study has several limitations. Firstly, it is a retrospective, single-center cohort study with a limited sample size and lacks external validation. Secondly, although we employed adjusted multivariate logistic regression analysis to account for multiple potential confounding factors, residual confounding may still influence the results. Lastly, while we observed a correlation between the levels of hemostatic molecular markers and patient outcomes, this does not necessarily imply causality; further research is required to establish such relationships.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe interaction mechanism between the coagulation-fibrinolysis system and vascular endothelial injury during the acute phase of ischemic stroke is extremely intricate. Novel thrombotic biomarkers facilitate early assessment of both coagulation-fibrinolysis system function and endothelial injury status. Our study represents the first investigation into the dynamic changes in serum levels of these novel thrombotic markers within 24 hours following intravenous thrombolysis in patients with AIS. We found that patients with good outcomes exhibited significantly higher levels of TM and t-PAIC at 24 hours post-thrombolysis compared to those with poor outcomes. These findings suggest that elevated TM and t-PAIC levels might serve as pertinent prognostic indicators for positive outcomes in this patient population, providing valuable insights for future research on the potential protective role of TM in AIS.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eXL and JZ conceptualized the study and revised the manuscript. SX, FL, YX, YZ, and PW acquired the data. WS and SX analyzed and interpreted the data, drafted and revised the manuscript, and prepared the figures. All authors contributed to the writing and revisions of the paper. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Bureau of Science and Technology of Ganzhou Municipality (2022-ZD1360).\u003c/p\u003e\n\u003cp\u003eData Availability\u003c/p\u003e\n\u003cp\u003eThe original contributions made for this study are included in the article, and further inquiries can be addressed to the corresponding author.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Ganzhou Hospital-Nanfang Hospital, Southern Medical University (TY-ZKY2023-053-01) and adhered to the principles outlined in the Helsinki Declaration. Written consent was obtained from the patients or their legal representatives for this study.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eAuthor details\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Neurology and Stroke Center, Ganzhou Hospital-Nanfang Hospital, Southern Medical University, Ganzhou, China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eDepartment of Neurology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eDepartment of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003ePowers WJ, Rabinstein AA, Ackerson T, et al. 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Quantitation by an enzyme-linked differential antibody immunosorbent assay. The Journal of clinical investigation. 1981 Jul;68(1):46-55. eng. Epub 1981/07/01. doi:10.1172/jci110253. Cited in: Pubmed; PMID 6166634.\u003c/li\u003e\n \u003cli\u003eMinami K, Notohamiprodjo G, Buschler H, et al. Alpha-2 plasmin inhibitor-plasmin complex and postoperative blood loss: double-blind study with aprotinin in reoperation for myocardial revascularization. The Journal of thoracic and cardiovascular surgery. 1993 Nov;106(5):934-6. eng. Epub 1993/11/01. Cited in: Pubmed; PMID 7694000.\u003c/li\u003e\n \u003cli\u003eLi Y, Li H, Wang Y, et al. Potential Biomarkers for Early Diagnosis, Evaluation, and Prognosis of Sepsis-Induced Coagulopathy. Clinical and applied thrombosis/hemostasis : official journal of the International Academy of Clinical and Applied Thrombosis/Hemostasis. 2023 Jan-Dec;29:10760296231195089. eng. Epub 2023/08/22. doi:10.1177/10760296231195089. 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Cited in: Pubmed; PMID 15226246.\u003c/li\u003e\n \u003cli\u003eDohi Y, Ohashi M, Sugiyama M, et al. Circulating thrombomodulin levels are related to latent progression of atherosclerosis in hypertensive patients. Hypertension research : official journal of the Japanese Society of Hypertension. 2003 Jun;26(6):479-83. eng. Epub 2003/07/17. doi:10.1291/hypres.26.479. Cited in: Pubmed; PMID 12862205.\u003c/li\u003e\n \u003cli\u003eOlivot JM, Labreuche J, Aiach M, et al. Soluble thrombomodulin and brain infarction: case-control and prospective study. Stroke. 2004 Aug;35(8):1946-51. eng. Epub 2004/06/12. doi:10.1161/01.STR.0000133340.37712.9b. Cited in: Pubmed; PMID 15192246.\u003c/li\u003e\n \u003cli\u003eZhao X, Yang S, Lei R, et al. Clinical study on the feasibility of new thrombus markers in predicting massive cerebral infarction. Frontiers in Neurology. 2023;13. doi:10.3389/fneur.2022.942887.\u003c/li\u003e\n \u003cli\u003eZhao X, Yang S, Lei R, et al. Value of novel thrombotic markers for predicting occurrence of the malignant cerebral artery infarction: a prospective clinical study. Front Neurol. 2023;14:1238742. eng. Epub 2023/12/15. doi:10.3389/fneur.2023.1238742. Cited in: Pubmed; PMID 38099069.\u003c/li\u003e\n \u003cli\u003eWiecz\u0026oacute;r R, Wiecz\u0026oacute;r AM, Rość D. Tissue-type plasminogen activator and plasminogen activator inhibitor type 1 in patients with symptomatic lower extremity artery disease. Minerva cardiology and angiology. 2021 Apr;69(2):161-171. eng. Epub 2020/07/10. doi:10.23736/s2724-5683.20.05114-2. Cited in: Pubmed; PMID 32643893.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"acute ischemic stroke, intravenous thrombolysis, coagulation-fibrinolysis system, endothelial injury, thrombomodulin","lastPublishedDoi":"10.21203/rs.3.rs-5491763/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5491763/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eNovel thrombotic molecular markers include the thrombin-antithrombin complex (TAT), plasmin inhibitor-plasmin complex (PIC), thrombomodulin (TM), and tissue plasminogen activator-plasminogen activator inhibitor-1 complex (t-PAIC). These molecular markers facilitate the early assessment of coagulation and fibrinolysis system functions, as well as vascular endothelial injury; however, their clinical application following intravenous thrombolysis for acute ischemic stroke (AIS) remains unclear. Therefore, our study aims to evaluate the dynamic levels of these novel thrombosis-related molecular markers within 24 hours after intravenous thrombolysis in patients with AIS and analyze their relationship with patients outcome.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective cohort study based on the data of 77 patients with AIS who underwent alteplase intravenous thrombolysis between November 2022 and February 2024. Novel thrombotic markers were evaluated at four time points: prior to thrombolysis, 1 hour after thrombolysis, 6 hours after thrombolysis, and 24 hours after thrombolysis. Based on the modified Rankin scale (mRS) score at day 90 post-discharge, patients were categorized into the good outcome group (mRS\u0026thinsp;\u0026le;\u0026thinsp;1) and the poor outcome group (mRS\u0026thinsp;\u0026gt;\u0026thinsp;1). Stepwise multivariate logistic regression was employed to analyze the association between 90-day functional outcomes and the measured variables. The area under the receiver operating characteristic curve (AUC) was utilized to assess the predictive ability of novel thrombotic markers.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eOur study demonstrated that, compared to the poor outcome group, the good outcome group exhibited significant lower serum TAT levels both prior to thrombolysis and at 6 hours post-thrombolysis (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and serum TM and t-PAIC levels were also significantly elevated in the good outcome group at 1 hour, 6 hours, and 24 hours following thrombolysis (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Stepwise logistic regression analysis indicated that increased serum TM and t-PAIC levels at 24 hours post-thrombolysis were protective factors for a good 90-day outcome. The AUC values of TM, t-PAIC, and TM combined with t-PAIC for predicting 90-day functional outcomes were 0.918 (sensitivity 80.0%; specificity 85.7%), 0.658 (sensitivity 91.4%; specificity: 45.2%), and 0.984 (sensitivity: 97.1%; specificity 97.6%), respectively.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eNovel thrombotic molecular markers might serve as indicators for the early monitoring of dysfunction in the coagulation-fibrinolysis system and endothelial injury following intravenous thrombolysis for AIS. TM and t-PAIC exhibit predictive value regarding the outcome of intravenous thrombolysis in AIS, providing insights for future research on the protective role of TM in AIS.\u003c/p\u003e","manuscriptTitle":"Dynamic alterations of novel thrombotic molecular markers in acute ischemic stroke patients after intravenous thrombolysis: a retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-19 13:21:00","doi":"10.21203/rs.3.rs-5491763/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-18T04:04:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-17T06:04:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"252230658958266726428226510905258829663","date":"2026-02-05T08:49:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T03:26:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305426929105039293008366070820396287989","date":"2026-02-04T09:56:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-28T11:59:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"110633619239272990131357832756598447285","date":"2025-01-23T08:09:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-01-09T06:38:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-11-27T15:02:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-25T14:03:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-25T14:01:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2024-11-20T14:32:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8de36cdd-a127-4a5f-ba6c-83a60ecd2cb2","owner":[],"postedDate":"December 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-17T09:53:14+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-19 13:21:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5491763","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5491763","identity":"rs-5491763","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}