Role of asymmetric dimethyl-arginine and NOX-2 in activation of leptomeningeal collaterals after acute ischemic stroke

Role of asymmetric dimethyl-arginine and NOX-2 in activation of leptomeningeal collaterals after acute ischemic stroke | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Role of asymmetric dimethyl-arginine and NOX-2 in activation of leptomeningeal collaterals after acute ischemic stroke Manuela De Michele, Angela Risitano, Marta Iacobucci, Paolo Amisano, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7614889/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Dec, 2025 Read the published version in Scientific Reports → Version 1 posted 9 You are reading this latest preprint version Abstract Leptomeningeal collateral (LMC) circulation helps preserve brain tissue during acute ischemic stroke (AIS), with poor collateral status predicting worse outcomes. This study assessed the association between asymmetric dimethylarginine (ADMA), LMCs, infarct volume, and oxidative stress in 101 AIS patients with large vessel occlusion within 6h or wake-up stroke. LMC status was graded using the Menon score on CT angiography (categorized as poor, intermediate, or good), and recanalization was assessed by the modified Thrombolysis in Cerebral Infarction score. Serum ADMA and NOX2 levels were measured at admission (< 6h, T0), 24h (T1), and 48h (T2). Among patients, 43.1% had good, 35.3% intermediate, 21.6% poor LMC status. Higher admission ADMA levels were significantly associated with poor LMC (p = 0.028) and more severe neurological deficits at T1 and T2 (p = 0.005, p = 0.008). ADMA levels increased over time (p = 0.046), and correlated with NOX2 at T1 (p < 0.001). Rising NOX2 was associated with increased neutrophils (p = 0.013) and decreased lymphocytes (p = 0.006). ADMA likely impairs endothelial function by reducing nitric oxide availability and enhancing NOX2-driven oxidative stress. Statin use was associated with lower NOX2 levels. These findings support a role for the ADMA-NO-NOX2 axis in limiting collateral circulation. Targeting this axis may represent a therapeutic strategy to improve outcomes in AIS. Health sciences/Diseases Health sciences/Medical research Health sciences/Neurology Biological sciences/Neuroscience ADMA NOX2 leptomeningeal collaterals acute ischemic stroke reperfusion Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Ischemic stroke (IS) is the second leading cause of death worldwide [ 1 ]. Recent advances in reperfusion therapies—mainly intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT)—have improved outcomes, with earlier treatment linked to better functional independence [ 1 , 2 ]. However, some patients do not respond effectively despite early intervention. Beyond the classic “time is brain” concept, growing evidence emphasizes the “brain tissue window”, where treatment is tailored based on the mismatch between the ischemic core (irreversibly damaged tissue) and the ischemic penumbra (hypoperfused but salvageable tissue). The extent of leptomeningeal collateral (LMC) circulation influences penumbra viability. Patients with poor collateral circulation have worse outcomes even when treated within 4.5–6 hours, compared to those with good collaterals who can benefit beyond this time window (fast and slow progressors) [ 3 ]. This new concept is known as the “collateral clock” [ 4 ]. LMCs are involved in normal brain function, dilating in correspondence with the active brain areas at a given moment. This phenomenon is the basis of neurovascular coupling. Pressure gradients between the various arterial territories involved would activate LMCs [ 5 ]. Animal models classify collaterals into three types based on their persistence over time: persistent, transient, or intermediate [ 5 ]. Collateral compensation ceases after vessel recanalization or due to “collateral failure,” caused by endothelial damage, platelet aggregation, and increased blood viscosity, leading to microvascular obstruction (no-reflow phenomenon) [ 6 ]. Early ischemia also involves precapillary smooth muscle cell contraction, which worsens hypoperfusion and microthrombosis [ 7 , 8 ]. In humans, poor collaterals correlate with older age [ 9 ], metabolic syndrome [ 10 , 11 ], and chronic hypertension [ 12 ], while ipsilateral extracranial stenosis > 75% associate with better collaterals [ 13 ]. Mechanisms driving LMC and smooth muscle cell activation remain unclear but may involve metabolic, hemodynamic, or congenital factors. Nitric oxide (NO), produced by three nitric oxide synthase isoforms—neuronal (nNOS), endothelial (eNOS), and inducible (iNOS)—is a key vasodilator and endothelial function marker [ 14 ]. eNOS-derived NO preserves cerebral microcirculation, inhibits platelet aggregation, leukocyte adhesion, and smooth muscle proliferation, exerting vascular protection [ 15 ]. After stroke, iNOS expression peaks at 4–7 days [ 16 ]. NO reacts with superoxide (O₂⁻) to form peroxynitrite (ONOO⁻), causing mitochondrial damage, lipid peroxidation, protein nitrosylation, and DNA injury [ 16 ]. eNOS uncoupling, due to lack of cofactors like tetrahydrobiopterin, leads to ROS rather than NO production, exacerbating ischemic damage. NO also inhibits endothelin-1 (ET-1) synthesis, a potent vasoconstrictor, by reducing release of endothelin converting enzyme-1 (ECE-1) [ 16 ]. Asymmetric dimethylarginine (ADMA) is an endogenous NOS inhibitor and marker of endothelial dysfunction and atherosclerosis [ 17 ]. ADMA levels rise after acute IS, correlating with stroke severity [ 18 ]. It promotes NOS uncoupling, oxidative stress, and inflammation via ROS and NF-kB pathways [ 18 ]. Allopurinol, a xanthine oxidase inhibitor, reduces ADMA and improves endothelium-dependent vasodilation in heart failure patients [ 19 ]. The main vascular source of reactive oxygen species (ROS) is NADPH oxidase (NOX), especially the NOX2 isoform, which is upregulated in cerebral arteries after IS and contributes to oxidative stress and brain injury [ 20 – 24 ]. NOX inhibition reduces ischemic brain damage in experimental models [ 24 ]. Excessive NOX2-derived ROS also activates inflammasomes and leads to worsening inflammatory responses and ischemia-reperfusion injury [ 25 ]. The primary objective of this study was to investigate the correlation between ADMA serum levels, the degree of leptomeningeal collateral circulation and the final ischemic volume in patients with AIS. The secondary objective was to evaluate whether the levels of this biomarker were associated with increased oxidative stress, worse stroke severity and poor outcomes. Results We enrolled 101 patients with LVO AIS, 37 males (36.6%) and 64 females (63.4%); mean ±SD age 76.4 ±12.4 years. Twenty-nine patients (28.5%) had a wake-up stroke or unknown onset of symptoms. Patients were divided into three groups according to the collateral status: poor, intermediate and good collaterals (Figure 1). Patients’ Characteristics No statistically significant differences were found among the three groups regarding demographic characteristics, prior medical therapies, blood pressure or heart rate at the three time points (Table 1, Supplementary Table S1 online). However, patients with poor collateral status presented with more severe strokes as per higher NIHSS score at T0 (poor vs. intermediate vs. good collateral status; p = 0.038). Biomarkers ADMA values significantly increase in all patients from T0 to T2 (112.55 at T0 vs 132.18 at T1 vs 146.42 at T2 p=0.047) regardless of the collateral status (p=0.046) (Figure 2.A, B; Supplementary Table S2). NOX2 serum levels also increased from T0 to T2, although not significantly (p=0.249), and the increase was sharper in poor than in intermediate and good collaterals, although the between-group difference did not reach a statistical significance (p=0.261) (Figure 2. C, D; Supplementary Table S2 online). ADMA serum concentration at T0 also correlated with clinical severity at T1 and T2 (Spearman’s rho=0.327 and 0.323; p=0.005 and 0.008, respectively) (Supplementary Fig. 1 online. A, B). This association was confirmed after considering dichotomic variable of mild stroke (NIHSS≤6) and moderate-severe stroke (NIHSS >6), respectively at T1 p=0.005 and T2 p=0.013 (Supplementary Fig. 1 online.C, D). A significant association was found between ADMA level at T0 and LMC; specifically higher levels were associated with poor LMC (mean in overall population 112.55 ng/ml ±31.75; good 102.40 ng/ml ± 25.72 vs moderate 119.80 ng/ml ± 29.30 vs poor 123.85 ng/ml ± 42.36 LMC; p=0.028) (Figure 3). ADMA at T0 tended to inversely correlate with ASPECT at basal CT (Spearman’s rho= -0.217; p=0.059), although this value did not reach a statistically significance. Median ADMA serum levels at T0 were also associated with carotid atherosclerosis > 70% (86.75 ng/ml vs 115.38 ng/ml in patients with carotid stenosis ≤70%; p=0.049). ADMA serum levels at T1 correlated with NOX2 at the same time point (Spearman’s rho=0.436; p<0.001) (Figure 4) and tended to be lower in patients who used antiplatelets prior to the index stroke (median levels, 120.76 ng/ml vs 134.68 ng/ml in patients who did not take antiplatelet prior to stroke; p=0.059). NOX2 serum levels at T2 were correlated with peripheral blood neutrophils count at T2 (neutrophil absolute number, Spearman’s rho= 0.322, p=0.013; neutrophil percentage, Spearman’s rho= 0.259, p=0.032), and inversely correlated with lymphocytes count at T2 (lymphocyte absolute number, Spearman’s rho=-0.353, p=0.006; lymphocyte percentage, Spearman’s rho= -0.342, p=0.008) (Supplementary Fig. S2 online). Statin use was associated with lower median levels of NOX2 at T1 (13.36 pg/ml vs. 17.11 pg/ml; p=0.032). No significant correlation was found between serum biomarker measured at the three timepoints and stroke volume. The biomarker values examined − both in the pre- and post-occlusion arterial intracranial blood samples − at the three time points did not show significant differences between groups according to the collateral status (Supplementary Table S3 online). Clinical outcome There were any significant associations between the extent of LMC and clinical outcomes, whether measured as any mRS at 3 months, good outcome (mRS 0–2), excellent outcome (mRS 0–1), poor outcome (mRS 2–6 or 3–6), or in-hospital and 90-day mortality (Supplementary Table S4 online). Multivariate analysis Ordinal regression analysis identified ADMA levels at T0 as an independent predictor of LMC status (estimates 0.019 (95% CI 0.005-0.034); OR 1.019, p=0.009) after adjustment for age, sex, NIHSS at T0, and NOX2 levels at T0 (Table 2). The binary logistic regression did not identify in the LMC status and the examined biomarkers (ADMA or NOX2) as independent predictors of clinical functional outcome or death at 90 days (Supplementary Tables S5 and S6 online). Discussion The extent of collateral circulation partly depends on good collaterogenesis influenced by genetic factors, but this alone appears insufficient to ensure effective LMC activation in LVO. This has prompted research into metabolic and hemodynamic conditions that may regulate collateral activation [ 7 – 13 ]. According to the rLMC scoring system, our cohort showed 43.1% with good, 35.3% with medium, and 21.6% with poor LMC status, consistent with proportions reported in the literature [ 26 ]. Poor LMC was significantly associated with higher NIHSS scores at admission and with higher levels of ADMA. Moreover, ADMA serum concentration at T0 correlated with clinical severity at T1 and T2. We found that ADMA values significantly increased in all patients from T0 to T2 regardless of collateral status—a plausible finding since ADMA is a well-established marker of endothelial dysfunction and oxidative stress [ 27 ]. In our study, ADMA levels at admission were significantly associated with poor LMCs. This suggests a possible role for ADMA in failure of collateral vasodilation, indirectly by reducing NO availability. Supporting this hypothesis, previous studies demonstrated a decrease in CBF following ADMA infusion in healthy volunteers (measured by MRI perfusion) [ 28 ], and an increase in anaerobic cerebral metabolism in patients with severe carotid stenosis undergoing endarterectomy—indicating that elevated ADMA may impair cerebral perfusion [ 29 ]. Due to poor collateral status, patients with higher ADMA at admission experienced more severe strokes (NIHSS > 6) at both T1 and T2, aligning with findings from other studies [ 30 ]. Recently, we observed higher NO concentrations in the early phases of stroke regardless of LMC status, followed by a progressive decrease—supporting the idea that NO plays a key role in LMC activation through collateral vasodilation, before declining later [ 31 ]. According to these findings, higher ADMA at admission may cause lower NO levels, poorer collateral status, and more severe stroke symptoms. In line with existing data, median ADMA serum levels at T0 were also associated with carotid atherosclerosis > 70% [ 32 , 33 ]. ADMA is linked to stroke risk factors and atherosclerosis, and correlates with stroke severity and poor outcomes [ 33 , 34 ]. This association may arise initially from ischemia-induced cellular proteolysis and secondarily from NOS inhibition [ 34 ]. Another proposed mechanism for ADMA-induced dysregulation of macrophage cholesterol metabolism involves NOX-derived ROS: oxidative stress suppresses liver X receptor alpha (LXRα) activity, downregulating ATP-binding cassette transporters A1 (ABCA1/G1) and impairing reverse cholesterol transport—promoting foam cell formation and atherosclerosis [ 35 ]. NOX₂ serum levels also increased from T0 to T2, albeit not significantly, likely due to progression of the ischemic penumbra and infarction evolution. ADMA levels at T1 correlated with NOX2 at the same time point, and tended to be lower in patients on prior antiplatelet therapy. ADMA reduces NO bioavailability, contributing to endothelial dysfunction. Concurrently, elevated NOX2 activity increases ROS, exacerbating oxidative stress. This synergy suggests that ADMA may contribute to NOX2 upregulation/activation [ 32 ], in part through the suppression of DDAH (dimethylarginine dimethylaminohydrolase), the key enzyme responsible for ADMA degradation. Oxidative stress, commonly present in the early phases of stroke, impairs DDAH activity, leading to the accumulation of ADMA. Elevated ADMA levels then further inhibit NO production by eNOS, reducing NO-mediated inhibition of NOX2. As a result, NOX2 activity increases, generating more ROS, which in turn further suppress DDAH activity—thereby perpetuating a self-amplifying oxidative loop (Fig. 5 ). At T2, elevated NOX2 levels positively correlated with neutrophil counts and inversely correlated with lymphocyte counts, reflecting an acute pro-oxidant state largely driven by innate immune activation and neutrophil-derived oxidative bursts [ 36 ]. This heightened oxidative stress may induce lymphocyte apoptosis or impair function, contributing to lymphopenia and compromised adaptive immunity [ 37 ]. These findings underscore the clinical relevance of the neutrophil-to-lymphocyte ratio as a biomarker of systemic inflammation and immune dysregulation in acute post-stroke pathology [ 38 ]. Statin use was associated with lower median NOX2 levels at T1, likely reflecting their antioxidant effects beyond lipid lowering. Statins have been shown to inhibit NADPH oxidase activation—particularly via suppression of the Rho/Rac1 pathway—thereby reducing NOX2-derived ROS production and improving endothelial redox balance [ 39 ]. Main limitations of this study are the small subgroup sample sizes that may have weakened statistical power to detect differences in collateral status vs. outcome, and the single-center design that may reduce generalizability. The strengths of the study lie on the comprehensive biomarker analysis (peripheral/intracranial), the integration with neuroimaging, the focus on clinically relevant LMC activation post-AIS, and the prospective design. In conclusion, our findings suggest that elevated ADMA levels are associated with impaired LMC vasodilation in AIS, likely through reduced NO bioavailability. This supports the hypothesis that endothelial dysfunction plays a central role in limiting collateral vessel recruitment. Furthermore, ADMA may contribute to the upregulation or activation of NOX2, promoting excessive ROS production and establishing a feed-forward oxidative loop during the first 24 hours after stroke onset. This pro-oxidative state was further reflected by a significant correlation between NOX2 levels and increased neutrophil counts, alongside decreased lymphocyte counts—indicating early innate immune activation and systemic inflammation. Importantly, the use of statins prior to stroke was associated with lower NOX2 levels, suggesting a potential protective effect mediated by their antioxidant properties and inhibition of NADPH oxidase activity. Together, these findings highlight a multifactorial pathophysiological process in AIS involving impaired endothelial function, oxidative stress, and innate immune activation, which collectively may compromise collateral circulation and worsen clinical outcomes. Future studies should explore whether modulation of the ADMA-NO-NOX2 axis, including through statin therapy, therapeutic strategies to reduce ADMA levels or counteract its effects and NOX-inhibithors, could enhance collateral flow and improve early stroke recovery. Materials and Methods Participants This is a prospective observational study. We enrolled consecutive AIS patients aged 18 years or older who were admitted to the Emergency Department of Umberto I Hospital – Sapienza University in Rome between November 2019 and December 2021. Inclusion criteria were: AIS within six hours of symptom onset or wake-up stroke / unknown-onset stroke, with the presence of large vessel occlusion (LVO) in the anterior cerebral circulation (including tandem occlusion – internal carotid artery [ICA] plus middle cerebral artery [MCA], or MCA occlusion at M1 or proximal M2 segments) confirmed by multiphasic Computed Tomography Angiography (CTA). Exclusion criteria included evidence of hemorrhagic stroke, stroke without LVO, or any contraindication to contrast media injection. Upon admission, patients underwent a comprehensive general and neurological examination, including ECG. Clinical data were collected, including demographic characteristics and the presence of stroke risk factors such as hypertension, atrial fibrillation, diabetes, hypercholesterolemia, significant carotid stenosis, tobacco use, alcohol abuse, history of transient ischemic attack (TIA), previous stroke, myocardial infarction, renal failure, cancer, and current medication use. Functional status was assessed using the modified Rankin Scale (mRS) both at admission and at 3 months post-stroke as a measure of clinical outcome. Stroke etiology was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria [ 40 ]. We defined three timepoints: time 0 (T0) at admission; time 1 (T1) at 24 hours; and time 2 (T2) at 48 hours. At each timepoint, stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), and blood samples were collected. Additionally, glucose levels, arterial pressure, heart rate, and temperature were measured at these timepoints. Laboratory data Blood samples were collected from patients into tubes with or without anticoagulant (3.8% sodium citrate) and centrifuged at 3000 rpm for 10 minutes at room temperature. Plasma and serum samples were immediately stored at − 80°C until analysis. Additional blood samples were taken at T0 for routine laboratory tests, including complete blood count, C-reactive protein (CRP), creatinine, glucose, and cholesterol. Some tests (blood count, CRP, and glucose) were repeated at T1 and T2. Intracranial blood samples were obtained during the endovascular procedure at two timepoints: 1) pre-occlusion—directly from the microcatheter positioned adjacent to the intracranial site of occlusion; and 2) post-occlusion—directly from the microcatheter located beyond the site of occlusion. - sNOX2-dp and ADMA Serum NOX2 was measured as soluble NOX2-derived peptide (sNOX2-dp) with an ELISA method as previously reported [ 41 ]. Values were expressed as pg/mL; intra- and inter-assay coefficients of variation were 8.95% and 9.01%, respectively. Quantitative determination of ADMA levels was measured in serum samples by ELISA kit [TEMA ricerca srl, Castenaso (Bologna), Italy] according to the manufacturer’s instructions. The values for ADMA were expressed in ng/mL. Both intra- and inter-assay coefficients of variation were < 10%. Radiological data All patients underwent multiphasic CTA upon admission to confirm the presence of large vessel occlusion (LVO), assess eligibility for endovascular treatment, and grade the extent of collateral circulation. Patients with wake-up or unknown-onset stroke underwent CT perfusion (CTp) or MRI perfusion (MRIp), and were included in the study only if multiphasic CTA was also performed. Leptomeningeal collateral (LMC) scoring was conducted using the regional LMC method (rLMCm) described by Menon et al. (2011) [ 26 ]. This scoring system evaluates retrograde filling of leptomeningeal collaterals distal to the occluded vessel—either the middle cerebral artery (MCA) or intracranial internal carotid artery (ICA)—by comparing the affected side to the healthy contralateral side. Scores were assigned separately to six MCA regions, the anterior cerebral artery (ACA) region, and the basal ganglia region. Each region was scored as 0 points if vessels were not detectable compared to the contralateral side, 1 point if less prominent, and 2 points if equal or more prominent. Higher scores were assigned to vessels in the sylvian sulcus due to their role as markers of good retrograde collateral filling, scored as 0 points if not detectable, 2 points if less prominent, and 4 points if equal or more prominent. The total LMC score was calculated by summing the scores of individual regions, ranging from 0 to 20 points. Patients were classified as having good LMC if their score was 17–20, moderate LMC for scores between 11–16, and poor LMC if 10 or lower. Based on collateral status, the study population was divided into three groups. The Alberta Stroke Program Early CT Score (ASPECTS) was calculated on non-contrast CT [ 42 ]. Patients eligible for endovascular treatment underwent digital subtraction angiography (DSA). Recanalization was assessed on DSA images using the modified Treatment in Cerebral Infarction (mTICI) score [ 43 ], defined as follows: Grade 0: no perfusion, Grade 1: anterograde reperfusion past the initial occlusion with minimal or slow distal reperfusion, Grade 2a: anterograde reperfusion of less than half of the occluded artery territory (e.g., one major MCA division), Grade 2b: anterograde reperfusion of more than half of the occluded territory (e.g., two major MCA divisions), Grade 3: complete anterograde reperfusion of the previously occluded artery. Patients were dichotomized into poor recanalization (mTICI 0–2a) and good recanalization (mTICI 2b–3). Final ischemic lesion volume was measured on diffusion-weighted imaging (DWI) MRI sequences using the ABC/2 formula [ 44 ]. MRI was performed 24–48 hours after admission. For patients with MRI contraindications, follow-up CT scans were used. Three experts in neuroimaging analysis (M.I., A.C., E.N.) independently rated the LMC status, ASPECTS, and ischemic lesion volume on multiphasic CTA. Any disagreements were resolved through consensus after joint review. If the consensus was not initially reached, a fourth neurologist expert in neuroimaging was consulted (M.D.M.). All study participants provided written informed consent. The study was conducted according to the Declaration of Helsinki and approved by the Ethics Committee of the University Hospital Umberto I (ID: 5323). Statistical Analysis Descriptive statistics were performed for the entire cohort and for the three groups of interest. Means or medians were calculated for continuous variables, depending on their normality distribution, while frequencies and proportions (percentages) were used for categorical variables. Chi-square test or Fisher’s exact test, Student’s t test or the Mann-Whitney U test, and ANOVA were used as appropriate to compare demographic, clinical, radiological, and laboratory characteristics among subgroups of patients. Correlations between variables were assessed using Pearson’s or Spearman’s correlation coefficients. The temporal trends of molecular biomarkers at different time points were analyzed, including mean/median changes over time according to the LMC status. Ordinal and binary logistic regression multivariate analyses were performed to individuate whether any of the investigated molecular biomarkers could result as independent predictor of the LMC status and clinical outcome as per mRS 0–2 at 90 days, respectively. A p-value of less than 0.05 was considered statistically significant. All analyses were conducted using SPSS software (IBM Corp., SPSS Statistics for Windows, Version 25, Armonk, NY, USA). Declarations Competing interests The authors declare no competing interests. The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article Supplementary information can be found on Scientific Report website. Funding This work was supported by Sapienza, University of Rome: Ricerca Ateneo Sapienza Progetti per Avvio alla ricerca (protocol number: AR120172B783068D). Author Contribution M.D.M. conceived and designed the study, enrolled the patients, interpreted the results, edited Figure 5 and prepared the original manuscript. M.I., E.N., and A.C. are neuroimaging experts who evaluated collateral status and measured infarct volumes. M.I. also edited Figure 1 of the manuscript. S.L. analyzed and interpreted the results, and edited Figures 2–5, all tables, and the supplementary materials. A.R., I.B., A.P., and M.B. participated in patient enrollment and data collection. R.C. and V.C. performed the serological biomarker analyses and contributed to result interpretation. S.L. and D.T. critically reviewed and edited the manuscript. All authors reviewed the manuscript. Acknowledgement The authors thank the clinical staff of the Emergency Department and Stroke Unit, for their assistance in data acquisition. Data Availability The data underlying this article cannot be shared publicly without restrictions due to concerns regarding the privacy of the study participants. However, the data may be made available upon reasonable request to the corresponding author, subject to approval by the local Institutional Review Board. References Saver, J. L. et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA 309 , 2480–2488 (2013). Saver, J. L. et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA 316 , 1279–1288 (2016). Rocha, M. & Jovin, T. G. Fast versus slow progressors of infarct growth in large vessel occlusion stroke: clinical and research implications. Stroke 48 , 2621–2627 (2017). Vagal, A. et al. Collateral clock is more important than time clock for tissue fate. Stroke 49 , 2102–2107 (2018). Wang, Z. et al. Dynamic change of collateral flow varying with distribution of regional blood flow in acute ischemic rat cortex. J. Biomed. Opt. 17 , 125001 (2012). Zhang, Y. et al. “No-reflow” phenomenon in acute ischemic stroke. J. Cereb. Blood Flow Metab. 44 , 19–37 (2024). Hill, R. A. et al. Regional blood flow in the normal and ischemic brain is controlled by arteriolar smooth muscle cell contractility and not by capillary pericytes. Neuron 87 , 95–110 (2015). Armitage, G. A. et al. Laser speckle contrast imaging of collateral blood flow during acute ischemic stroke. J. Cereb. Blood Flow Metab. 30 , 1432–1436 (2010). Arsava, E. M. et al. The detrimental effect of aging on leptomeningeal collaterals in ischemic stroke. J. Stroke Cerebrovasc. Dis. 23 , 421–426 (2014). Menon, B. K. et al. Leptomeningeal collaterals are associated with modifiable metabolic risk factors. Ann. Neurol. 74 , 241–248 (2013). Lazzaro, M. A. et al. The impact of diabetes on the extent of pial collaterals in acute ischemic stroke patients. J. Neurointerv. Surg. 3 , 242–245 (2011). Chan, S. L. et al. Pial collateral reactivity during hypertension and aging: understanding the function of collaterals for stroke therapy. Stroke 47 , 1618–1625 (2016). Pienimäki, J. P. et al. Carotid artery stenosis is associated with better intracranial collateral circulation in stroke patients. Cerebrovasc. Dis. 49 , 200–205 (2020). Garry, P. S. et al. The role of the nitric oxide pathway in brain injury and its treatment—from bench to bedside. Exp. Neurol. 263 , 235–243 (2015). Tran, N. et al. Endothelial Nitric Oxide Synthase (eNOS) and the cardiovascular system: in physiology and in disease states. Am. J. Biomed. Sci. Res. 15 , 153–177 (2022). Minhas, R., Bansal, Y. & Bansal, G. Inducible nitric oxide synthase inhibitors: a comprehensive update. Med. Res. Rev. 40 , 823–855 (2020). Cooke, J. P. Asymmetrical dimethylarginine: the uber marker? Circulation 109 , 1813–1818 (2004). Chen, S. et al. Asymmetric dimethylarginine as marker and mediator in ischemic stroke. Int. J. Mol. Sci. 13 , 15983–16004 (2012). Von Haehling, S. et al. Elevated levels of asymmetric dimethylarginine in chronic heart failure: a pathophysiologic link between oxygen radical load and impaired vasodilator capacity and the therapeutic effect of allopurinol. Clin. Pharmacol. Ther. 88 , 506–512 (2010). Drummond, G. R. et al. Combating oxidative stress in vascular disease: NADPH oxidases as therapeutic targets. Nat. Rev. Drug Discov. 10 , 453–471 (2011). Yoshioka, H. et al. NADPH oxidase mediates striatal neuronal injury after transient global cerebral ischemia. J. Cereb. Blood Flow Metab. 31 , 868–880 (2011). McCann, S. K. & Roulston, C. L. NADPH oxidase as a therapeutic target for neuroprotection against ischaemic stroke: future perspectives. Brain Sci. 3 , 561–598 (2013). Duan, J. et al. Pathophysiology and therapeutic potential of NADPH oxidases in ischemic stroke-induced oxidative stress. Oxid. Med. Cell Longev. 2021 , 6631805 (2021). Chen, H., Song, Y. S. & Chan, P. H. Inhibition of NADPH oxidase is neuroprotective after ischemia-reperfusion. J. Cereb. Blood Flow Metab. 29 , 1262–1272 (2009). Chen, H. et al. NADPH oxidase is involved in post-ischemic brain inflammation. Neurobiol. Dis. 42 , 341–348 (2011). Menon, B. K. et al. Regional leptomeningeal score on CT angiography predicts clinical and imaging outcomes in patients with acute anterior circulation occlusions. AJNR Am. J. Neuroradiol. 32 , 1640–1645 (2011). Janes, F. et al. ADMA as a possible marker of endothelial damage. A study in young asymptomatic patients with cerebral small vessel disease. Sci. Rep. 9 , 14207 (2019). Kielstein, J. T. et al. ADMA increases arterial stiffness and decreases cerebral blood flow in humans. Stroke 37 , 2024–2029 (2006). Szabo, P. et al. l-Arginine pathway metabolites predict need for intra-operative shunt during carotid endarterectomy. Eur. J. Vasc. Endovasc. Surg. 52 , 721–728 (2016). Brouns, R. et al. Dimethylarginine levels in cerebrospinal fluid of hyperacute ischemic stroke patients are associated with stroke severity. Neurochem. Res. 34 , 1642–1649 (2009). Iacobucci, M. et al. Role of endothelin-1 and nitric oxide in acute ischemic stroke leptomeningeal collateral activation. Int. J. Mol. Sci. 26 , 3205 (2025). Chen, S. et al. Asymmetric dimethylarginine as marker and mediator in ischemic stroke. Int. J. Mol. Sci. 13 , 15983–16004 (2012). Qin, Z. et al. A systematic review of the correlation between serum asymmetric dimethylarginine, carotid atherosclerosis and ischaemic stroke. Eur. J. Clin. Invest. 51 , e13558 (2021). Brouns, R. et al. Dimethylarginine levels in cerebrospinal fluid of hyperacute ischemic stroke patients are associated with stroke severity. Neurochem. Res. 34 , 1642–1649 (2009). Chen, C. H. et al. The detrimental effect of asymmetric dimethylarginine on cholesterol efflux of macrophage foam cells: Role of the NOX/ROS signaling. Free Radic. Biol. Med. 143 , 354–365 (2019). Tu, D. et al. Activation of neuronal NADPH oxidase NOX2 promotes inflammatory neurodegeneration. Free Radic. Biol. Med. 200 , 47–58 (2023). Chen, J. et al. NADPH Oxidase 2-derived reactive oxygen species promote CD8+ T Cell Effector Function. J. Immunol. 212 , 258–270 (2024). Zuo, L. et al. Circulating neutrophil-to-lymphocyte ratio predicts stroke-associated infection and poststroke fatigue affecting long-term neurological outcomes in stroke patients. Mediators Inflamm. 2025 , 5202480 (2025). Chen, W. H. et al. Advances in the molecular mechanisms of statins in regulating endothelial nitric oxide bioavailability: interlocking biology between eNOS activity and L-arginine metabolism. Biomed. Pharmacother. 171 , 116192 (2024). Adams, H. P. Jr et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24 , 35–41 (1993). Carnevale, R. et al. Oleuropein, a component of extra virgin olive oil, lowers postprandial glycaemia in healthy subjects. Br. J. Clin. Pharmacol. 84 , 1566–1574 (2018). Aviv, R. I. et al. Alberta Stroke Program Early CT Scoring of CT perfusion in early stroke visualization and assessment. AJNR Am. J. Neuroradiol. 28 , 1975–1980 (2007). Zaidat, O. O. et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke 44 , 2650–2663 (2013). Sims, J. R. et al. ABC/2 for rapid clinical estimate of infarct, perfusion, and mismatch volumes. Neurology 72 , 2104–2110 (2009). Tables Table 1. Demographics and clinical characteristics of the overall study population and by collateral status All patients N=101 Good n=44 Moderate n=35 Poor n=22 p value Demographics and clinical characteristics Age (years), mean (SD) 76.4 (12.4) 75.0 (11.1) 77.3 (15.0) 77.8 (10.1) 0.587 Sex (females) (%) 64 (63.4) 32 (72.7) 19 (54.3) 13 (59.1) 0.215 Pre-stroke mRS (%) - 0 - 1 - 2 - 3 - 4 - 5 74 (73.3) 8 (7.9) 6 (5.9) 10 (9.9) 2 (2.0) 1 (1.0) 38 (86.4) 2 (4.5) 3 (6.8) 1 (2.3) 0 0 22 (62.9) 3 (8.6) 3 (8.6) 6 (17.1) 1 (2.9) 0 14 (63.6) 3 (13.6) 0 3 (13.6) 1 (4.5) 1 (4.5) 0.124 Pre-stroke mRS 0-1 (%) 82 (81.2) 40 (90.9) 25 (71.4) 17 (77.3) 0.077 Obesity (BMI ≥30) (%) 16/96 (16.7) 8/42 (19.0) 3/33 (9.1) 5/21 (23.8) 0.316 Smoking (%) 16/95 (16.8) 8/43 (18.6) 3/32 (9.4) 5/20 (25.0) 0.314 Alcohol consumption (%) 6/100 (6.0) 1 (2.3) 4/34 (11.8) 1 (4.5) 0.205 Drug abuse (%) 3/100 (3.0) 0 2/34 (5.9) 1 (4.5) 0.285 Hypertension (%) 81/99 (81.8) 33/43 (76.7) 29/34 (85.3) 19 (86.4) 0.515 Hyperlipidemia (%) 53/96 (55.2) 29/43 (67.4) 16/33 (48.5) 8/20 (40.0) 0.079 Atrial fibrillation (%) 62/98 (63.3) 25/43 (58.1) 19/34 (55.9) 18/21 (85.7) 0.054 Ischemic cardiopathy (%) 30/100 (30.0) 10 (22.7) 11/34 (32.4) 9 (40.9) 0.295 Diabetes mellitus (%) 25/100 (25.0) 8 (18.2) 11/34 (32.4) 6 (27.3) 0.344 Previous stroke (%) 16/98 (16.3) 5 (11.4) 7/33 (21.2) 4/21 (19.0) 0.476 Previous TIA (%) 8/99 (8.1) 2 (4.5) 5/34 (14.7) 1/21 (4.8) 0.216 Previous CEA (%) 4/100 (4.0) 1 (2.3) 3/34 (8.8) 0 0.190 Carotid artery stenosis 70% (%) 15/100 (15.0) 4/43 (9.3) 5/34 (14.7) 6 (27.3) 0.149 Antiplatelet therapy (%) 36/92 (39.1) 15/41 (36.6) 15/31 (48.4) 6/20 (30.0) 0.382 Stroke characteristics Stroke onset on awakening/unknown (%) - Stroke on awakening 29/100 (29.0) 21/101 (20.8) 14 (31.8) 10/44 (22.7) 12/34 (35.3) 9 (25.7) 3 (13.6) 2 (9.1) 0.188 0.295 NIHSS, median (IQR) - Admission (T0) - 24 h (T1) - 48 h (T2) - Discharge 15 (10-20) 10 (4-17) 9.50 (3.25-17) 5 (2-9) 14 (10-20) 8 (2-14) 6 (2-16) 4 (1-9) 15 (9-17) 10.50 (5.50-20) 10.50 (4-18) 5 (2-11.50) 18 (14-22.50) 14 (10-17.25) 13.9 (7.8) 5 (4.50-14.25) 0.038 0.090 0.095 0.263 ASPECTS - mean (SD) - median (IQR) 8.26 (1.23) 8 (7-9) 8.48 (1.19) 9 (8-9) 8.24 (1.23) 8 (7.75-9) 7.86 (1.21) 8 (7-8.25) 0.155 Vessel occlusion site (%) - M1 - M2 - ICA - Tandem ICA+M1 53/93 (57.0) 29/93 (31.2) 2/93 (2.2) 9/93 (9.7) 24/41 (58.5) 12/41 (29.3) 0 5/41 (12.2) 16/33 (48.5) 14/33 (42.4) 1/33 (3.0) 2/33 (6.1) 13/19 (68.4) 3/19 (15.8) 1/19 (5.3) 2/19 (19.5) 0.392 Collateral status - mean (SD) - median (IQR) 14.62 (4.20) 15.00 (11-18) 18.45 (1.0) 18 (18-19) 13.66 (1.71) 14 (12-15) 8.50 (2.33) 8.50 (6.75-10) <0.001 Recanalization treatment (%) - IVT - MT - IVT+MT 51 (50.5) 87/100 (87.0) 43 (42.6) 20 (45.5) 38 (86.4) 15 (34.1) 19 (54.3) 31/34 (91.2) 17 (48.6) 12 (54.5) 18 (81.8) 9 (40.9) 0.673 0.588 0.526 MT technique (%) - Thromboaspiration - Stent retrieving - Thromboaspiration + - Stent retriever - Other 41/79 (51.9) 11/79 (13.9) 22/79 (27.8) 5/79 (6.3) 17/36 (47.2) 3/36 (8.3) 12/36 (33.3) 4736 (11.1) 14/28 (50.0) 7/28 (25.0) 7/28 (25.0) 0 10/15 (66.7) 1/15 (6.7) 3/15 (20.0) 1/15 (6.7) 0.202 Onset to IVT time (min), median (IQR) 150.0 (120-189) 150.0 (131.25-205.0) 147.50 (108.75-190.0) 135.0 (100.0-177.0) 0.652 Onset to MT time (min), Median (IQR) 265.0 (197.50-350) 265.0 (213-347.50) 286.0 (194.50-438.50) 208.50 (177.0-332.0) 0.300 TICI (%) - 0 - 1 - 2a - 2b - 3 7/82 (8.5) 4/82 (4.9) 11/82 (13.4) 17/82 (20.7) 43/82 (52.4) 1/36 (2.8) 0 5/36 (13.9) 10/36 (27.8) 20/36 (55.6) 3/30 (10.0) 4/30 (13.3) 5/30 (16.7) 5/30 (16.7) 13/30 (43.3) 3/16 (18.8) 0 1/16 (6.3) 2/16 (12.5) 10/16 (62.5) 0.090 TICI 2b-3 (%) 60/82 (73.2) 30/36 (83.3) 18/30 (60.0) 12/16 (75.0) 0.102 Imaging for V measurement (%) - RM (%) - CT (%) 85/103 (82.5) 18/103 (17.5) 36 (81.8) 8 (18.2) 31/35 (88.6) 4/35 (11.4) 17/21 (81.0) 4/21 (19.0) 0.655 Infarct volume, median (IQR) 10.0 (3.60-20.00) 5.90 (2.80-12.25) 13.60 (4.95-21.0) 14.60 (8.85-41.80) 0.478 Stroke etiopathogenesis (%) - LV atherothrombosis - Cardioembolic - Other determined cause - Other indetermined cause 10/95 (10.5) 66/95 (69.5) 7/95 (7.4) 12/95 (12.6) 5/41 (12.2) 25/41 (61.0) 4/41 (9.8) 7/41 (17.1) 1/34 (2.9) 25/34 (73.5) 3/34 (8.8) 5/34 (14.7) 4/21 (19.0) 17/21 (81.0) 0 0 0.140 SD=standard deviation; mRS=modified Rankin Scale. One-Way ANOVA: a. NIHSS at T0: good vs. poor p=0.056 (Tukey) or p=0.047 (Games-Howell); Moderate vs. poor p=0.050 (Tukey) p=0.033 (Games-Howell); b. Collateral status (continuous variable): for all between-group comparisons p<0.001 (for both Tukey and Games-Howell). p-values highlighted in bold indicate statistically significant results (p < 0.05). Section headings are formatted in italics and highlight in gray to distinguish different categories of data within the table. TIA=transient ischemic attack; CEA=carotid endarterectomy; NIHSS=National Institutes of Health Stroke Scale; IQR=interquartile range; T0=timepoint 0; T1=timepoint 1; T2=timepoint 2; ASPECTS=Alberta Stroke Program Early CT Score; M1=M1 segment of the Middle Cerebral Artery; M2=M2 segment of the middle cerebral artery; ICA=internal carotid artery; IVT=intravenous thrombolysis; MT=mechanical thrombectomy; TICI=thrombolysis in cerebral infarction; V=volume: RM=Magnetic Resonance Imaging; CT=Computed Tomography; LV=large vessel; Table 2. Ordinal regression analysis for collateral status Estimates 95% CIs OR p value ADMA levels at T0 0.020 0.005, 0.035 1.020 0.009 NOX2 levels at T0 -0.008 -0.088, 0.071 0.992 0.842 Age 0.012 -0.025, 0.049 1.012 0.521 Sex (male) 0.731 -0.188, 1.651 2.077 0.119 NIHSS levels at T0 0.020 -0.058, 0.098 1.020 0.616 Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterials.pdf Cite Share Download PDF Status: Published Journal Publication published 23 Dec, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 09 Oct, 2025 Reviews received at journal 06 Oct, 2025 Reviews received at journal 04 Oct, 2025 Reviewers agreed at journal 25 Sep, 2025 Reviewers agreed at journal 23 Sep, 2025 Reviewers invited by journal 22 Sep, 2025 Editor assigned by journal 16 Sep, 2025 Submission checks completed at journal 15 Sep, 2025 First submitted to journal 14 Sep, 2025 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-7614889","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":524643308,"identity":"275cf99e-2bb1-49b3-9945-825faeb1470f","order_by":0,"name":"Manuela De Michele","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABMklEQVRIie2RT0vDMBTAXynUy9t6TdiYXyEgiAepXyWloBdXhIF4GpVCPPjnPPFLFATxZssOXlK9TnpY+wEG9eZA0KwylK69e8iPEJKX98vLHwCN5j8Sq2YE0IetACBn0LdATRUcfnrSpiCgGnEG+Ecx1SZANhyVCJVCeJWG64VKMXLYKNN9vnTj5eM+2nSR5PzEwW4vPC/fxYNv915VBPbGNYXKNEqu5SHSO99jnHlo9ZOQ3opsRG88k/HNg7HZMJoaYoosO94lnMVoEVeYHZG5kTQt0qTMFyvlCw/eZE15alNmnZUSIyNYr4LNCpVDdRfhIZHruxA3pJOXbESkuaMihAb1F0vvy6VwBvZFmuTlpzPYnhwVZXma+faVURQfZ2O7/i+/YGOUtQttikaj0WjgGw9ZcoteKUVvAAAAAElFTkSuQmCC","orcid":"","institution":"Policlinico Umberto I","correspondingAuthor":true,"prefix":"","firstName":"Manuela","middleName":"","lastName":"De Michele","suffix":""},{"id":524643309,"identity":"3e7f39a5-980e-47e9-9717-a4dce290f19d","order_by":1,"name":"Angela Risitano","email":"","orcid":"","institution":"Sapienza University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Angela","middleName":"","lastName":"Risitano","suffix":""},{"id":524643310,"identity":"949af2ac-01fb-4364-82a5-186378b79a6b","order_by":2,"name":"Marta Iacobucci","email":"","orcid":"","institution":"Policlinico Umberto I","correspondingAuthor":false,"prefix":"","firstName":"Marta","middleName":"","lastName":"Iacobucci","suffix":""},{"id":524643311,"identity":"f10cf0d0-0908-4a90-a982-4e6212246ccc","order_by":3,"name":"Paolo Amisano","email":"","orcid":"","institution":"Sapienza University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Paolo","middleName":"","lastName":"Amisano","suffix":""},{"id":524643312,"identity":"034478cb-7ad9-4545-a589-938d03bdc2e5","order_by":4,"name":"Irene Berto","email":"","orcid":"","institution":"Policlinico Umberto I","correspondingAuthor":false,"prefix":"","firstName":"Irene","middleName":"","lastName":"Berto","suffix":""},{"id":524643314,"identity":"8ff25d80-9814-43dd-997b-ed2502624630","order_by":5,"name":"Roberto Carnevale","email":"","orcid":"","institution":"Sapienza University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Roberto","middleName":"","lastName":"Carnevale","suffix":""},{"id":524643316,"identity":"3613cf80-59a4-4a93-87f8-9d273db56b42","order_by":6,"name":"Vittoria Cammisotto","email":"","orcid":"","institution":"Sapienza University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Vittoria","middleName":"","lastName":"Cammisotto","suffix":""},{"id":524643317,"identity":"aaad7654-8b94-4dd1-9f90-5cb296eb4a19","order_by":7,"name":"Angela Pascariello","email":"","orcid":"","institution":"Sapienza University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Angela","middleName":"","lastName":"Pascariello","suffix":""},{"id":524643318,"identity":"58efb091-109f-486b-99f0-5582d35478fe","order_by":8,"name":"Matteo Beccia","email":"","orcid":"","institution":"Sapienza University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Matteo","middleName":"","lastName":"Beccia","suffix":""},{"id":524643319,"identity":"daed2fc5-59dc-458a-90be-8c05f2c58149","order_by":9,"name":"Antonio Ciacciarelli","email":"","orcid":"","institution":"Policlinico Umberto I","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"","lastName":"Ciacciarelli","suffix":""},{"id":524643320,"identity":"be0b464a-5eca-469c-aaab-24df5cc0c3bc","order_by":10,"name":"Ettore Nicolini","email":"","orcid":"","institution":"Sapienza University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Ettore","middleName":"","lastName":"Nicolini","suffix":""},{"id":524643321,"identity":"71b8f694-6fe8-4a02-9b84-1b60c3ab8927","order_by":11,"name":"Danilo Toni","email":"","orcid":"","institution":"Sapienza University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Danilo","middleName":"","lastName":"Toni","suffix":""},{"id":524643322,"identity":"3d3ef286-c195-47b0-bb9f-462bcf92caff","order_by":12,"name":"Svetlana Lorenzano","email":"","orcid":"","institution":"Sapienza University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Svetlana","middleName":"","lastName":"Lorenzano","suffix":""}],"badges":[],"createdAt":"2025-09-14 23:08:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7614889/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7614889/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-30283-z","type":"published","date":"2025-12-23T15:57:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":92842943,"identity":"26173408-ad91-469b-adac-2ca0fe4ae725","added_by":"auto","created_at":"2025-10-06 09:16:08","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":68622,"visible":true,"origin":"","legend":"","description":"","filename":"Maintext.docx","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/2c3127dd58f240dd201a4e3f.docx"},{"id":92844590,"identity":"f3acdfa9-308c-4e1d-b31f-5ce6b0e9f071","added_by":"auto","created_at":"2025-10-06 09:24:08","extension":"tif","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":32623532,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.tif","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/f08bb8326f71ddd0b8579a71.tif"},{"id":92844591,"identity":"366fa007-4f07-4e5d-aa0c-0fdc86d20c3f","added_by":"auto","created_at":"2025-10-06 09:24:08","extension":"tif","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2247808,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2.tif","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/38eec595e05b2e5934337d52.tif"},{"id":92842947,"identity":"30d14afb-3cd8-48d0-90e4-c8d466885581","added_by":"auto","created_at":"2025-10-06 09:16:08","extension":"tif","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1941092,"visible":true,"origin":"","legend":"","description":"","filename":"Figure3.tif","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/b93dd6f50ff04913cb70d199.tif"},{"id":92844593,"identity":"ad2fc4e6-9124-45ba-a723-2c13608d8105","added_by":"auto","created_at":"2025-10-06 09:24:09","extension":"tif","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2139922,"visible":true,"origin":"","legend":"","description":"","filename":"Figure4.tif","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/48f2b4c14b166237ad482d0f.tif"},{"id":92842965,"identity":"407151cb-9086-4b31-a039-2fe62e858020","added_by":"auto","created_at":"2025-10-06 09:16:09","extension":"tif","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":32622,"visible":true,"origin":"","legend":"","description":"","filename":"Figure5.tif","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/be884b86cce387ac6f6f8807.tif"},{"id":92842952,"identity":"2f9fb7f0-2100-4886-b5d6-ec50c32545cd","added_by":"auto","created_at":"2025-10-06 09:16:08","extension":"json","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":13251,"visible":true,"origin":"","legend":"","description":"","filename":"9407b9f33b8145948bbeedb79bded96d.json","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/884d7096194bcd0ae1dfde14.json"},{"id":92842954,"identity":"726634ab-b429-4d89-b4bc-53b5a326d8b7","added_by":"auto","created_at":"2025-10-06 09:16:08","extension":"pdf","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":415776,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterials.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/03c24b34300adbfc2327ab33.pdf"},{"id":92842949,"identity":"b846559c-af62-46a8-9357-441c7667335c","added_by":"auto","created_at":"2025-10-06 09:16:08","extension":"xml","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":123265,"visible":true,"origin":"","legend":"","description":"","filename":"9407b9f33b8145948bbeedb79bded96d1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/2073866a30f1c54d8116de3d.xml"},{"id":92842970,"identity":"d7f8da75-72ec-4128-8ffe-ecf4b53ada4f","added_by":"auto","created_at":"2025-10-06 09:16:09","extension":"tif","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":32623532,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.tif","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/69c3821f3c6a7a23c45af663.tif"},{"id":92842972,"identity":"c7e8d528-91ed-409c-9c1e-4c85fd9d91e9","added_by":"auto","created_at":"2025-10-06 09:16:09","extension":"tif","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2247808,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2.tif","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/dab96fa22fd33fa74cfda43f.tif"},{"id":92844585,"identity":"97c456cd-0356-40c5-b7f2-dee207c43393","added_by":"auto","created_at":"2025-10-06 09:24:08","extension":"tif","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1941092,"visible":true,"origin":"","legend":"","description":"","filename":"Figure3.tif","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/2fb9272467142b307f2cb39e.tif"},{"id":92844594,"identity":"84dea653-4392-41cf-ad68-22b4a70e6867","added_by":"auto","created_at":"2025-10-06 09:24:09","extension":"tif","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2139922,"visible":true,"origin":"","legend":"","description":"","filename":"Figure4.tif","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/a71ed51269a783876fe8b2c6.tif"},{"id":92842966,"identity":"8dd0ffb2-0124-4f1c-bc83-ea7d6417692c","added_by":"auto","created_at":"2025-10-06 09:16:09","extension":"tif","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":32622,"visible":true,"origin":"","legend":"","description":"","filename":"Figure5.tif","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/a5f5a566715fe1b206a0483d.tif"},{"id":92844592,"identity":"75d4c4d6-dabf-4e32-9b07-80cfe9020563","added_by":"auto","created_at":"2025-10-06 09:24:09","extension":"png","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2684969,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/ee1d47bc8153c30d37a329eb.png"},{"id":92842964,"identity":"620fef2b-5a01-441f-95b6-ed3848bee7dc","added_by":"auto","created_at":"2025-10-06 09:16:09","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":149007,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/cd57dc747bd92256928ccc21.png"},{"id":92842969,"identity":"eb58036a-21b8-42dd-a54f-198cb4af3f31","added_by":"auto","created_at":"2025-10-06 09:16:09","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":71063,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/1bf528ab50fac941144bf91d.png"},{"id":92844583,"identity":"e1f52e02-0630-4a24-881a-5de6042068fd","added_by":"auto","created_at":"2025-10-06 09:24:08","extension":"png","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":111315,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure4.png","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/0e8fb4c03c324cb55bb16177.png"},{"id":92844586,"identity":"c8e78f39-4c2c-49a9-b0eb-01745cb64e84","added_by":"auto","created_at":"2025-10-06 09:24:08","extension":"png","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":14525,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure5.png","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/a00b35be4a22bd1db98d115e.png"},{"id":92844588,"identity":"59b6fd27-508a-4f4d-aa18-a0526f9f1ca6","added_by":"auto","created_at":"2025-10-06 09:24:08","extension":"xml","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":122110,"visible":true,"origin":"","legend":"","description":"","filename":"9407b9f33b8145948bbeedb79bded96d1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/b3e6d70cfe4ff5f34b66c6ef.xml"},{"id":92845678,"identity":"ace657e1-908b-4c09-a977-694f589f3ce8","added_by":"auto","created_at":"2025-10-06 09:32:08","extension":"html","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":136153,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/799eb02889e7609d994e7ad4.html"},{"id":92842956,"identity":"4b8ec97d-c509-4890-a743-71b47d82f44e","added_by":"auto","created_at":"2025-10-06 09:16:08","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":8651862,"visible":true,"origin":"","legend":"\u003cp\u003eThe figure illustrates three representative cases of leptomeningeal collateral status—good, intermediate, and poor—in patients with acute LVO\u003cstrong\u003e \u003c/strong\u003estroke.\u003c/p\u003e\n\u003cp\u003eThe first row shows a case of LVO involving the M1 segment of the right middle cerebral artery (MCA) with good collateral circulation, as indicated by CTA (arrow in A). The corresponding perfusion maps demonstrate a large ischemic penumbra supported by robust collateral flow (CBV in B; CBF in C; MTT in D; and Tmax in E).\u003c/p\u003e\n\u003cp\u003eThe second row presents a case with intermediate collateral circulation (arrow in F). The associated perfusion maps reveal a smaller penumbra (CBV in G; CBF in H; MTT in I; and TTP in J), indicating moderate collateral support.\u003c/p\u003e\n\u003cp\u003eThe third row depicts a case with poor collateral circulation (arrow in K). The corresponding perfusion maps show no significant ischemic penumbra, suggesting insufficient collateral perfusion.\u003c/p\u003e\n\u003cp\u003eLVO: large vessel occlusion; MCA: middle cerebral artery; CBV: cerebral blood volume; CBF: cerebral blood flow; MTT: mean transit time; Tmax: time to maximum; TTP: time to peak.\u003c/p\u003e","description":"","filename":"Figure1.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/173d914cd3aa4cbbcf663739.jpg"},{"id":92842959,"identity":"32eebac6-1102-4e89-8382-36f727067527","added_by":"auto","created_at":"2025-10-06 09:16:08","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":125750,"visible":true,"origin":"","legend":"\u003cp\u003eTemporal course of ADMA and NOX2 levels in the three collateral groups.\u003c/p\u003e","description":"","filename":"Figure2.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/db83446d036b18876ded78d9.jpg"},{"id":92842961,"identity":"40899816-4338-4a04-9110-baa5819af001","added_by":"auto","created_at":"2025-10-06 09:16:08","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":55532,"visible":true,"origin":"","legend":"\u003cp\u003eAssociation between ADMA levels at T0 and collateral grades.\u003c/p\u003e","description":"","filename":"Figure3.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/7c22ac37ca01234a715d087b.jpg"},{"id":92842946,"identity":"55b0bf75-a13b-4cb7-b69e-d4d99bc264c8","added_by":"auto","created_at":"2025-10-06 09:16:08","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":66283,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelations between serum levels of ADMA and NOX2 at T1.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/3a52b91d45b3a61e959d3845.jpg"},{"id":92844589,"identity":"f18dffca-e43e-4081-8c28-e94558f90d4c","added_by":"auto","created_at":"2025-10-06 09:24:08","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":65375,"visible":true,"origin":"","legend":"\u003cp\u003eThe ADMA–NO–NOX2 loop. ADMA inhibits NO production triggering NOX2-mediated ROS generation. ROS impairs DDAH, the enzyme that breaks down ADMA inducing more ADMA accumulation. The loop amplifies oxidative injury, promotes collateral failure and worsens severity of stroke.\u003c/p\u003e","description":"","filename":"Figure5.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/88ee38569d2529bbc5768955.jpg"},{"id":99172355,"identity":"09a5f256-f7f8-4339-abc5-71260accf663","added_by":"auto","created_at":"2025-12-29 16:08:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":10399406,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/25ca9e35-16e9-4614-9cda-775726291cad.pdf"},{"id":92842938,"identity":"979289af-1dc2-4469-ae4f-4b2fad5cea00","added_by":"auto","created_at":"2025-10-06 09:16:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":415776,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterials.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7614889/v1/e9b193716fe87981ea75469a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Role of asymmetric dimethyl-arginine and NOX-2 in activation of leptomeningeal collaterals after acute ischemic stroke","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIschemic stroke (IS) is the second leading cause of death worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Recent advances in reperfusion therapies\u0026mdash;mainly intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT)\u0026mdash;have improved outcomes, with earlier treatment linked to better functional independence [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, some patients do not respond effectively despite early intervention. Beyond the classic \u0026ldquo;time is brain\u0026rdquo; concept, growing evidence emphasizes the \u0026ldquo;brain tissue window\u0026rdquo;, where treatment is tailored based on the mismatch between the ischemic core (irreversibly damaged tissue) and the ischemic penumbra (hypoperfused but salvageable tissue). The extent of leptomeningeal collateral (LMC) circulation influences penumbra viability. Patients with poor collateral circulation have worse outcomes even when treated within 4.5\u0026ndash;6 hours, compared to those with good collaterals who can benefit beyond this time window (fast and slow progressors) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This new concept is known as the \u0026ldquo;collateral clock\u0026rdquo; [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLMCs are involved in normal brain function, dilating in correspondence with the active brain areas at a given moment. This phenomenon is the basis of neurovascular coupling. Pressure gradients between the various arterial territories involved would activate LMCs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Animal models classify collaterals into three types based on their persistence over time: persistent, transient, or intermediate [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Collateral compensation ceases after vessel recanalization or due to \u0026ldquo;collateral failure,\u0026rdquo; caused by endothelial damage, platelet aggregation, and increased blood viscosity, leading to microvascular obstruction (no-reflow phenomenon) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Early ischemia also involves precapillary smooth muscle cell contraction, which worsens hypoperfusion and microthrombosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn humans, poor collaterals correlate with older age [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], metabolic syndrome [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and chronic hypertension [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], while ipsilateral extracranial stenosis\u0026thinsp;\u0026gt;\u0026thinsp;75% associate with better collaterals [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Mechanisms driving LMC and smooth muscle cell activation remain unclear but may involve metabolic, hemodynamic, or congenital factors.\u003c/p\u003e\u003cp\u003eNitric oxide (NO), produced by three nitric oxide synthase isoforms\u0026mdash;neuronal (nNOS), endothelial (eNOS), and inducible (iNOS)\u0026mdash;is a key vasodilator and endothelial function marker [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. eNOS-derived NO preserves cerebral microcirculation, inhibits platelet aggregation, leukocyte adhesion, and smooth muscle proliferation, exerting vascular protection [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. After stroke, iNOS expression peaks at 4\u0026ndash;7 days [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. NO reacts with superoxide (O₂⁻) to form peroxynitrite (ONOO⁻), causing mitochondrial damage, lipid peroxidation, protein nitrosylation, and DNA injury [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. eNOS uncoupling, due to lack of cofactors like tetrahydrobiopterin, leads to ROS rather than NO production, exacerbating ischemic damage. NO also inhibits endothelin-1 (ET-1) synthesis, a potent vasoconstrictor, by reducing release of endothelin converting enzyme-1 (ECE-1) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAsymmetric dimethylarginine (ADMA) is an endogenous NOS inhibitor and marker of endothelial dysfunction and atherosclerosis [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. ADMA levels rise after acute IS, correlating with stroke severity [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. It promotes NOS uncoupling, oxidative stress, and inflammation via ROS and NF-kB pathways [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Allopurinol, a xanthine oxidase inhibitor, reduces ADMA and improves endothelium-dependent vasodilation in heart failure patients [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe main vascular source of reactive oxygen species (ROS) is NADPH oxidase (NOX), especially the NOX2 isoform, which is upregulated in cerebral arteries after IS and contributes to oxidative stress and brain injury [\u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. NOX inhibition reduces ischemic brain damage in experimental models [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Excessive NOX2-derived ROS also activates inflammasomes and leads to worsening inflammatory responses and ischemia-reperfusion injury [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe primary objective of this study was to investigate the correlation between ADMA serum levels, the degree of leptomeningeal collateral circulation and the final ischemic volume in patients with AIS.\u003c/p\u003e\u003cp\u003eThe secondary objective was to evaluate whether the levels of this biomarker were associated with increased oxidative stress, worse stroke severity and poor outcomes.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe enrolled 101 patients with LVO AIS, 37 males (36.6%) and 64 females (63.4%); mean \u0026plusmn;SD age 76.4 \u0026plusmn;12.4 years. Twenty-nine patients (28.5%) had a wake-up stroke or unknown onset of symptoms. Patients were divided into three groups according to the collateral status: poor, intermediate and good collaterals (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatients\u0026rsquo; Characteristics\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNo statistically significant differences were found among the three groups regarding demographic characteristics, prior medical therapies, blood pressure or heart rate at the three time points (Table 1, Supplementary Table S1 online). However, patients with poor collateral status presented with more severe strokes as per higher NIHSS score at T0 (poor vs. intermediate vs. good collateral status; p = 0.038).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBiomarkers\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eADMA values significantly increase in all patients from T0 to T2 (112.55 at T0 vs 132.18 at T1 vs 146.42 at T2 p=0.047) regardless of the collateral status (p=0.046) (Figure 2.A, B; Supplementary Table S2). NOX2 serum levels also increased from T0 to T2, although not significantly (p=0.249), and the increase was sharper in poor than in intermediate and good collaterals, although the between-group difference did not reach a statistical significance (p=0.261) (Figure 2. C, D; Supplementary Table S2 online).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eADMA serum concentration at T0 also correlated with clinical severity at T1 and T2 (Spearman\u0026rsquo;s rho=0.327 and 0.323; p=0.005 and 0.008, respectively) (Supplementary Fig. 1 online. A, B). This association was confirmed after considering dichotomic variable of mild stroke (NIHSS\u0026le;6) and moderate-severe stroke (NIHSS \u0026gt;6), respectively at T1 p=0.005 and T2 p=0.013 (Supplementary Fig. 1 online.C, D).\u003c/p\u003e\n\u003cp\u003eA significant association was found between ADMA level at T0 and LMC; specifically higher levels were associated with poor LMC (mean in overall population 112.55 ng/ml \u0026plusmn;31.75; good 102.40 ng/ml \u0026plusmn; 25.72 vs moderate 119.80 ng/ml \u0026plusmn; 29.30 vs poor 123.85 ng/ml \u0026plusmn; 42.36 LMC; p=0.028) (Figure 3).\u003c/p\u003e\n\u003cp\u003eADMA at T0 tended to inversely correlate with ASPECT at basal CT (Spearman\u0026rsquo;s rho= -0.217; p=0.059), although this value did not reach a statistically significance. Median ADMA serum levels at T0 were also associated with carotid atherosclerosis \u0026gt; 70% (86.75 ng/ml vs 115.38 ng/ml in patients with carotid stenosis \u0026le;70%; p=0.049).\u003c/p\u003e\n\u003cp\u003eADMA serum levels at T1 correlated with NOX2 at the same time point (Spearman\u0026rsquo;s rho=0.436; p\u0026lt;0.001) (Figure 4) and tended to be lower in patients who used antiplatelets prior to the index stroke (median levels, 120.76 ng/ml vs 134.68 ng/ml in patients who did not take antiplatelet prior to stroke; p=0.059).\u003c/p\u003e\n\u003cp\u003eNOX2\u003csub\u003e\u0026nbsp;\u003c/sub\u003eserum levels at T2 were correlated with peripheral blood neutrophils count at T2 (neutrophil absolute number, Spearman\u0026rsquo;s rho= 0.322, p=0.013; neutrophil percentage, Spearman\u0026rsquo;s rho= 0.259, p=0.032), and inversely correlated with lymphocytes count at T2 (lymphocyte absolute number, Spearman\u0026rsquo;s rho=-0.353, p=0.006; lymphocyte percentage, Spearman\u0026rsquo;s rho= -0.342, p=0.008) (Supplementary Fig. S2 online).\u003c/p\u003e\n\u003cp\u003eStatin use was associated with lower median levels of NOX2 at T1 (13.36 pg/ml vs. 17.11 pg/ml; p=0.032).\u003c/p\u003e\n\u003cp\u003eNo significant correlation was found between serum biomarker measured at the three timepoints and stroke volume.\u003c/p\u003e\n\u003cp\u003eThe biomarker values examined \u0026minus; both in the pre- and post-occlusion arterial intracranial blood samples \u0026minus; at the three time points did not show significant differences between groups according to the collateral status (Supplementary Table S3 online).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical outcome\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere were any significant associations between the extent of LMC and clinical outcomes, whether measured as any mRS at 3 months, good outcome (mRS 0\u0026ndash;2), excellent outcome (mRS 0\u0026ndash;1), poor outcome (mRS 2\u0026ndash;6 or 3\u0026ndash;6), or in-hospital and 90-day mortality (Supplementary Table S4 online).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMultivariate analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOrdinal regression analysis identified ADMA levels at T0 as an independent predictor of LMC status (estimates 0.019 (95% CI 0.005-0.034); OR 1.019, p=0.009) after adjustment for age, sex, NIHSS at T0, and NOX2 levels at T0 (Table 2). The binary logistic regression did not identify in the LMC status and the examined biomarkers (ADMA or NOX2) as independent predictors of clinical functional outcome or death at 90 days (Supplementary Tables S5 and S6 online).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe extent of collateral circulation partly depends on good collaterogenesis influenced by genetic factors, but this alone appears insufficient to ensure effective LMC activation in LVO. This has prompted research into metabolic and hemodynamic conditions that may regulate collateral activation [\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. According to the rLMC scoring system, our cohort showed 43.1% with good, 35.3% with medium, and 21.6% with poor LMC status, consistent with proportions reported in the literature [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Poor LMC was significantly associated with higher NIHSS scores at admission and with higher levels of ADMA. Moreover, ADMA serum concentration at T0 correlated with clinical severity at T1 and T2. We found that ADMA values significantly increased in all patients from T0 to T2 regardless of collateral status\u0026mdash;a plausible finding since ADMA is a well-established marker of endothelial dysfunction and oxidative stress [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn our study, ADMA levels at admission were significantly associated with poor LMCs. This suggests a possible role for ADMA in failure of collateral vasodilation, indirectly by reducing NO availability. Supporting this hypothesis, previous studies demonstrated a decrease in CBF following ADMA infusion in healthy volunteers (measured by MRI perfusion) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and an increase in anaerobic cerebral metabolism in patients with severe carotid stenosis undergoing endarterectomy\u0026mdash;indicating that elevated ADMA may impair cerebral perfusion [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Due to poor collateral status, patients with higher ADMA at admission experienced more severe strokes (NIHSS\u0026thinsp;\u0026gt;\u0026thinsp;6) at both T1 and T2, aligning with findings from other studies [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRecently, we observed higher NO concentrations in the early phases of stroke regardless of LMC status, followed by a progressive decrease\u0026mdash;supporting the idea that NO plays a key role in LMC activation through collateral vasodilation, before declining later [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. According to these findings, higher ADMA at admission may cause lower NO levels, poorer collateral status, and more severe stroke symptoms.\u003c/p\u003e\u003cp\u003eIn line with existing data, median ADMA serum levels at T0 were also associated with carotid atherosclerosis\u0026thinsp;\u0026gt;\u0026thinsp;70% [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. ADMA is linked to stroke risk factors and atherosclerosis, and correlates with stroke severity and poor outcomes [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. This association may arise initially from ischemia-induced cellular proteolysis and secondarily from NOS inhibition [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Another proposed mechanism for ADMA-induced dysregulation of macrophage cholesterol metabolism involves NOX-derived ROS: oxidative stress suppresses liver X receptor alpha (LXRα) activity, downregulating ATP-binding cassette transporters A1 (ABCA1/G1) and impairing reverse cholesterol transport\u0026mdash;promoting foam cell formation and atherosclerosis [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNOX₂ serum levels also increased from T0 to T2, albeit not significantly, likely due to progression of the ischemic penumbra and infarction evolution. ADMA levels at T1 correlated with NOX2 at the same time point, and tended to be lower in patients on prior antiplatelet therapy. ADMA reduces NO bioavailability, contributing to endothelial dysfunction. Concurrently, elevated NOX2 activity increases ROS, exacerbating oxidative stress. This synergy suggests that ADMA may contribute to NOX2 upregulation/activation [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], in part through the suppression of DDAH (dimethylarginine dimethylaminohydrolase), the key enzyme responsible for ADMA degradation. Oxidative stress, commonly present in the early phases of stroke, impairs DDAH activity, leading to the accumulation of ADMA. Elevated ADMA levels then further inhibit NO production by eNOS, reducing NO-mediated inhibition of NOX2. As a result, NOX2 activity increases, generating more ROS, which in turn further suppress DDAH activity\u0026mdash;thereby perpetuating a self-amplifying oxidative loop (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAt T2, elevated NOX2 levels positively correlated with neutrophil counts and inversely correlated with lymphocyte counts, reflecting an acute pro-oxidant state largely driven by innate immune activation and neutrophil-derived oxidative bursts [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. This heightened oxidative stress may induce lymphocyte apoptosis or impair function, contributing to lymphopenia and compromised adaptive immunity [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. These findings underscore the clinical relevance of the neutrophil-to-lymphocyte ratio as a biomarker of systemic inflammation and immune dysregulation in acute post-stroke pathology [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStatin use was associated with lower median NOX2 levels at T1, likely reflecting their antioxidant effects beyond lipid lowering. Statins have been shown to inhibit NADPH oxidase activation\u0026mdash;particularly via suppression of the Rho/Rac1 pathway\u0026mdash;thereby reducing NOX2-derived ROS production and improving endothelial redox balance [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMain limitations of this study are the small subgroup sample sizes that may have weakened statistical power to detect differences in collateral status vs. outcome, and the single-center design that may reduce generalizability.\u003c/p\u003e\u003cp\u003eThe strengths of the study lie on the comprehensive biomarker analysis (peripheral/intracranial), the integration with neuroimaging, the focus on clinically relevant LMC activation post-AIS, and the prospective design.\u003c/p\u003e\u003cp\u003eIn conclusion, our findings suggest that elevated ADMA levels are associated with impaired LMC vasodilation in AIS, likely through reduced NO bioavailability. This supports the hypothesis that endothelial dysfunction plays a central role in limiting collateral vessel recruitment. Furthermore, ADMA may contribute to the upregulation or activation of NOX2, promoting excessive ROS production and establishing a feed-forward oxidative loop during the first 24 hours after stroke onset. This pro-oxidative state was further reflected by a significant correlation between NOX2 levels and increased neutrophil counts, alongside decreased lymphocyte counts\u0026mdash;indicating early innate immune activation and systemic inflammation. Importantly, the use of statins prior to stroke was associated with lower NOX2 levels, suggesting a potential protective effect mediated by their antioxidant properties and inhibition of NADPH oxidase activity. Together, these findings highlight a multifactorial pathophysiological process in AIS involving impaired endothelial function, oxidative stress, and innate immune activation, which collectively may compromise collateral circulation and worsen clinical outcomes. Future studies should explore whether modulation of the ADMA-NO-NOX2 axis, including through statin therapy, therapeutic strategies to reduce ADMA levels or counteract its effects and NOX-inhibithors, could enhance collateral flow and improve early stroke recovery.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eThis is a prospective observational study. We enrolled consecutive AIS patients aged 18 years or older who were admitted to the Emergency Department of Umberto I Hospital \u0026ndash; Sapienza University in Rome between November 2019 and December 2021.\u003c/p\u003e\u003cp\u003eInclusion criteria were: AIS within six hours of symptom onset or wake-up stroke / unknown-onset stroke, with the presence of large vessel occlusion (LVO) in the anterior cerebral circulation (including tandem occlusion \u0026ndash; internal carotid artery [ICA] plus middle cerebral artery [MCA], or MCA occlusion at M1 or proximal M2 segments) confirmed by multiphasic Computed Tomography Angiography (CTA).\u003c/p\u003e\u003cp\u003eExclusion criteria included evidence of hemorrhagic stroke, stroke without LVO, or any contraindication to contrast media injection.\u003c/p\u003e\u003cp\u003eUpon admission, patients underwent a comprehensive general and neurological examination, including ECG. Clinical data were collected, including demographic characteristics and the presence of stroke risk factors such as hypertension, atrial fibrillation, diabetes, hypercholesterolemia, significant carotid stenosis, tobacco use, alcohol abuse, history of transient ischemic attack (TIA), previous stroke, myocardial infarction, renal failure, cancer, and current medication use. Functional status was assessed using the modified Rankin Scale (mRS) both at admission and at 3 months post-stroke as a measure of clinical outcome. Stroke etiology was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWe defined three timepoints: time 0 (T0) at admission; time 1 (T1) at 24 hours; and time 2 (T2) at 48 hours. At each timepoint, stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), and blood samples were collected. Additionally, glucose levels, arterial pressure, heart rate, and temperature were measured at these timepoints.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eLaboratory data\u003c/h3\u003e\n\u003cp\u003eBlood samples were collected from patients into tubes with or without anticoagulant (3.8% sodium citrate) and centrifuged at 3000 rpm for 10 minutes at room temperature. Plasma and serum samples were immediately stored at \u0026minus;\u0026thinsp;80\u0026deg;C until analysis. Additional blood samples were taken at T0 for routine laboratory tests, including complete blood count, C-reactive protein (CRP), creatinine, glucose, and cholesterol. Some tests (blood count, CRP, and glucose) were repeated at T1 and T2.\u003c/p\u003e\u003cp\u003eIntracranial blood samples were obtained during the endovascular procedure at two timepoints: 1) pre-occlusion\u0026mdash;directly from the microcatheter positioned adjacent to the intracranial site of occlusion; and 2) post-occlusion\u0026mdash;directly from the microcatheter located beyond the site of occlusion.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e- sNOX2-dp and ADMA\u003c/h2\u003e\u003cp\u003eSerum NOX2 was measured as soluble NOX2-derived peptide (sNOX2-dp) with an ELISA method as previously reported [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Values were expressed as pg/mL; intra- and inter-assay coefficients of variation were 8.95% and 9.01%, respectively.\u003c/p\u003e\u003cp\u003eQuantitative determination of ADMA levels was measured in serum samples by ELISA kit [TEMA ricerca srl, Castenaso (Bologna), Italy] according to the manufacturer\u0026rsquo;s instructions. The values for ADMA were expressed in ng/mL. Both intra- and inter-assay coefficients of variation were \u0026lt;\u0026thinsp;10%.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eRadiological data\u003c/h2\u003e\u003cp\u003eAll patients underwent multiphasic CTA upon admission to confirm the presence of large vessel occlusion (LVO), assess eligibility for endovascular treatment, and grade the extent of collateral circulation. Patients with wake-up or unknown-onset stroke underwent CT perfusion (CTp) or MRI perfusion (MRIp), and were included in the study only if multiphasic CTA was also performed.\u003c/p\u003e\u003cp\u003eLeptomeningeal collateral (LMC) scoring was conducted using the regional LMC method (rLMCm) described by Menon et al. (2011) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This scoring system evaluates retrograde filling of leptomeningeal collaterals distal to the occluded vessel\u0026mdash;either the middle cerebral artery (MCA) or intracranial internal carotid artery (ICA)\u0026mdash;by comparing the affected side to the healthy contralateral side. Scores were assigned separately to six MCA regions, the anterior cerebral artery (ACA) region, and the basal ganglia region. Each region was scored as 0 points if vessels were not detectable compared to the contralateral side, 1 point if less prominent, and 2 points if equal or more prominent. Higher scores were assigned to vessels in the sylvian sulcus due to their role as markers of good retrograde collateral filling, scored as 0 points if not detectable, 2 points if less prominent, and 4 points if equal or more prominent. The total LMC score was calculated by summing the scores of individual regions, ranging from 0 to 20 points. Patients were classified as having good LMC if their score was 17\u0026ndash;20, moderate LMC for scores between 11\u0026ndash;16, and poor LMC if 10 or lower. Based on collateral status, the study population was divided into three groups.\u003c/p\u003e\u003cp\u003eThe Alberta Stroke Program Early CT Score (ASPECTS) was calculated on non-contrast CT [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePatients eligible for endovascular treatment underwent digital subtraction angiography (DSA). Recanalization was assessed on DSA images using the modified Treatment in Cerebral Infarction (mTICI) score [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], defined as follows: Grade 0: no perfusion, Grade 1: anterograde reperfusion past the initial occlusion with minimal or slow distal reperfusion, Grade 2a: anterograde reperfusion of less than half of the occluded artery territory (e.g., one major MCA division), Grade 2b: anterograde reperfusion of more than half of the occluded territory (e.g., two major MCA divisions), Grade 3: complete anterograde reperfusion of the previously occluded artery.\u003c/p\u003e\u003cp\u003ePatients were dichotomized into poor recanalization (mTICI 0\u0026ndash;2a) and good recanalization (mTICI 2b\u0026ndash;3).\u003c/p\u003e\u003cp\u003eFinal ischemic lesion volume was measured on diffusion-weighted imaging (DWI) MRI sequences using the ABC/2 formula [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. MRI was performed 24\u0026ndash;48 hours after admission. For patients with MRI contraindications, follow-up CT scans were used.\u003c/p\u003e\u003cp\u003eThree experts in neuroimaging analysis (M.I., A.C., E.N.) independently rated the LMC status, ASPECTS, and ischemic lesion volume on multiphasic CTA. Any disagreements were resolved through consensus after joint review. If the consensus was not initially reached, a fourth neurologist expert in neuroimaging was consulted (M.D.M.).\u003c/p\u003e\u003cp\u003e All study participants provided written informed consent. The study was conducted according to the Declaration of Helsinki and approved by the Ethics Committee of the University Hospital Umberto I (ID: 5323).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics were performed for the entire cohort and for the three groups of interest. Means or medians were calculated for continuous variables, depending on their normality distribution, while frequencies and proportions (percentages) were used for categorical variables. Chi-square test or Fisher\u0026rsquo;s exact test, Student\u0026rsquo;s t test or the Mann-Whitney U test, and ANOVA were used as appropriate to compare demographic, clinical, radiological, and laboratory characteristics among subgroups of patients. Correlations between variables were assessed using Pearson\u0026rsquo;s or Spearman\u0026rsquo;s correlation coefficients. The temporal trends of molecular biomarkers at different time points were analyzed, including mean/median changes over time according to the LMC status. Ordinal and binary logistic regression multivariate analyses were performed to individuate whether any of the investigated molecular biomarkers could result as independent predictor of the LMC status and clinical outcome as per mRS 0\u0026ndash;2 at 90 days, respectively.\u003c/p\u003e\u003cp\u003eA p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e\u003cp\u003eAll analyses were conducted using SPSS software (IBM Corp., SPSS Statistics for Windows, Version 25, Armonk, NY, USA).\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article\u003c/p\u003e\u003cp\u003e\u003ch2\u003eSupplementary information\u003c/h2\u003e\u003cp\u003ecan be found on Scientific Report website.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work was supported by Sapienza, University of Rome: Ricerca Ateneo Sapienza Progetti per Avvio alla ricerca (protocol number: AR120172B783068D).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eM.D.M. conceived and designed the study, enrolled the patients, interpreted the results, edited Figure 5 and prepared the original manuscript. M.I., E.N., and A.C. are neuroimaging experts who evaluated collateral status and measured infarct volumes. M.I. also edited Figure 1 of the manuscript. S.L. analyzed and interpreted the results, and edited Figures 2\u0026ndash;5, all tables, and the supplementary materials. A.R., I.B., A.P., and M.B. participated in patient enrollment and data collection. R.C. and V.C. performed the serological biomarker analyses and contributed to result interpretation. S.L. and D.T. critically reviewed and edited the manuscript. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank the clinical staff of the Emergency Department and Stroke Unit, for their assistance in data acquisition.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data underlying this article cannot be shared publicly without restrictions due to concerns regarding the privacy of the study participants. However, the data may be made available upon reasonable request to the corresponding author, subject to approval by the local Institutional Review Board.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSaver, J. L. et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. \u003cem\u003eJAMA\u003c/em\u003e \u003cstrong\u003e309\u003c/strong\u003e, 2480\u0026ndash;2488 (2013).\u003c/li\u003e\n\u003cli\u003eSaver, J. L. et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. \u003cem\u003eJAMA\u003c/em\u003e \u003cstrong\u003e316\u003c/strong\u003e, 1279\u0026ndash;1288 (2016).\u003c/li\u003e\n\u003cli\u003eRocha, M. \u0026amp; Jovin, T. G. Fast versus slow progressors of infarct growth in large vessel occlusion stroke: clinical and research implications. \u003cem\u003eStroke\u003c/em\u003e \u003cstrong\u003e48\u003c/strong\u003e, 2621\u0026ndash;2627 (2017).\u003c/li\u003e\n\u003cli\u003eVagal, A. et al. Collateral clock is more important than time clock for tissue fate. \u003cem\u003eStroke\u003c/em\u003e \u003cstrong\u003e49\u003c/strong\u003e, 2102\u0026ndash;2107 (2018).\u003c/li\u003e\n\u003cli\u003eWang, Z. et al. Dynamic change of collateral flow varying with distribution of regional blood flow in acute ischemic rat cortex. \u003cem\u003eJ. Biomed. Opt.\u003c/em\u003e \u003cstrong\u003e17\u003c/strong\u003e, 125001 (2012).\u003c/li\u003e\n\u003cli\u003eZhang, Y. et al. \u0026ldquo;No-reflow\u0026rdquo; phenomenon in acute ischemic stroke. \u003cem\u003eJ. Cereb. Blood Flow Metab.\u003c/em\u003e \u003cstrong\u003e44\u003c/strong\u003e, 19\u0026ndash;37 (2024).\u003c/li\u003e\n\u003cli\u003eHill, R. A. et al. Regional blood flow in the normal and ischemic brain is controlled by arteriolar smooth muscle cell contractility and not by capillary pericytes. \u003cem\u003eNeuron\u003c/em\u003e \u003cstrong\u003e87\u003c/strong\u003e, 95\u0026ndash;110 (2015).\u003c/li\u003e\n\u003cli\u003eArmitage, G. A. et al. Laser speckle contrast imaging of collateral blood flow during acute ischemic stroke. \u003cem\u003eJ. Cereb. Blood Flow Metab.\u003c/em\u003e \u003cstrong\u003e30\u003c/strong\u003e, 1432\u0026ndash;1436 (2010).\u003c/li\u003e\n\u003cli\u003eArsava, E. M. et al. The detrimental effect of aging on leptomeningeal collaterals in ischemic stroke. \u003cem\u003eJ. Stroke Cerebrovasc. Dis.\u003c/em\u003e \u003cstrong\u003e23\u003c/strong\u003e, 421\u0026ndash;426 (2014).\u003c/li\u003e\n\u003cli\u003eMenon, B. K. et al. Leptomeningeal collaterals are associated with modifiable metabolic risk factors. \u003cem\u003eAnn. Neurol.\u003c/em\u003e \u003cstrong\u003e74\u003c/strong\u003e, 241\u0026ndash;248 (2013).\u003c/li\u003e\n\u003cli\u003eLazzaro, M. A. et al. The impact of diabetes on the extent of pial collaterals in acute ischemic stroke patients. \u003cem\u003eJ. Neurointerv. Surg.\u003c/em\u003e \u003cstrong\u003e3\u003c/strong\u003e, 242\u0026ndash;245 (2011).\u003c/li\u003e\n\u003cli\u003eChan, S. L. et al. Pial collateral reactivity during hypertension and aging: understanding the function of collaterals for stroke therapy. \u003cem\u003eStroke\u003c/em\u003e \u003cstrong\u003e47\u003c/strong\u003e, 1618\u0026ndash;1625 (2016).\u003c/li\u003e\n\u003cli\u003ePienim\u0026auml;ki, J. P. et al. Carotid artery stenosis is associated with better intracranial collateral circulation in stroke patients. \u003cem\u003eCerebrovasc. Dis.\u003c/em\u003e \u003cstrong\u003e49\u003c/strong\u003e, 200\u0026ndash;205 (2020).\u003c/li\u003e\n\u003cli\u003eGarry, P. S. et al. The role of the nitric oxide pathway in brain injury and its treatment\u0026mdash;from bench to bedside. \u003cem\u003eExp. Neurol.\u003c/em\u003e \u003cstrong\u003e263\u003c/strong\u003e, 235\u0026ndash;243 (2015).\u003c/li\u003e\n\u003cli\u003eTran, N. et al. Endothelial Nitric Oxide Synthase (eNOS) and the cardiovascular system: in physiology and in disease states. \u003cem\u003eAm. J. Biomed. Sci. Res.\u003c/em\u003e \u003cstrong\u003e15\u003c/strong\u003e, 153\u0026ndash;177 (2022).\u003c/li\u003e\n\u003cli\u003eMinhas, R., Bansal, Y. \u0026amp; Bansal, G. Inducible nitric oxide synthase inhibitors: a comprehensive update. \u003cem\u003eMed. Res. Rev.\u003c/em\u003e \u003cstrong\u003e40\u003c/strong\u003e, 823\u0026ndash;855 (2020).\u003c/li\u003e\n\u003cli\u003eCooke, J. P. Asymmetrical dimethylarginine: the uber marker? \u003cem\u003eCirculation\u003c/em\u003e \u003cstrong\u003e109\u003c/strong\u003e, 1813\u0026ndash;1818 (2004).\u003c/li\u003e\n\u003cli\u003eChen, S. et al. Asymmetric dimethylarginine as marker and mediator in ischemic stroke. \u003cem\u003eInt. J. Mol. Sci.\u003c/em\u003e \u003cstrong\u003e13\u003c/strong\u003e, 15983\u0026ndash;16004 (2012).\u003c/li\u003e\n\u003cli\u003eVon Haehling, S. et al. Elevated levels of asymmetric dimethylarginine in chronic heart failure: a pathophysiologic link between oxygen radical load and impaired vasodilator capacity and the therapeutic effect of allopurinol. \u003cem\u003eClin. Pharmacol. Ther.\u003c/em\u003e \u003cstrong\u003e88\u003c/strong\u003e, 506\u0026ndash;512 (2010).\u003c/li\u003e\n\u003cli\u003eDrummond, G. R. et al. Combating oxidative stress in vascular disease: NADPH oxidases as therapeutic targets. \u003cem\u003eNat. Rev. Drug Discov.\u003c/em\u003e \u003cstrong\u003e10\u003c/strong\u003e, 453\u0026ndash;471 (2011).\u003c/li\u003e\n\u003cli\u003eYoshioka, H. et al. NADPH oxidase mediates striatal neuronal injury after transient global cerebral ischemia. \u003cem\u003eJ. Cereb. Blood Flow Metab.\u003c/em\u003e \u003cstrong\u003e31\u003c/strong\u003e, 868\u0026ndash;880 (2011).\u003c/li\u003e\n\u003cli\u003eMcCann, S. K. \u0026amp; Roulston, C. L. NADPH oxidase as a therapeutic target for neuroprotection against ischaemic stroke: future perspectives. \u003cem\u003eBrain Sci.\u003c/em\u003e \u003cstrong\u003e3\u003c/strong\u003e, 561\u0026ndash;598 (2013).\u003c/li\u003e\n\u003cli\u003eDuan, J. et al. Pathophysiology and therapeutic potential of NADPH oxidases in ischemic stroke-induced oxidative stress. \u003cem\u003eOxid. Med. Cell Longev.\u003c/em\u003e \u003cstrong\u003e2021\u003c/strong\u003e, 6631805 (2021).\u003c/li\u003e\n\u003cli\u003eChen, H., Song, Y. S. \u0026amp; Chan, P. H. Inhibition of NADPH oxidase is neuroprotective after ischemia-reperfusion. \u003cem\u003eJ. Cereb. Blood Flow Metab.\u003c/em\u003e \u003cstrong\u003e29\u003c/strong\u003e, 1262\u0026ndash;1272 (2009).\u003c/li\u003e\n\u003cli\u003eChen, H. et al. NADPH oxidase is involved in post-ischemic brain inflammation. \u003cem\u003eNeurobiol. Dis.\u003c/em\u003e \u003cstrong\u003e42\u003c/strong\u003e, 341\u0026ndash;348 (2011).\u003c/li\u003e\n\u003cli\u003eMenon, B. K. et al. Regional leptomeningeal score on CT angiography predicts clinical and imaging outcomes in patients with acute anterior circulation occlusions. \u003cem\u003eAJNR Am. J. Neuroradiol.\u003c/em\u003e \u003cstrong\u003e32\u003c/strong\u003e, 1640\u0026ndash;1645 (2011).\u003c/li\u003e\n\u003cli\u003eJanes, F. et al. ADMA as a possible marker of endothelial damage. A study in young asymptomatic patients with cerebral small vessel disease. \u003cem\u003eSci. Rep.\u003c/em\u003e \u003cstrong\u003e9\u003c/strong\u003e, 14207 (2019).\u003c/li\u003e\n\u003cli\u003eKielstein, J. T. et al. ADMA increases arterial stiffness and decreases cerebral blood flow in humans. \u003cem\u003eStroke\u003c/em\u003e \u003cstrong\u003e37\u003c/strong\u003e, 2024\u0026ndash;2029 (2006).\u003c/li\u003e\n\u003cli\u003eSzabo, P. et al. l-Arginine pathway metabolites predict need for intra-operative shunt during carotid endarterectomy. \u003cem\u003eEur. J. Vasc. Endovasc. Surg.\u003c/em\u003e \u003cstrong\u003e52\u003c/strong\u003e, 721\u0026ndash;728 (2016).\u003c/li\u003e\n\u003cli\u003eBrouns, R. et al. Dimethylarginine levels in cerebrospinal fluid of hyperacute ischemic stroke patients are associated with stroke severity. \u003cem\u003eNeurochem. Res.\u003c/em\u003e \u003cstrong\u003e34\u003c/strong\u003e, 1642\u0026ndash;1649 (2009).\u003c/li\u003e\n\u003cli\u003eIacobucci, M. et al. Role of endothelin-1 and nitric oxide in acute ischemic stroke leptomeningeal collateral activation. \u003cem\u003eInt. J. Mol. Sci.\u003c/em\u003e \u003cstrong\u003e26\u003c/strong\u003e, 3205 (2025).\u003c/li\u003e\n\u003cli\u003eChen, S. et al. Asymmetric dimethylarginine as marker and mediator in ischemic stroke. \u003cem\u003eInt. J. Mol. Sci.\u003c/em\u003e \u003cstrong\u003e13\u003c/strong\u003e, 15983\u0026ndash;16004 (2012).\u003c/li\u003e\n\u003cli\u003eQin, Z. et al. A systematic review of the correlation between serum asymmetric dimethylarginine, carotid atherosclerosis and ischaemic stroke. \u003cem\u003eEur. J. Clin. Invest.\u003c/em\u003e \u003cstrong\u003e51\u003c/strong\u003e, e13558 (2021).\u003c/li\u003e\n\u003cli\u003eBrouns, R. et al. Dimethylarginine levels in cerebrospinal fluid of hyperacute ischemic stroke patients are associated with stroke severity. \u003cem\u003eNeurochem. Res.\u003c/em\u003e \u003cstrong\u003e34\u003c/strong\u003e, 1642\u0026ndash;1649 (2009).\u003c/li\u003e\n\u003cli\u003eChen, C. H. et al. The detrimental effect of asymmetric dimethylarginine on cholesterol efflux of macrophage foam cells: Role of the NOX/ROS signaling. \u003cem\u003eFree Radic. Biol. Med.\u003c/em\u003e \u003cstrong\u003e143\u003c/strong\u003e, 354\u0026ndash;365 (2019).\u003c/li\u003e\n\u003cli\u003eTu, D. et al. Activation of neuronal NADPH oxidase NOX2 promotes inflammatory neurodegeneration. \u003cem\u003eFree Radic. Biol. Med.\u003c/em\u003e \u003cstrong\u003e200\u003c/strong\u003e, 47\u0026ndash;58 (2023).\u003c/li\u003e\n\u003cli\u003eChen, J. et al. NADPH Oxidase 2-derived reactive oxygen species promote CD8+ T Cell Effector Function. \u003cem\u003eJ. Immunol.\u003c/em\u003e \u003cstrong\u003e212\u003c/strong\u003e, 258\u0026ndash;270 (2024).\u003c/li\u003e\n\u003cli\u003eZuo, L. et al. Circulating neutrophil-to-lymphocyte ratio predicts stroke-associated infection and poststroke fatigue affecting long-term neurological outcomes in stroke patients. \u003cem\u003eMediators Inflamm.\u003c/em\u003e \u003cstrong\u003e2025\u003c/strong\u003e, 5202480 (2025).\u003c/li\u003e\n\u003cli\u003eChen, W. H. et al. Advances in the molecular mechanisms of statins in regulating endothelial nitric oxide bioavailability: interlocking biology between eNOS activity and L-arginine metabolism. \u003cem\u003eBiomed. Pharmacother.\u003c/em\u003e \u003cstrong\u003e171\u003c/strong\u003e, 116192 (2024).\u003c/li\u003e\n\u003cli\u003eAdams, H. P. Jr et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. \u003cem\u003eStroke\u003c/em\u003e \u003cstrong\u003e24\u003c/strong\u003e, 35\u0026ndash;41 (1993).\u003c/li\u003e\n\u003cli\u003eCarnevale, R. et al. Oleuropein, a component of extra virgin olive oil, lowers postprandial glycaemia in healthy subjects. \u003cem\u003eBr. J. Clin. Pharmacol.\u003c/em\u003e \u003cstrong\u003e84\u003c/strong\u003e, 1566\u0026ndash;1574 (2018).\u003c/li\u003e\n\u003cli\u003eAviv, R. I. et al. Alberta Stroke Program Early CT Scoring of CT perfusion in early stroke visualization and assessment. \u003cem\u003eAJNR Am. J. Neuroradiol.\u003c/em\u003e \u003cstrong\u003e28\u003c/strong\u003e, 1975\u0026ndash;1980 (2007).\u003c/li\u003e\n\u003cli\u003eZaidat, O. O. et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. \u003cem\u003eStroke\u003c/em\u003e \u003cstrong\u003e44\u003c/strong\u003e, 2650\u0026ndash;2663 (2013).\u003c/li\u003e\n\u003cli\u003eSims, J. R. et al. ABC/2 for rapid clinical estimate of infarct, perfusion, and mismatch volumes. \u003cem\u003eNeurology\u003c/em\u003e \u003cstrong\u003e72\u003c/strong\u003e, 2104\u0026ndash;2110 (2009).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eDemographics and clinical characteristics of the overall study population and by collateral status \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"120%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll patients\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=101\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGood\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=44\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=35\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePoor\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=22\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 693px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographics and clinical characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years), mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e76.4 (12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e75.0 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e77.3 (15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e77.8 (10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.587\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex (females) (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e64 (63.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e32 (72.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e19 (54.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e13 (59.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.215\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-stroke mRS (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e- 0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e- 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e- 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e- 3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e- 4\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e- 5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e74 (73.3)\u003c/p\u003e\n \u003cp\u003e8 (7.9)\u003c/p\u003e\n \u003cp\u003e6 (5.9)\u003c/p\u003e\n \u003cp\u003e10 (9.9)\u003c/p\u003e\n \u003cp\u003e2 (2.0)\u003c/p\u003e\n \u003cp\u003e1 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e38 (86.4)\u003c/p\u003e\n \u003cp\u003e2 (4.5)\u003c/p\u003e\n \u003cp\u003e3 (6.8)\u003c/p\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22 (62.9)\u003c/p\u003e\n \u003cp\u003e3 (8.6)\u003c/p\u003e\n \u003cp\u003e3 (8.6)\u003c/p\u003e\n \u003cp\u003e6 (17.1)\u003c/p\u003e\n \u003cp\u003e1 (2.9)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (63.6)\u003c/p\u003e\n \u003cp\u003e3 (13.6)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e3 (13.6)\u003c/p\u003e\n \u003cp\u003e1 (4.5)\u003c/p\u003e\n \u003cp\u003e1 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.124\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-stroke mRS 0-1 (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e82 (81.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e40 (90.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e25 (71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e17 (77.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.077\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObesity (BMI \u0026ge;30) (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e16/96 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e8/42 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e3/33 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e5/21 (23.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.316\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e16/95 (16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e8/43 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e3/32 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e5/20 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlcohol consumption (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e6/100 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4/34 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e1 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.205\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDrug abuse (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e3/100 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e2/34 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e1 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.285\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypertension (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e81/99 (81.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e33/43 (76.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e29/34 (85.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e19 (86.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.515\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHyperlipidemia (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e53/96 (55.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e29/43 (67.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e16/33 (48.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e8/20 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.079\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAtrial fibrillation (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e62/98 (63.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e25/43 (58.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e19/34 (55.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e18/21 (85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIschemic cardiopathy (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e30/100 (30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e10 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e11/34 (32.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e9 (40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.295\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes mellitus (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e25/100 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e8 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e11/34 (32.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e6 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.344\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious stroke (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e16/98 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e5 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e7/33 (21.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4/21 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.476\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious TIA (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e8/99 (8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e2 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e5/34 (14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e1/21 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.216\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious CEA (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4/100 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e3/34 (8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.190\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCarotid artery stenosis \u0026lt;50% (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e35/99 (35.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e15/43 (34.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e13/34 (38.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e7 (31.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.883\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCarotid artery stenosis (50-70%) (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e7/99 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e4/43 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e3/34 (8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.340\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCarotid artery stenosis \u0026gt;70% (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e15/100 (15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e4/43 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e5/34 (14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e6 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.149\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntiplatelet therapy (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e36/92 (39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e15/41 (36.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e15/31 (48.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e6/20 (30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.382\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 693px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStroke characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStroke onset on\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eawakening/unknown (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;- \u0026nbsp; Stroke on awakening\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e29/100 (29.0)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21/101 (20.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e14 (31.8)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10/44 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e12/34 (35.3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (25.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e3 (13.6)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.188\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.295\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNIHSS, median (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eAdmission (T0)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003e24 h (T1)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003e48 h (T2)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eDischarge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (10-20)\u003c/p\u003e\n \u003cp\u003e10 (4-17)\u003c/p\u003e\n \u003cp\u003e9.50 (3.25-17)\u003c/p\u003e\n \u003cp\u003e5 (2-9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (10-20)\u003c/p\u003e\n \u003cp\u003e8 (2-14)\u003c/p\u003e\n \u003cp\u003e6 (2-16)\u003c/p\u003e\n \u003cp\u003e4 (1-9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (9-17)\u003c/p\u003e\n \u003cp\u003e10.50 (5.50-20)\u003c/p\u003e\n \u003cp\u003e10.50 (4-18)\u003c/p\u003e\n \u003cp\u003e5 (2-11.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 (14-22.50)\u003c/p\u003e\n \u003cp\u003e14 (10-17.25)\u003c/p\u003e\n \u003cp\u003e13.9 (7.8)\u003c/p\u003e\n \u003cp\u003e5 (4.50-14.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.038\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003cp\u003e0.095\u003c/p\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eASPECTS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003emean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003emedian (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8.26 (1.23)\u003c/p\u003e\n \u003cp\u003e8 (7-9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8.48 (1.19)\u003c/p\u003e\n \u003cp\u003e9 (8-9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8.24 (1.23)\u003c/p\u003e\n \u003cp\u003e8 (7.75-9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.86 (1.21)\u003c/p\u003e\n \u003cp\u003e8 (7-8.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.155\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVessel occlusion site (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eM1\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eM2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eICA\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eTandem ICA+M1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53/93 (57.0)\u003c/p\u003e\n \u003cp\u003e29/93 (31.2)\u003c/p\u003e\n \u003cp\u003e2/93 (2.2)\u003c/p\u003e\n \u003cp\u003e9/93 (9.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24/41 (58.5)\u003c/p\u003e\n \u003cp\u003e12/41 (29.3)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e5/41 (12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16/33 (48.5)\u003c/p\u003e\n \u003cp\u003e14/33 (42.4)\u003c/p\u003e\n \u003cp\u003e1/33 (3.0)\u003c/p\u003e\n \u003cp\u003e2/33 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13/19 (68.4)\u003c/p\u003e\n \u003cp\u003e3/19 (15.8)\u003c/p\u003e\n \u003cp\u003e1/19 (5.3)\u003c/p\u003e\n \u003cp\u003e2/19 (19.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.392\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCollateral status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;- mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;- median (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14.62 (4.20)\u003c/p\u003e\n \u003cp\u003e15.00\u003c/p\u003e\n \u003cp\u003e(11-18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18.45 (1.0)\u003c/p\u003e\n \u003cp\u003e18\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(18-19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13.66 (1.71)\u003c/p\u003e\n \u003cp\u003e14\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(12-15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8.50 (2.33)\u003c/p\u003e\n \u003cp\u003e8.50\u003c/p\u003e\n \u003cp\u003e(6.75-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecanalization treatment (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eIVT\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eMT\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eIVT+MT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e51 (50.5)\u003c/p\u003e\n \u003cp\u003e87/100 (87.0)\u003c/p\u003e\n \u003cp\u003e43 (42.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 (45.5)\u003c/p\u003e\n \u003cp\u003e38 (86.4)\u003c/p\u003e\n \u003cp\u003e15 (34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19 (54.3)\u003c/p\u003e\n \u003cp\u003e31/34 (91.2)\u003c/p\u003e\n \u003cp\u003e17 (48.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (54.5)\u003c/p\u003e\n \u003cp\u003e18 (81.8)\u003c/p\u003e\n \u003cp\u003e9 (40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.673\u003c/p\u003e\n \u003cp\u003e0.588\u003c/p\u003e\n \u003cp\u003e0.526\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMT technique (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eThromboaspiration\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eStent retrieving\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eThromboaspiration +\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eStent retriever\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eOther\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e41/79 (51.9)\u003c/p\u003e\n \u003cp\u003e11/79 (13.9)\u003c/p\u003e\n \u003cp\u003e22/79 (27.8)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5/79 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17/36 (47.2)\u003c/p\u003e\n \u003cp\u003e3/36 (8.3)\u003c/p\u003e\n \u003cp\u003e12/36 (33.3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4736 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14/28 (50.0)\u003c/p\u003e\n \u003cp\u003e7/28 (25.0)\u003c/p\u003e\n \u003cp\u003e7/28 (25.0)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10/15 (66.7)\u003c/p\u003e\n \u003cp\u003e1/15 (6.7)\u003c/p\u003e\n \u003cp\u003e3/15 (20.0)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1/15 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.202\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOnset to IVT time (min),\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003emedian (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e150.0\u003c/p\u003e\n \u003cp\u003e(120-189)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e150.0\u003c/p\u003e\n \u003cp\u003e(131.25-205.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e147.50\u003c/p\u003e\n \u003cp\u003e(108.75-190.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e135.0\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(100.0-177.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.652\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOnset to MT time (min),\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e265.0\u003c/p\u003e\n \u003cp\u003e(197.50-350)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e265.0\u003c/p\u003e\n \u003cp\u003e(213-347.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e286.0\u003c/p\u003e\n \u003cp\u003e(194.50-438.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e208.50\u003c/p\u003e\n \u003cp\u003e(177.0-332.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.300\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTICI (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003e2a\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003e2b\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7/82 (8.5)\u003c/p\u003e\n \u003cp\u003e4/82 (4.9)\u003c/p\u003e\n \u003cp\u003e11/82 (13.4)\u003c/p\u003e\n \u003cp\u003e17/82 (20.7)\u003c/p\u003e\n \u003cp\u003e43/82 (52.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1/36 (2.8)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e5/36 (13.9)\u003c/p\u003e\n \u003cp\u003e10/36 (27.8)\u003c/p\u003e\n \u003cp\u003e20/36 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3/30 (10.0)\u003c/p\u003e\n \u003cp\u003e4/30 (13.3)\u003c/p\u003e\n \u003cp\u003e5/30 (16.7)\u003c/p\u003e\n \u003cp\u003e5/30 (16.7)\u003c/p\u003e\n \u003cp\u003e13/30 (43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3/16 (18.8)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1/16 (6.3)\u003c/p\u003e\n \u003cp\u003e2/16 (12.5)\u003c/p\u003e\n \u003cp\u003e10/16 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTICI 2b-3 (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e60/82 (73.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e30/36 (83.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e18/30 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e12/16 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImaging for V measurement (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eRM (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eCT (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e85/103 (82.5)\u003c/p\u003e\n \u003cp\u003e18/103 (17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e36 (81.8)\u003c/p\u003e\n \u003cp\u003e8 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e31/35 (88.6)\u003c/p\u003e\n \u003cp\u003e4/35 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17/21 (81.0)\u003c/p\u003e\n \u003cp\u003e4/21 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.655\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInfarct volume, median\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e10.0\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(3.60-20.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e5.90\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(2.80-12.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e13.60\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(4.95-21.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e14.60\u003c/p\u003e\n \u003cp\u003e(8.85-41.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.478\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStroke etiopathogenesis (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eLV atherothrombosis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eCardioembolic\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eOther determined cause\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- \u003cstrong\u003eOther indetermined cause\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10/95 (10.5)\u003c/p\u003e\n \u003cp\u003e66/95 (69.5)\u003c/p\u003e\n \u003cp\u003e7/95 (7.4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12/95 (12.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5/41 (12.2)\u003c/p\u003e\n \u003cp\u003e25/41 (61.0)\u003c/p\u003e\n \u003cp\u003e4/41 (9.8)\u003c/p\u003e\n \u003cp\u003e7/41 (17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1/34 (2.9)\u003c/p\u003e\n \u003cp\u003e25/34 (73.5)\u003c/p\u003e\n \u003cp\u003e3/34 (8.8)\u003c/p\u003e\n \u003cp\u003e5/34 (14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4/21 (19.0)\u003c/p\u003e\n \u003cp\u003e17/21 (81.0)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.140\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD=standard deviation; mRS=modified Rankin Scale.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne-Way ANOVA: a. NIHSS at T0: good vs. poor p=0.056 (Tukey) or p=0.047 (Games-Howell); Moderate vs. poor p=0.050 (Tukey) p=0.033 (Games-Howell); b. Collateral status (continuous variable): for all between-group comparisons p\u0026lt;0.001 (for both Tukey and Games-Howell).\u003c/p\u003e\n\u003cp\u003ep-values highlighted in bold indicate statistically significant results (p \u0026lt; 0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSection headings are formatted in italics and highlight in gray to distinguish different categories of data within the table.\u003c/p\u003e\n\u003cp\u003eTIA=transient ischemic attack; CEA=carotid endarterectomy; NIHSS=National Institutes of Health Stroke Scale; IQR=interquartile range; T0=timepoint 0; T1=timepoint 1; T2=timepoint 2; ASPECTS=Alberta Stroke Program Early CT Score; M1=M1 segment of the Middle Cerebral Artery; M2=M2 segment of the middle cerebral artery; ICA=internal carotid artery; IVT=intravenous thrombolysis; MT=mechanical thrombectomy; TICI=thrombolysis in cerebral infarction; V=volume: RM=Magnetic Resonance Imaging; CT=Computed Tomography; LV=large vessel;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eOrdinal regression analysis for collateral status \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"581\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CIs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eADMA levels at T0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0.005, 0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e1.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.009\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNOX2 levels at T0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e-0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e-0.088, 0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.992\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.842\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e-0.025, 0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e1.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.521\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex (male)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.731\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e-0.188, 1.651\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e2.077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.119\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNIHSS levels at T0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e-0.058, 0.098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e1.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.616\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"ADMA, NOX2, leptomeningeal collaterals, acute ischemic stroke, reperfusion","lastPublishedDoi":"10.21203/rs.3.rs-7614889/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7614889/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eLeptomeningeal collateral (LMC) circulation helps preserve brain tissue during acute ischemic stroke (AIS), with poor collateral status predicting worse outcomes. This study assessed the association between asymmetric dimethylarginine (ADMA), LMCs, infarct volume, and oxidative stress in 101 AIS patients with large vessel occlusion within 6h or wake-up stroke. LMC status was graded using the Menon score on CT angiography (categorized as poor, intermediate, or good), and recanalization was assessed by the modified Thrombolysis in Cerebral Infarction score. Serum ADMA and NOX2 levels were measured at admission (\u0026lt;\u0026thinsp;6h, T0), 24h (T1), and 48h (T2). Among patients, 43.1% had good, 35.3% intermediate, 21.6% poor LMC status. Higher admission ADMA levels were significantly associated with poor LMC (p\u0026thinsp;=\u0026thinsp;0.028) and more severe neurological deficits at T1 and T2 (p\u0026thinsp;=\u0026thinsp;0.005, p\u0026thinsp;=\u0026thinsp;0.008). ADMA levels increased over time (p\u0026thinsp;=\u0026thinsp;0.046), and correlated with NOX2 at T1 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Rising NOX2 was associated with increased neutrophils (p\u0026thinsp;=\u0026thinsp;0.013) and decreased lymphocytes (p\u0026thinsp;=\u0026thinsp;0.006). ADMA likely impairs endothelial function by reducing nitric oxide availability and enhancing NOX2-driven oxidative stress. Statin use was associated with lower NOX2 levels. These findings support a role for the ADMA-NO-NOX2 axis in limiting collateral circulation. Targeting this axis may represent a therapeutic strategy to improve outcomes in AIS.\u003c/p\u003e","manuscriptTitle":"Role of asymmetric dimethyl-arginine and NOX-2 in activation of leptomeningeal collaterals after acute ischemic stroke","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-06 09:16:03","doi":"10.21203/rs.3.rs-7614889/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-09T07:29:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-06T13:38:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-04T11:56:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147921351969305519231501204317730250188","date":"2025-09-25T18:49:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"270337443727310045964479032925125412584","date":"2025-09-23T18:06:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-22T20:39:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-16T08:30:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-15T07:06:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-09-14T22:58:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a85c88cc-2c18-401c-90e3-739d3464f79d","owner":[],"postedDate":"October 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":55767052,"name":"Health sciences/Diseases"},{"id":55767053,"name":"Health sciences/Medical research"},{"id":55767054,"name":"Health sciences/Neurology"},{"id":55767055,"name":"Biological sciences/Neuroscience"}],"tags":[],"updatedAt":"2025-12-29T16:01:46+00:00","versionOfRecord":{"articleIdentity":"rs-7614889","link":"https://doi.org/10.1038/s41598-025-30283-z","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-12-23 15:57:11","publishedOnDateReadable":"December 23rd, 2025"},"versionCreatedAt":"2025-10-06 09:16:03","video":"","vorDoi":"10.1038/s41598-025-30283-z","vorDoiUrl":"https://doi.org/10.1038/s41598-025-30283-z","workflowStages":[]},"version":"v1","identity":"rs-7614889","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7614889","identity":"rs-7614889","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}