Luminal Vascular Dysfunction Drives Rapid Blood Brain Barrier Injury in Hyperglycemic Stroke: Key Roles for Luminal Glycocalyx and Complement.

BACKGROUND

Acute hyperglycemia affects approximately 40% of stroke patients and is associated with worse outcomes. The underlying mechanisms linking this metabolic stress to stroke-induced brain injury remains unclear, and effective therapies are lacking.

METHODS

In a mouse model of acute hyperglycemic stroke, luminal disruption, blood-brain barrier (BBB) leakage, neurological deficit, motor function, and mortality were evaluated. Vascular luminal glycocalyx and complement activation were assessed by immunostaining, with glycocalyx loss confirmed by electron microscopy. Complement C3's causal role was tested using C3 knockout mice and site-targeted inhibition with CR2-Crry. To enhance translational relevance, post-mortem human stroke and control brains were immunostained to assess the association between endothelial glycocalyx loss and vascular complement activation. In a separate stroke patient cohort, soluble complement activation products were measured in pre-thrombectomy plasma, and their predictive value for modified Rankin Scale (mRS) outcomes evaluated using elastic net regression.

RESULTS

Hyperglycemic stroke mice exhibited accelerated and more severe BBB breakdown, greater functional deficits, and higher mortality than normoglycemic controls, mirroring clinical observations. Acute hyperglycemia triggered rapid vascular luminal injury characterized by loss of endothelial luminal glycocalyx, luminal IgM/IgG deposition, and vascular complement C3 activation, leading to BBB disruption. This vascular luminal injury was corroborated in human stroke brain tissue. These luminal changes persisted despite glucose normalization and were exacerbated by reperfusion, driving injury into the brain parenchyma. Genetic and pharmacological approaches confirmed vascular complement activation as a causal driver of severe BBB disruption and poor outcomes. Importantly, site-targeted pharmacological inhibition of complement after reperfusion preserved BBB integrity and improved outcomes, defining a time-specific, luminal-directed strategy as a promising adjunct to thrombectomy. Notably, soluble complement activation markers in pre-thrombectomy stroke plasma predicted clinical outcomes, highlighting their potential as pre-intervention markers for patient stratification and tailored therapy.

CONCLUSION

This study reframes acute hyperglycemic stroke as a vascular luminal disorder, establishing a novel linking metabolic stress to endothelial luminal glycocalyx loss, vascular complement activation, and BBB breakdown in both mice and humans. This new mechanistic understanding transforms the therapeutic landscape of hyperglycemic stroke, offering a potential time-defined, luminal-focused adjunct therapy alongside thrombectomy.

CLINICAL PERSPECTIVE

• This study reframes hyperglycemic stroke as an acute vascular problem, marked by rapid loss of endothelial luminal glycocalyx and complement C3 activation at the vascular luminal surface. - The rapid luminal changes, identified in both rodent and human stroke brain tissues, establish a novel linking metabolic stress to luminal damage, blood-brain barrier (BBB) breakdown, and injury progression into the brain parenchyma. - The first clinical evidence that pre-thrombectomy plasma complement activation markers independently predict stroke outcomes - laying the foundation for risk stratification before reperfusion and precision adjunct therapies. - The rapidity and persistence of the MCV axis activation-even after glucose normalization-help explain the limited efficacy of insulin therapy, shifting the therapeutic focus from glycemic control to luminal-targeted interventions.- Identification of a narrow but actionable window following reperfusion where complement C3 inhibition preserves the BBB and limits injury progression to the parenchyma, offers a promising adjunct to thrombectomy in metabolically vulnerable stroke patients.- Targeting the vascular luminal surface reshapes the therapeutic landscape for hyperglycemic stroke by enabling systemic interventions-bypassing the challenge of BBB penetration, supporting rapid clinical translation using existing FDA-approved C3 inhibitors, and framing the endothelial glycocalyx as a promising area for therapeutic and diagnostic exploration in hyperglycemic stroke and broader cerebrovascular disease.