Plasma protein signatures associated with functional outcome heterogeneity in rtPA-treated acute ischemic stroke

The mechanisms underlying heterogeneous neurological functional outcomes following recombinant tissue plasminogen activator (rtPA) therapy in acute ischemic stroke (AIS) remain elusive. This exploratory study aimed to explore proteomic signatures associated with rtPA response using data-independent acquisition (DIA) mass spectrometry.

We performed plasma proteomic profiling on 10 AIS patients (6 with favorable outcomes [90-day mRS ≤ 2], 4 with unfavorable outcomes [90-day mRS > 2]) and 6 healthy controls. Differential protein expression analysis, functional enrichment (GO, KEGG), and weighted gene co-expression network analysis (WGCNA) were applied to identify outcome-related proteins and pathways.

AIS induced significant perturbations in energy metabolism, inflammatory responses, and oxidative stress responses, with more pronounced proteomic dysregulation observed in unfavorable-outcome patients. The differentially expressed proteins (DEPs) associated with rtPA therapy (such as CP, CA1, CA2, ABCC2, COL1A2) were functionally linked to oxidative stress, metabolic transport, and transforming growth factor (TGF)-β receptor signaling. Pathway analysis revealed enrichment in porphyrin metabolism, nitrogen metabolism, and ABC transporter pathways. Additionally, DEPs between patients with distinct outcomes demonstrated significant enrichment in NF-κB signaling pathway and ABC transporters.

This exploratory study suggests that rtPA may influence acid-base balance, redox homeostasis, and TGF-β signaling. The association of NF-κB signaling and ABC transporters with outcome heterogeneity highlights their potential for further investigation as therapeutic targets. These findings provide preliminary mechanistic insights that warrant validation in larger cohorts.