BACKGROUND: Animal studies suggest that high-density lipoprotein cholesterol (HDL-C) attenuates reperfusion injury. We aimed to assess whether higher serum HDL-C levels modulate the risk of intracranial haemorrhage (ICH) after thrombectomy in human stroke survivors. METHODS: We included consecutive patients from our prospective anterior circulation large vessel occlusion (acLVO) registry who underwent thrombectomy between 01/2017 and 01/2023 at the tertiary stroke centre of the University Hospital Carl Gustav Carus in Dresden, Germany in a propensity score-matched analysis. We assessed the association between serum HDL-C levels and post-interventional ICH as well as 90-day functional outcome quantified by the modified Rankin Scale (mRS). For sensitivity analysis, we used multivariable lasso logistic regression. Analyses were adjusted for demographics, cardiovascular risk profiles, stroke characteristics, and procedural times. RESULTS: Of 1702 patients screened, 807 (420 women, median age 77 years [66-84, IQR]) were included. Post-interventional ICH reduced the probability of a favourable functional outcome (90-day mRS 0-2) by 14.8% (ß = 0.15
95% CI [0.06
0.24]
p = 0.001. An HDL-C level above the median (1.15 mmol/L) decreased the probability of ICH by 13.6% (ß = - 0.14
95CI% [- 0.22
- 0.05]
p = 0.002) and increased the probability of favourable functional outcome by 13.2% (ß = - 0.13
95CI% [- 0.22
- 0.05]
p = 0.003). In sensitivity analyses, higher HDL-C levels were independently associated with lower odds of ICH (adjusted OR 0.62
95% CI [0.43
0.88]
p = 0.008) and higher odds of favourable functional outcome (adjusted OR 0.60
95% CI [0.40
0.90]
p = 0.015). CONCLUSIONS: In patients undergoing thrombectomy for acLVO, higher HDL-C levels were associated with a reduced probability of post-interventional ICH and a favourable functional outcome. These observations could not be explained by conventional vascular risk profiles.