Evolution of clinicopathological features in patients with and without recanalization therapy before and after the introduction of thrombolysis

<title>Abstract</title> <p> <bold>Background:</bold> Reperfusion therapies have substantially improved outcomes in ischemic stroke, yet their impact on clinicopathological complications observed at autopsy remains insufficiently characterized. This study investigated temporal changes in autopsy findings before and after the introduction of thrombolysis. <bold>Methods:</bold> We performed a retrospective cohort study of 916 deceased ischemic stroke patients who underwent complete autopsy at the Department of Neurology, University of Debrecen. Patients from the pre-thrombolysis era (1989–1999; n=477) were compared with patients treated in the reperfusion era (2007–2017; n=439), including non-thrombolyzed (n=274) and thrombolyzed (n=165) subgroups. Demographic characteristics and autopsy-confirmed hemorrhagic transformation (HT), thromboembolic complications, pneumonia, and systemic malignancies were analyzed. <bold>Results:</bold> Patients who died in 2007–2017 were older than those in 1989–1999 (76.3±10.6 vs. 72.3±12.0 years, p&lt;0.001). HT increased significantly over time, occurring in 18.0% of patients in 1989–1999, 32.1% in the 2007–2017 non-thrombolysis subgroup, and 49.1% in thrombolyzed patients (both p&lt;0.001). Logistic regression demonstrated significantly higher odds of HT in the later period and in thrombolyzed patients. In contrast, thromboembolic complications markedly decreased from 39.8% to 11.0% between the two eras (p&lt;0.001), without differences between thrombolyzed and non-thrombolyzed patients in 2007–2017. Pneumonia remained highly prevalent across all groups. Systemic malignancies showed a modest increase in the later cohort. <bold>Conclusions:</bold> Introduction of modern stroke therapies was associated with a substantial reduction in thromboembolic complications but a marked increase in hemorrhagic transformation, particularly after thrombolysis. These findings emphasize the importance of careful monitoring for HT and individualized antithrombotic management in contemporary stroke care. </p>