Abstract Background and aims In acute ischaemic stroke (AIS), central autonomic dysfunction is common and has been linked to increased cardiovascular mortality. However, a reliable and easily applicable biomarker for post-stroke dysautonomia is lacking. We investigated whether pupillomotor dysfunction is associated with functional outcomes following AIS. Methods APEX was a prospective observational study including patients with AIS treated at a tertiary stroke centre in Germany (06/2023-05/2025). Patients were enrolled within 72 hours of stroke onset and underwent automated pupillography at baseline and day 3, comprehensive cardiovascular phenotyping, and assessment of functional outcome (mRS) at 90 days. Adjusted probabilities were derived from ordinal logistic regression models adjusting for age, ASPECTS, baseline NIHSS, BMI, prior stroke, atrial fibrillation, diabetes, hypercholesterolemia, nicotine and alcohol use, coronary heart disease, beta-blocker therapy, and antithrombotic medication. Results The study population comprised 100 AIS patients (median age 76 years IQR 69–83, 47% female). Each one-standard-deviation increase in maximal pupillary latency was associated with a 64% higher odds of being in a worse mRS category at 90 days (adjusted OR 1.64, 95% CI 1.02–2.63; p=0.042). Adjusted probabilities of poor functional outcome (90-day mRS≥3) increased stepwise across quartiles of maximal pupillary latency (Figure). No change in pupillomotor function was observed between day 1 and day 3 (p=ns), and no association with new-onset atrial fibrillation or autonomic symptoms at 90 days was found (p=ns). Conclusions Early pupillomotor dysfunction is independently associated with worse functional outcome after AIS. Automated pupillography may provide a non-invasive marker to improve early risk stratification after stroke. Conflict of interest Daniela Schöne: nothing to disclose, Lara Kretzschmar: nothing to disclose, Martin Arndt: nothing to disclose, Annahita Sedghi: nothing to disclose, Lydia Plitzko: nothing to disclose, Isabella Püschel: nothing to disclose, Kristian Barlinn: nothing to disclose, Hagen B Huttner: nothing to disclose, Timo Siepmann: nothing to disclose Figure 1 - belongs to Conclusions
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