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Introduction Despite successful macrovascular recanalization following endovascular thrombectomy (EVT), up to 50% of patients fail to achieve functional independence, a phenomenon attributed to microvascular ‘no-reflow’ and reperfusion-associated inflammation. This gap between technical success and clinical recovery highlights an unmet need for adjunctive therapies targeting post-reperfusion injury. Here, we use a translational approach to identify key drivers of microvascular dysfunction and develop a site-targeted inhibitor of thrombo-inflammation following stroke.Methods Using the transient middle cerebral artery occlusion (tMCAO) murine model of stroke, we performed high-throughput transcriptomic profiling using the NanoString Immunology panel compared to sham controls (N=10/group). Network topology analysis of differentially expressed genes identified core disease modules and upstream regulators. P-selectin and complement C3 were identified as candidate therapeutic targets and validated in human post-mortem stroke specimens. A fusion protein combining a P-selectin-targeting moiety and complement inhibitor (Crry), termed Psel-Crry, was developed to inhibit leukocyte/platelet adhesion and complement activation. In vivo studies were performed in tMCAO mice (N=8/group), with Psel-Crry (10 mg/kg) administered intravenously 2 hours after reperfusion. Outcomes included tissue targeting, complement inhibition, leukocyte adhesion, infarct size, hemorrhagic transformation, and sub-acute functional recovery.Results Network analysis revealed a rich-club architecture of 33 highly interconnected hub genes associated with infarct size and functional outcomes (R 2>0.6, p<0.001). These genes segregated into three modules: leukocyte adhesion/trafficking, innate immune activation, and myeloid thrombo-inflammatory signaling. P-selectin and C3 emerged as central upstream regulators spanning all modules, collectively targeting 85% of rich-club genes. Human stroke tissue demonstrated 3-fold enrichment of P-selectin and C3 deposition in the ischemic penumbra compared to contralateral tissue (p<0.01), with clear co-localization. In-vivo live-animal fluorescent tomography of labeled Psel-Crry showed selective binding of Psel-Crry to the ipsilateral MCA territory as compared to contralateral hemisphere or vehicle (P<0.01) with a tissue-specific half-life of 30 hrs. Compared with vehicle, Psel-Crry significantly reduced complement activation (C3a, 60% reduction; p<0.05), infarct volume (62% reduction; p<0.05), and microglial activation (Iba1, 50% reduction; p<0.05). Multiphoton imaging demonstrated reduced leukocyte rolling within the cerebral microvasculature after Psel-Crry administration. There was no increase in hemorrhagic transformation (hemoglobin content, p=0.89). At 7 days, Psel-Crry improved survival (75% vs. 35%, p<0.05), neurological severity scores (p<0.01), and sensorimotor function (corner task, p<0.05).Conclusions Microvascular no-reflow after EVT is driven by interconnected inflammatory and thrombotic pathways organized within a rich-club network structure. P-selectin and complement C3 act as central regulators across these modules, and their combined inhibition provides a unified therapeutic strategy.Disclosures A. Alawieh: 1; C; NIH, Abbott Point of Care, Society of Neurological Surgeons, Department of Defense. 6; C; Comlantech Therapeutics, Inc. D. Hatchell: None. S. Tomlinson: 1; C; NIH, Department of VA, AHA. 6; C; Comlantech Therapeutics, Inc.Abstract O-040 Figure 1