Insulin resistance is an independent risk factor for early neurological deterioration in non-diabetic patients with acute ischemic stroke

An innovative metabolic index for insulin resistance correlates with early neurological deterioration following intravenous thrombolysis in minor acute ischemic stroke patients

Background and purpose

The composite score for insulin resistance (IR), known as the Metabolic Score of Insulin Resistance (METS-IR), serves as an assessment tool for IR and has been previously linked to symptomatic intracranial hemorrhage and poor functional outcomes in patients with acute ischemic stroke (AIS). Despite these associations, the impact of METS-IR on early neurological deterioration (END) in patients with minor AIS who underwent intravenous administration of recombinant tissue-type plasminogen activator (IV-rtPA) remains inadequately established. This investigation explored the link between METS-IR and END in patients with minor AIS receiving IV-rtPA treatment.

Methods

In this study, a cohort comprising 425 consecutive patients with National Institutes of Health Stroke Scale Score (NIHSS)≤5 who underwent IV-rtPA treatment was included. The METS-IR was computed using the formula ln METS-IR=ln (2 × FBG + TG) × BMI/ln (HDL). END was defined as a NIHSS ≥2 within 24 h post IV-rtPA administration, while poor functional outcome was defined as a modified Rankin Scale (mRS) of 2-6. Multivariate logistical regression was performed to investigate the association between METS-IR and both poor functional outcomes and END.

Results

Among the 425 enrolled patients, 64 (15.1 %) patients experienced END, while 80 (18.8 %) had poor functional outcomes three months post-discharge. Upon adjusting for confounding factors, a higher METS-IR emerged as an independent predictor for both END and poor functional outcomes. Similarly, noteworthy findings were observed when METS-IR was defined as a categorical group. The restricted cubic spline (RCS) analysis indicated a linear relationship between METS-IR and END (P = 0.593 for non-linearity, P = 0.034 for overall). The incorporation of METS-IR into the conventional model resulted in a significant enhancement of predictive accuracy for both END and poor functional outcomes.

Conclusion

METS-IR emerges as an independent predictor for END and poor functional outcome at three months post-discharge in patients with minor AIS subjected to IV-rtPA. Considering its simplicity and clinical accessibility as an indicator of IR, METS-IR may hold guiding significance in clinical practice.

Prognostic utility of sTREM-1 in predicting early neurological deterioration in patients with acute ischemic stroke treated without reperfusion therapy

OBJECTIVE

Serum triggering receptor expressed on myeloid cells type 1 (sTREM-1) is a new type of immunoglobulin superfamily receptor related to inflammation that aggravates brain injury. This study aimed to assess the clinical value of sTREM-1 in predicting early neurological deterioration in patients with acute ischemic stroke (AIS) treated without reperfusion therapy.

METHODS

This prospective cohort study enrolled 315 patients with acute ischemic stroke admitted to the Affiliated Taizhou People's Hospital of Nanjing Medical University between October 2020 and October 2022. The study excluded patients treated with reperfusion therapy. sTREM-1 levels were evaluated within 24 h of the acute ischemic stroke. Early neurological deterioration (END) was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 points within three days after admission. Multivariable analyses were used to investigate the relationship between sTREM-1 levels and END.

RESULTS

A total of 81 (25.7 %) patients had early neurological deterioration. Patients in the END group had a higher NIHSS score at admission (P =0.007), CRP levels (P =0.011), white blood cell count (P =0.002), fasting blood glucose levels (P =0.028), and sTREM-1 levels (P <0.001). After adjusting for confounders, higher sTREM-1 levels were significantly associated with an increased risk of early neurological deterioration (OR, 1.98; 95 % CI, 1.17-3.38, P=0.012). Moreover, sTREM-1 levels efficiently differentiated END (area under the curve: 0.779; 95 % CI: 0.731-0.822). Furthermore, the results showed significant differences between the high sTREM-1 group and the low sTREM-1 group in NIHSS scores (P=0.019), C-reactive protein (P=0.018), white blood cell count (P=0.013), and the incidence of early neurological deterioration (P<0.001). According to the multivariate logistic regression model, we discovered that the high sTREM-1 group was a significant independent predictor of early neurological deterioration incidence (OR, 4.19; 95 % CI, 1.46-9.84; P= 0.003).

CONCLUSION

sTREM-1 could be a potential biomarker for predicting early neurological deterioration in AIS patients not treated with reperfusion therapy.

Stress hyperglycemia predicts early neurological deterioration and poor outcomes in patients with single subcortical infarct

AIM

The goal of this study was to determine whether the stress hyperglycemia ratio (SHR) is associated with early neurological deterioration (END) and poor outcomes in patients with single subcortical infarct (SSI).

METHODS

For this study, we prospectively enrolled patients with SSI admitted between 2015 and 2021. SHR was distributed in quartiles according to the size of each subgroup. END was defined as an increase of ≥ 2 total points in the National Institutes of Health Stroke Scale (NIHSS) or ≥ 1 point in the motor items of the NIHSS within 7 days of hospital admission. The modified Rankin Scale (mRS) was used to evaluate patient prognosis. Good and poor outcomes were defined as mRS scores ≤ 2 and > 2, respectively. The relationships between SHR and risk of END as well as outcomes were analyzed using multivariate logistic regression models.

RESULTS

A total of 1049 patients with SSI with an average age of 59.49 years met the inclusion criteria for the analysis. The incidence of END markedly increased with increasing SHR. Multivariate logistic regression analysis revealed that the highest SHR quartile was independently associated with an increased risk of both END (OR 4.04, 95% CI, 2.43-6.69, P < 0.001) and 3-month poor outcomes (OR 2.34, 95% CI, 1.44-3.82, P = 0.001), compared to the lowest quartile. A receiver operating characteristic curve analysis of the SHR based on the area under the curve showed a diagnostic accuracy equal or greater than fasting plasma glucose .

CONCLUSION

SHR is a reliable predictor of END and poor outcomes in patients with SSI.

Study on insulin resistance and ischemic cerebrovascular disease: A bibliometric analysis via CiteSpace

Background

It is reported that insulin resistance widely exists in non-diabetic patients with a recent history of transient ischemic attack (TIA) or ischemic stroke. There is currently strong evidence to prove the bidirectional effect of glucose metabolism disorders and stroke events. Therefore, it is necessary to retrospectively tease out the current status, hotspots, and frontiers of insulin resistance and ischemic cerebrovascular disease through CiteSpace.

Materials and methods

We searched the Web of Science (WOS) for studies related to insulin resistance and ischemic cerebrovascular disease from 1999 to April 2022, then downloaded the data into CiteSpace to generate a knowledge visualization map.

Results

A total of 1,500 publications relevant to insulin resistance and ischemic cerebrovascular disease were retrieved. The USA had the most articles on this topic, followed by PEOPLES R CHINA and JAPAN. WALTER N KERNAN was the most prolific author, whose research mainly focused on insulin resistance intervention after stroke (IRIS) trial. The most common keywords were myocardial ischemia, metabolic syndrome, ischemic stroke, cerebral ischemia, association, oxidative stress, inflammation, and adipose tissue. Major ongoing research trends include three aspects: (1) the association between insulin resistance and ischemic cerebrovascular disease in non-diabetic patients, (2) the intrinsic pathological mechanism between insulin resistance and ischemic cerebrovascular disease, and (3) early intervention of insulin resistance to improve the prognosis of stroke.

Conclusion

The results of this bibliometric study provide the current status and trends of clinical research publications in the field of insulin resistance and ischemic cerebrovascular disease. Insulin resistance is strongly associated with the occurrence of ischemic stroke, early neurological deterioration in stroke patients, post-stroke depression, and cerebral small vessel disease. Early treatment of insulin resistance can be an effective way to prevent the onset of ischemic stroke and improve stroke prognosis. This study may help researchers to identify hot topics and explore new research directions.

Predictive Value of Insulin Resistance as Determined by Homeostasis Model Assessment in Acute Ischemic Stroke Patients: A Systematic Review and Meta-Analysis

Studies on association between homeostasis model assessment of insulin resistance (HOMA-IR) and adverse outcomes have yielded conflicting results in patients with acute ischemic stroke (AIS). This meta-analysis aimed to assess the predictive value of HOMA-IR in AIS patients. Two authors comprehensively searched PubMed and Embase databases until February 28, 2021. All observational studies investigating the association between HOMA-IR and adverse outcomes in AIS patients were included. Outcome measures were poor functional outcome (Modified Rankin Scale≥3), all-cause mortality, stroke recurrence, and neurologic worsening. Seven studies (eight articles) involving 8330 AIS patients were identified. For the highest versus lowest HOMA-IR, the pooled risk ratio (RR) of poor functional outcome was 2.55 (95% CI 1.76-3.70) after adjustment of conventional confounding factors. In addition, elevated HOMA-IR was associated with higher risk of neurologic worsening (RR 1.93; 95% CI 1.15-3.26). However, there were conflicting findings on the association of HOMA-IR with stroke recurrence and all-cause mortality. This meta-analysis confirms that HOMA-IR is significantly associated with an increased risk of poor functional outcome in patients with AIS. However, interpretation of the results of mortality, stroke recurrence, and neurologic worsening should be done with caution due to small number of studies available.

Association between insulin resistance and aspirin or clopidogrel resistance in Chinese patients with recent ischemic stroke/TIA

Objective: This study aims to discover whether insulin resistance is an independent predictor for antiplatelet drug resistance in patients with ischemic cerebrovascular disease.Methods: This study used a prospective cohort method. Patients diagnosed as minor ischemic stroke or transient ischemic attack (TIA) were enrolled successively. All patients have been administrated aspirin and/or clopidogrel and were tested for fasting glucose and insulin and platelet aggregation inhibition tests which was detected by light transmission aggregometry (LTA). The maximum platelet aggregation rate (AA) of ≥20% or the maximum platelet aggregation rate (ADP) of ≥50% was defined as antiplatelet drug resistance. Multivariable logistic regression was performed to estimate the association between HOMA-IR and antiplatelet drug resistance.Results: This study recruited successively 237 patients with mild-to-moderate ischemic stroke or TIA in Beijing Tiantan Hospital from 2018 to 2019. Of them 60 cases were recognized as having insulin resistance. There are 46 patients in insulin resistance group (76.7%) developed antiplatelet drug resistance, which was significantly more frequent than patients without insulin resistance (35%, P < 0.0001). Insulin resistance was an independent risk factor for antiplatelet drug resistance in patients with recent ischemic stroke/TIA after adjusted for confounding factors (Odds Ratio 5.281; 95%CI, 2.15 to 13.01, P < 0.0001).Conclusions: Insulin resistance was an independent predictor for development of antiplatelet drug resistance in patients with recent minor ischemic stroke or TIA. More attention should be paid to recognize these patients and antithrombotic effect should be monitored when antiplatelet drugs were applied to these patients.