The impact of postadmission glycemia on stroke outcome: Glucose normalisation is associated with better survival

DNA methylation and stroke prognosis: an epigenome-wide association study

BACKGROUND AND AIMS

Stroke is the leading cause of adult-onset disability. Although clinical factors influence stroke outcome, there is a significant variability among individuals that may be attributed to genetics and epigenetics, including DNA methylation (DNAm). We aimed to study the association between DNAm and stroke prognosis.

METHODS AND RESULTS

To that aim, we conducted a two-phase study (discovery-replication and meta-analysis) in Caucasian patients with ischemic stroke from two independent centers (BasicMar [discovery, N = 316] and St. Pau [replication, N = 92]). Functional outcome was assessed using the modified Rankin Scale (mRS) at three months after stroke, being poor outcome defined as mRS > 2. DNAm was determined using the 450K and EPIC BeadChips in whole-blood samples collected within the first 24 h. We searched for differentially methylated positions (DMPs) in 370,344 CpGs, and candidates below p-value < 10-5 were subsequently tested in the replication cohort. We then meta-analyzed DMP results from both cohorts and used them to identify differentially methylated regions (DMRs). After doing the epigenome-wide association study, we found 29 DMPs at p-value < 10-5 and one of them was replicated: cg24391982, annotated to thrombospondin-2 (THBS2) gene (p-valuediscovery = 1.54·10-6; p-valuereplication = 9.17·10-4; p-valuemeta-analysis = 6.39·10-9). Besides, four DMRs were identified in patients with poor outcome annotated to zinc finger protein 57 homolog (ZFP57), Arachidonate 12-Lipoxygenase 12S Type (ALOX12), ABI Family Member 3 (ABI3) and Allantoicase (ALLC) genes (p-value < 1·10-9 in all cases).

DISCUSSION

Patients with poor outcome showed a DMP at THBS2 and four DMRs annotated to ZFP57, ALOX12, ABI3 and ALLC genes. This suggests an association between stroke outcome and DNAm, which may help identify new stroke recovery mechanisms.

Incidence of Stress-Induced Hyperglycemia in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

The aim of this study was to systematically evaluate the incidence of stress-induced hyperglycemia (SIH) in acute ischemic stroke (AIS). Studies that reported SIH incidence in AIS and examined risk factors for SIH and non-SIH patients were systematically searched in PubMed, Embase, Cochrane Library, and Web of Science from the inception of each database to December 2021. Article screening and data extraction were performed by two independent reviewers according to the inclusion and exclusion criteria. The quality of the included studies was assessed using the Newcastle–Ottawa Scale (NOS), and meta-analysis was performed using Stata. A total of 13 studies involving 4552 patients (977 in the SIH group and 3575 in the non-SIH group) were included. Meta-analysis showed that the incidence of SIH was 24% (95% CI: 21–27%) in the total population, 33% (14–52%) in North America, 25% (20–29%) in Europe, and 21% (12–29%) in Asia. Subgroup analysis by year of publication revealed that the pooled incidence of SIH was 27% (22–32%) in studies published before 2010 and 19% (14–24%) in those published after 2010. SIH is relatively common in AIS and poses a serious public health problem. Therefore, more emphasis should be placed on the prevention and control of SIH in AIS.

Persistent hyperglycemia is a useful glycemic pattern to predict stroke mortality: a systematic review and meta-analysis

BACKGROUND

Glycemic patterns have been reported to be prognostic factors for stroke; however, this remains to be further evaluated. This meta-analysis aimed to evaluate the usefulness of glycemic patterns such as persistent hyperglycemia (PH) including short duration and long duration PH (SPH; LPH), admission hyperglycemia (AH), short-duration hyperglycemia (SH), and persistent normoglycemia (PN) in predicting stroke prognosis using published results.

METHODS

Major scientific databases including but are not limited to PubMed, EMBASE, Web of Science, Ovid, CNKI (Chinese National Knowledge Infrastructure), and Clinicaltrials.gov were searched till 1st March 2021 for clinical trials on the correlation between glycemic patterns and stroke outcomes. The primary outcome was defined as short-term (1- or 3-month) post-stroke mortality, and the secondary outcome was post-stroke hemorrhage at 6 months.

RESULTS

Ten studies involving 3584 individuals were included in the final analysis. In subgroup analyses, PH patients with no history of diabetes had increased post-stroke mortality (odds ratio [OR]: 4.80, 95% CI: 3.06-7.54) than patients with no PH; and patients with glucose levels > 140 mg/dl had greater mortality (OR: 5.12, 95% CI: 3.21-8.18) than those with glucose levels < 140 mg/dl; compared with AH patients, PH patients had increased short-term mortality (OR: 0.31, 95% CI: 0.16-0.60). In the prediction of stroke mortality among patients without diabetes, SPH (OR: 0.28, 95%CI: 0.12-0.69) seemed to be more related to increased mortality than LPH (OR: 0.35, 95% CI: 0.14--0.90).

CONCLUSIONS

PH, especially SPH, could predict increased post-stroke mortality in non-diabetic patients. The rank of individual glycemic patterns in predicting stroke mortality in non-diabetic patients was SPH > LPH > AH > PN.

Fasting Hyperglycemia and Long-term Outcome in Patients with Acute Ischemic Stroke Treated with Mechanical Thrombectomy

BACKGROUND

Little is known about the prognostic role of fasting glucose after mechanical thrombectomy (MT).

AIMS

We investigated whether fasting glucose on the next day after MT was associated with long-term outcome in acute ischemic stroke patients according to diabetes.

METHODS

We retrospectively analyzed 181 consecutive patients with acute anterior circulation ischemic stroke who underwent MT in 2 comprehensive stroke centers in Poland. Glucose levels were evaluated on admission and on the next day after MT. Fasting hyperglycemia (FHG) was defined as the glucose level above 5.5 mmol/L. Unfavorable outcome was defined as modified Rankin scale (mRS) of 3-6 at day 90 from stroke onset.

RESULTS

Patients with FHG had higher mRS at 3-month follow-up compared with those without FHG (3.71 ± 2.56 versus 1.87 ± 2.22, P < .001). In the subgroup analyses, FHG was associated with poor neurological outcome in the group without diabetes (3.74 ± 2.52 versus 1.81 ± 3.74, P < .001) but not with diabetes (3.64 ± 2.67 versus 2.30 ± 3.74, P= .11). Patients without diabetes who had FHG were older, had higher glucose on admission, higher prevalence of atrial fibrillation, cardioembolic stroke etiology and bleeding brain complications compared with the group with normal fasting glucose. After adjustment for potential confounders, fasting glucose (odds ratio [OR] 1.46; 95% CI 1.19-1.79, P < .001), age (OR 1.06; 95% CI 1.02-1.10, P = .001), successful reperfusion (OR 0.09; 95% CI 0.04-0.22, P < .001) and baseline NIHSS score (OR 1.18; 95% CI 1.08-1.29, P < .001) were predictors of mRS 3-6 at 3-month follow-up in the whole group. In the subgroup without diabetes, fasting glucose (OR 1.57; 95% CI 1.17-2.11, P = .002), age (OR 1.05; 95% CI 1.01-1.08, P = .008), successful reperfusion (OR 0.11; 95% CI 0.04-0.30, P < .001) and baseline NIHSS score (OR 1.14; 95% CI 1.04-1.26, P = .011) were independent predictors of unfavorable 3-month outcome.

CONCLUSIONS

Fasting glucose on the next day after MT in patients with acute ischemic stroke is an independent risk factor for worse 3-month outcome.

Treatment with exenatide in acute ischemic stroke trial protocol: A prospective, randomized, open label, blinded end-point study of exenatide vs. standard care in post stroke hyperglycemia

Rationale Post-stroke hyperglycemia occurs in up to 50% of patients presenting with acute ischemic stroke. It reduces the efficacy of thrombolysis, increases infarct size, and worsens clinical outcomes. Insulin-based therapies have generally not been beneficial in treating post-stroke hyperglycemia as they are difficult to implement, may cause hypoglycaemia, possibly increase mortality and worsen clinical outcomes. Exenatide may be a safer, simpler, and more effective alternative to insulin in acute ischemic stroke. Design TEXAIS is a three year, Phase 2, multi-center, prospective, randomized, open label, blinded end-point trial comparing exenatide to standard of care. It aims to recruit 528 patients with a primary end point of major neurological improvement at 7 days defined as a ≥8-point improvement in NIHSS score, or NIHSS 0-1. Secondary outcomes of hyper- and hypoglycaemia at 5 days and NIHSS and mRS at 90 days will be measured. The treatment arm will receive exenatide 5 µg subcutaneously twice daily. The control arm will receive standard stroke unit care. Continuous glucose monitors will track the dynamic variability of glucose. Conclusion TEXAIS aims to show that exenatide is safe and effective in the treatment of post-stroke hyperglycemia. It has been designed to be highly generalizable with an ability to enroll a large percentage of patients with acute ischemic stroke, regardless of admission blood glucose level, diabetes status, or stroke severity, with very low risk of hypoglycemia. Trial registration: ClinicalTrials.gov/ANZCTR NTA1127.

European Stroke Organisation (ESO) guidelines on glycaemia management in acute stroke

Background

Hyperglycaemia is a frequent complication in acute stroke that has been shown to be independently associated with larger infarct size, haematoma growth, poor clinical outcome and mortality. This Guideline Document presents the European Stroke Organisation (ESO) Guidelines for the management of blood glucose levels in patients with acute ischemic or haemorrhagic stroke.

Methods

The working group identified related questions and developed its recommendations based on evidence from randomised controlled trials following the standard operating procedure of the ESO. This Guideline Document was reviewed and approved by the European Stroke Organisation Guidelines Committee and the European Stroke Organisation Executive Committee.

Results

We found low-quality evidence from clinical trials in ischemic or haemorrhagic stroke exploring the use of intravenous insulin aimed to achieve a tight glycaemic control with different glucose level targets and several other sources of heterogeneity. None of these trials neither the meta-analysis of them have demonstrated any significant benefit of tight glycaemic control with intravenous insulin in acute ischemic or haemorrhagic stroke patients on functional outcome or in survival and they have shown an increased risk for hypoglycaemia.

Conclusions

We suggest against the routine use of tight glycaemic control with intravenous insulin as a means to improve outcomes. The currently available data about the management of glycaemia in patients with acute stroke are limited and the strengths of the recommendations are therefore weak. Nevertheless, this does not prevent that hyperglycaemia in acute stroke patients could be treated as any other hospitalised patient.

Glycemia in Acute Stroke II study: a call to improve post-stroke hyperglycemia management in clinical practice

BACKGROUND AND PURPOSE

The aim of the study was to analyze the effect of conventional glucose management, which aimed to maintain glucose levels <155 mg/dL (8.5 mmol/L), on glucose control and the outcomes of patients with acute ischaemic stroke (IS) in a clinical practice setting.

METHODS

This was a multicenter, prospective cohort study of patients with acute IS. Patients were classified into four groups based on their initial 48-h capillary glucose levels and the administration of and response to corrective treatment: (i) untreated and maximum glucose levels <155 mg/dL (8.5 mmol/L) within the first 48 h; (ii) treated and good responders [glucose levels persistently <155 mg/dL (8.5 mmol/L)]; (iii) treated and non-responders [any glucose values ≥155 mg/dL (8.5 mmol/L) during the 24 h after the start of corrective treatment]; and (iv) untreated with any glucose value ≥155 mg/dL (8.5 mmol/L). The primary outcome was death or dependence at 3 months (blinded rater).

RESULTS

A total of 213 patients were included. Ninety-seven (45.5%) patients developed glucose levels ≥155 mg/dL (8.5 mmol/L), 69 (71.1%) underwent corrective treatment and 31 patients underwent no corrective treatment at the physician's discretion [28 of whom had isolated values ≥155 mg/dL (8.5 mmol/L)]. Only 11 (16%) patients responded to conventional treatment, whereas 58 (84%) patients were non-responsive. Non-responders showed a twofold higher risk of death or dependence at 3 months (odds ratio, 2.472; 95% confidence interval, 1.096-5.576; P = 0.029).

CONCLUSIONS

Lack of response to conventional treatment for glucose management in acute IS is frequent and associated with poor outcomes.

Hyperglycemia predicts poststroke infections in acute ischemic stroke

OBJECTIVE

To investigate whether admission hyperglycemia predicts poststroke infections and, if so, whether poststroke infections modify the effect of admission hyperglycemia on functional outcome in ischemic stroke.

METHODS

We used data from acute ischemic stroke patients in the Preventive Antibiotics in Stroke Study (PASS), a multicenter randomized controlled trial (n = 2,550) investigating the effect of preventive antibiotics on functional outcome. Admission hyperglycemia was defined as blood glucose ≥7.8 mmol/L and poststroke infection as any infection during admission judged by an expert adjudication committee. Functional outcome at 3 months was assessed with the modified Rankin Scale.

RESULTS

Of 1,676 nondiabetic ischemic stroke patients, 338 (20%) had admission hyperglycemia. After adjustment for potential confounding variables, admission hyperglycemia was associated with poststroke infection (adjusted odds ratio [aOR] 2.31, 95% CI 1.31-4.07), worse 3-month functional outcome (common aOR 1.40, 95% CI 1.12-1.73), and 3-month mortality (aOR 2.11, 95% CI 1.40-3.19). Additional adjustment for poststroke infection in the functional outcome analysis, done to assess poststroke infection as an intermediate in the pathway from admission hyperglycemia to functional outcome, did not substantially change the model. In patients with recorded diabetes mellitus (n = 418), admission hyperglycemia was not associated with poststroke infection (aOR 0.49, 95% CI 0.15-1.58).

CONCLUSIONS

In nondiabetic acute ischemic stroke patients, admission hyperglycemia is associated with poststroke infection and worse functional outcome. Poststroke infections did not modify the effect of admission hyperglycemia on functional outcome in ischemic stroke.

An Investigation of the Glucose Monitoring Practices of Nurses in Stroke Care: A Descriptive Cohort Study

Glucose derangement is commonly observed among adults admitted to hospital with acute stroke. This paper presents the findings from a descriptive cohort study that investigated the glucose monitoring practices of nurses caring for adults admitted to hospital with stroke or transient ischaemic attack. We found that a history of diabetes mellitus was strongly associated with initiation of glucose monitoring and higher frequency of that monitoring. Glucose monitoring was continued for a significantly longer duration of days for adults with a history of diabetes mellitus, when compared to the remainder of the cohort. As glucose monitoring was not routine practice for adults with no history of diabetes mellitus, the detection and treatment of hyperglycaemia and hypoglycaemia events could be delayed. There was a significant positive association between the admission hospital that is most likely to offer stroke unit care and the opportunity for glucose monitoring. We concluded that adults with acute stroke, irrespective of their diabetes mellitus status prior to admission to hospital, are vulnerable to both hyperglycaemic and hypoglycaemic events. This study suggests that the full potential of nurses in the monitoring of glucose among hospitalised adults with stroke has yet to be realised.

Systematic review of descriptive cohort studies on the dynamics of glycaemia among adults admitted to hospital with acute stroke

AIM

This article presents the results of a systematic review of descriptive cohort studies on the dynamics of glycaemia among adults admitted to hospital with acute stroke.

BACKGROUND

Hyperglycaemia is common among adults admitted to hospital with stroke.

DESIGN

Systematic review.

DATA SOURCES

A search for descriptive cohort studies published between January 1996-June 2011, was conducted in MEDLINE, PubMed and Embase electronic databases. The search was performed using the terms 'stroke', 'hyperglycaemia' and/or 'glucose' combined and limited to adults and English language publications. Searching of citations from identified studies supplemented the electronic searches.

REVIEW METHODS

A systematic review was conducted of eight studies, meeting the criteria of: (1) descriptive cohort studies; (2) adults admitted to hospital with acute stroke; and (3) glycaemic status monitored over at least two consecutive days from admission to hospital. The review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis standards.

RESULTS

The dynamics of glycaemia after stroke has been investigated in seven prospective cohort studies and one retrospective study. The patterns that emerged were persisting normoglycaemia, transient hyperglycaemia, persisting hyperglycaemia and delayed hyperglycaemia. Surges in glycaemia are likely on days 2 and 3 and some adults will not exhibit hyperglycaemia till day 7.

CONCLUSION

Further large cohort studies are required to explore the dynamic of glycaemia after stroke for at least 1 week duration. The timing of formal screening for diabetes mellitus is important, as early screening may overestimate detection rates.

Improving patient selection for endovascular treatment of acute cerebral ischemia: a review of the literature and an external validation of the Houston IAT and THRIVE predictive scoring systems

Outcome after intraarterial therapy (IAT) for acute ischemic stroke remains variable, suggesting that improved patient selection is needed to better identify patients likely to benefit from treatment. The authors evaluate the predictive accuracies of the Houston IAT (HIAT) and the Totaled Health Risks in Vascular Events (THRIVE) scores in an independent cohort and review the existing literature detailing additional predictive factors to be used in patient selection for IAT. They reviewed their center's endovascular records from January 2004 to July 2010 and identified patients who had acute ischemic stroke and underwent IAT. They calculated individual HIAT and THRIVE scores using patient age, admission National Institutes of Health Stroke Scale (NIHSS) score, admission glucose level, and medical history. The scores' predictive accuracies for good outcome (discharge modified Rankin Scale score ≤ 3) were analyzed using receiver operating characteristics analysis. The THRIVE score predicts poor outcome after IAT with reasonable accuracy and may perform better than the HIAT score. Nevertheless, both measures may have significant clinical utility; further validation in larger cohorts that accounts for differences in patient demographic characteristics, variation in time-to-treatment, and center preferences with respect to IAT modalities is needed. Additional patient predictive factors have been reported but not yet incorporated into predictive scales; the authors suggest the need for additional data analysis to determine the independent predictive value of patient admission NIHSS score, age, admission hyperglycemia, patient comorbidities, thrombus burden, collateral flow, time to treatment, and baseline neuroimaging findings.

Predictive value of admission blood glucose level on short-term mortality in acute cerebral ischemia

BACKGROUND

Admission hyperglycemia increases the risk of death in patients with acute stroke. However, the most appropriate cut-off of glucose level indicating an increased risk of short-term mortality remains unknown.

PURPOSE AND METHODS

We aimed at establishing the optimum cut-offs of several variables (including admission blood glucose levels) predicting case-fatality (72hours, 7days) and unfavorable outcome [modified Rankin Scale (mRS) score 5-6 at 7 days] in consecutive first-ever acute ischemic stroke. Receiver operating characteristic (ROC) curves were constructed.

RESULTS

Eight hundred eleven consecutive patients were included [median age of 77 (69-83) years; 418 (52%) male; 239 (30%) diabetics; median admission National Institutes of Health Stroke Scale (NIHSS) 7 (4-12), 32 (4%) dead within 72hours; 64 (8%) dead within day 7; 155 (19%) with unfavorable outcome]. Median admission glucose levels were 113 (97-155)mg/dL. Diabetics had significantly higher median glucose levels than non-diabetics [163 (133-214) vs. 107 (92-123) mg/dL, p<0.001]. According to ROC analysis, the only significant predictive value of glycemia was ≥143mg/dL for 72-hour fatality (sensitivity 88% and specificity 70%) especially in non-diabetics (sensitivity 88% and sensitivity 62%). This cut-off point was an independent predictor for 72-hour fatality (overall: OR=4.0, CI=1.6-9.9, p=0.003; non-diabetics: OR=4.9, CI=1.7-14.5, p=0.004). The cut-offs of fasting total cholesterol levels and admission leukocytes had poor predictive values for each outcome, while those of admission NIHSS had good discrimination in predicting short-term outcome measures.

CONCLUSIONS

Admission hyperglycemia (≥143mg/dL) is a strong and an independent predictor for 72-hour fatality, especially in patients with no prior history of diabetes mellitus.

[Management of acute ischemic stroke]

The management of acute ischemic stroke aims to verify the clinical diagnosis, to start general supportive care and to enable decision-making about specific forms of therapy.The risk-benefit ratio is time-dependent for many therapeutic options; therefore time delays are a disadvantage within the rescue chain. The trained and multidisciplinary team of the stroke unit forms the backbone of acute management. In addition, technical infrastructure influences therapeutic options and cerebral imaging is the cornerstone.The following four therapies are evidence-based: treatment on a stroke unit, thrombolysis, early administration of acetylsalicylic acid (ASS) and hemicraniectomy in patients younger than 60 years with a so-called malignant infarction.This article describes the necessary diagnostic steps and the general and specific therapeutic options that comprise acute management within the first 48 h.

Routinely assessed biochemical markers tested on admission as predictors of adverse outcomes in hospitalized elderly patients

AIM

To explore whether routinely assessed biochemical markers tested on admission will predict 3 predefined adverse outcomes for hospitalized elderly patients: discharge to a long-term care facility, in-hospital mortality, and prolonged hospital length of stay (> 14 days).

METHODS

A prospective observational study of elderly patients (aged ≥ 75 years) admitted to an acute-care geriatric ward over a 6-month period. Patients were assessed on admission and baseline characteristics were collected. Activities of daily living were assessed by the Barthel Index and cognitive function by the abbreviated mental test. Results from biochemical markers tested on admission were downloaded from the pathology laboratory database using patient details. Patients were followed-up with until discharge or in-hospital mortality.

RESULTS

A total of 392 patients formed the study population. Mean (standard deviation) age was 83.2 (± 5.5) years and 283 (72%) patients were men. Thirty-eight (10%) patients were discharged to a long-term care facility, 134 (34%) had a prolonged hospital length of stay, and 33 (8%) died in the hospital. Results from testing 5 biochemical markers independently predicted in-hospital mortality: hypoalbuminemia (adjusted odds ratio [OR], 2.5; 95% CI, 0.9-6.7; P = 0.04), low total cholesterol level (adjusted OR, 2.9; 95% CI, 1.3-6.3; P = 0.01), hyperglycemia (adjusted OR, 2.9; 95% CI, 1.2-7.4; P = 0.02), high C-reactive protein level (adjusted OR, 4.2; 95% CI, 1.3-13.4; P = 0.01), and renal impairment (adjusted OR, 3.8; 95% CI, 1.7-8.7; P = 0.002). High C-reactive protein level independently predicted prolonged hospital length of stay (OR, 1.7; 95% CI, 1.1-2.9; P = 0.03). Hypoalbuminemia predicted discharge to a long-term care facility independent of confounding factors except for physical dysfunction (OR, 2.4; 95% CI, 1.1-5.1; P = 0.03). Significance was reduced after adjustment for Barthel Index score (OR, 1.9; 95% CI, 0.9-4.1; P = 0.08).

CONCLUSION

Testing of routinely assessed biochemical markers on admission predicted adverse hospital outcomes for elderly patients. Their inclusion in a standardized prediction tool may help to create interventions to improve such outcomes.