Increased admission and fasting glucose are associated with unfavorable short-term outcome after intra-arterial treatment of ischemic stroke in the MR CLEAN pretrial cohort

Prevention and treatment of ischaemic and haemorrhagic stroke in people with diabetes mellitus: a focus on glucose control and comorbidities

Diabetes mellitus is a significant risk factor for both ischaemic and haemorrhagic stroke, affecting up to a third of individuals with cerebrovascular diseases. Beyond being a risk factor for stroke, diabetes and hyperglycaemia have a negative impact on outcomes after ischaemic and haemorrhagic stroke. Hyperglycaemia during the acute ischaemic stroke phase is associated with a higher risk of haemorrhagic transformation and poor functional outcome, with evidence in favour of early intervention to limit and manage severe hyperglycaemia. Similarly, intensive glucose control nested in a broader bundle of care, including blood pressure, coagulation and temperature control, can provide substantial benefit for clinical outcomes after haemorrhagic stroke. As micro- and macrovascular complications are frequent in people with diabetes, cardiovascular prevention strategies also need to consider tailored treatment. In this regard, the broader availability of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists can allow tailored treatments, particularly for those with heart failure and chronic kidney disease as comorbidities. Here, we review the main concepts of hyperacute stroke management and CVD prevention among people with diabetes, capitalising on results from large studies and RCTs to inform clinicians on preferred treatments.

Hyponatremia is associated with unfavorable outcomes after reperfusion treatment in acute ischemic stroke

BACKGROUND AND PURPOSE

In patients with acute ischemic stroke, hyponatremia (plasma sodium < 136 mmol/L) is common and associated with unfavorable outcomes. However, data are limited for patients who underwent intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT). Therefore, our aim was to assess the impact of hyponatremia on postreperfusion outcomes.

METHODS

We analyzed data of consecutive patients who presented with acute ischemic stroke and were treated with IVT and/or EVT at Isala Hospital, the Netherlands, in 2019 and 2020. The primary outcome measure was the adjusted common odds ratio (acOR) for a worse modified Rankin Scale (mRS) score at 3-month follow-up. Secondary outcomes included symptomatic intracranial hemorrhage, in-hospital mortality, infarct core, and penumbra volumes.

RESULTS

Of the 680 patients (median age = 73 years, 49% female, median National Institutes of Health Stroke Scale = 5), 430 patients (63%) were treated with IVT, 120 patients (18%) with EVT, and 130 patients (19%) with both. Ninety-two patients (14%) were hyponatremic on admission. Hyponatremia was associated with a worse mRS score at 3 months (acOR = 1.76, 95% confidence interval [CI] = 1.12-2.76) and in-hospital mortality (aOR = 2.39, 95% CI = 1.23-4.67), but not with symptomatic intracranial hemorrhage (OR = 1.17, 95% CI = 0.39-3.47). Hyponatremia was also associated with a larger core (17.2 mL, 95% CI = 2.9-31.5) and core to penumbra ratio (55.0%, 95% CI = 7.1-102.9).

CONCLUSIONS

Admission hyponatremia in patients with acute ischemic stroke treated with IVT and/or EVT was independently associated with unfavorable postreperfusion outcomes, a larger infarct core, and a larger core to penumbra ratio. Future studies should address whether correction of hyponatremia improves the prognosis.

XGBoost-Based Simple Three-Item Model Accurately Predicts Outcomes of Acute Ischemic Stroke

An all-inclusive and accurate prediction of outcomes for patients with acute ischemic stroke (AIS) is crucial for clinical decision-making. This study developed extreme gradient boosting (XGBoost)-based models using three simple factors-age, fasting glucose, and National Institutes of Health Stroke Scale (NIHSS) scores-to predict the three-month functional outcomes after AIS. We retrieved the medical records of 1848 patients diagnosed with AIS and managed at a single medical center between 2016 and 2020. We developed and validated the predictions and ranked the importance of each variable. The XGBoost model achieved notable performance, with an area under the curve of 0.8595. As predicted by the model, the patients with initial NIHSS score > 5, aged over 64 years, and fasting blood glucose > 86 mg/dL were associated with unfavorable prognoses. For patients receiving endovascular therapy, fasting glucose was the most important predictor. The NIHSS score at admission was the most significant predictor for those who received other treatments. Our proposed XGBoost model showed a reliable predictive power of AIS outcomes using readily available and simple predictors and also demonstrated the validity of the model for application in patients receiving different AIS treatments, providing clinical evidence for future optimization of AIS treatment strategies.

A review of stress-induced hyperglycaemia in the context of acute ischaemic stroke: Definition, underlying mechanisms, and the status of insulin therapy

The transient elevation of blood glucose produced following acute ischaemic stroke (AIS) has been described as stress-induced hyperglycaemia (SIH). SIH is common even in patients with AIS who have no previous diagnosis of diabetes mellitus. Elevated blood glucose levels during admission and hospitalization are strongly associated with enlarged infarct size and adverse prognosis in AIS patients. However, insulin-intensive glucose control therapy defined by admission blood glucose for SIH has not achieved the desired results, and new treatment ideas are urgently required. First, we explore the various definitions of SIH in the context of AIS and their predictive value in adverse outcomes. Then, we briefly discuss the mechanisms by which SIH arises, describing the dual effects of elevated glucose levels on the central nervous system. Finally, although preclinical studies support lowering blood glucose levels using insulin, the clinical outcomes of intensive glucose control are not promising. We discuss the reasons for this phenomenon.

Construction of a Glycaemia-Based Signature for Predicting Acute Kidney Injury in Ischaemic Stroke Patients after Endovascular Treatment

Background: Hyperglycaemia is thought to be connected to worse functional outcomes after ischaemic stroke. However, the association between hyperglycaemia and acute kidney injury (AKI) after endovascular treatment (EVT) remains elusive. The purpose of this study was to investigate the influence of glycaemic on AKI after EVT. Methods: We retrospectively collected the clinical information of patients who underwent EVT from April 2015 to August 2021. Blood glucose after EVT was recorded as acute glycaemia. Chronic glucose levels were estimated by glycosylated haemoglobin (HbA1c) using the following formula: chronic glucose levels (mg/dL) = 28.7 × HbA1c (%) − 46.7. AKI was defined as an increase in maximum serum creatinine to ≥1.5 baseline. We evaluated the association of AKI with blood glucose. A nomogram was established to predict the risk of AKI, and its diagnostic efficiency was determined by decision curve analysis. Results: We enrolled 717 acute ischaemic stroke patients who underwent EVT. Of them, 205 (28.6%) experienced AKI. Acute glycaemia (OR: 1.007, 95% CI: 1.003−1.011, p < 0.001), the acute/chronic glycaemic ratio (OR: 4.455, 95% CI: 2.237−8.871, p < 0.001) and the difference between acute and chronic glycaemia (ΔA-C) (OR: 1.008, 95% CI: 1.004−1.013, p < 0.001) were associated with the incidence of AKI. Additionally, age, atrial fibrillation, ASITN/SIR collateral grading, postoperative mTICI scale, and admission NIHSS were also significantly correlated with AKI. We then created a glycaemia-based nomogram, and its concordance index was 0.743. The net benefit of the nomogram was further confirmed by decision curve analysis. Conclusions: The glycaemia-based nomogram may be used to predict AKI in ischaemic stroke patients receiving EVT.

Association of diabetes mellitus and admission glucose levels with outcome after endovascular therapy in acute ischaemic stroke in anterior circulation

BACKGROUND

We aimed to assess the association of diabetes mellitus (DM) and admission hyperglycaemia (AH) respectively and outcome in patients with acute ischaemic stroke with large vessel occlusion in the anterior circulation treated with endovascular therapy (EVT) in daily clinical practice.

METHODS

Consecutive EVT patients admitted to our stroke centre between 02/2015-04/2020 were included in this observational cohort study. Patients with vs. without DM and with vs. without AH≥7.8mmol/l were compared.

RESULTS

We included 1020 patients (48.9% women, median age 73.1 years). 282 (27.6%) and 226 (22.2%) had DM and/or AH. Patients with vs. without DM showed less often successful reperfusion (_adjusted OR=0.61;p=0.023) and worse 3-month functional outcome (mRS:0-2:31.3% vs. 48%;_adjusted OR=0.59;p=0.004, death:38.9% vs. 24.1%;_adjusted OR=1.75;p=0.002 and mRS-shift:_adjusted p<0.0001, if moderate/good collaterals and mismatch:mRS:0-2:_adjusted OR=0.52;p=0.005, death:_adjusted OR=1.95;p=0.005). If analysis was adjusted for AH additionally, only mRS-shift was still significantly worse in patients with DM (_adjusted p=0.012). Patients with vs. without AH showed similar successful reperfusion rates and worse 3-month functional outcome (mRS:0-2:28.3% vs. 50.4%;_adjusted OR=0.52;p<0.0001, death:40.4% vs. 22.4%;_adjusted OR=1.80;p=0.001 and mRS-shift:_adjusted p<0.0001, if moderate/good collaterals and mismatch:mRS:0-2:_adjusted OR=0.38;p<0.0001, death:_adjusted OR=2.39;p<0.0001). If analysis was adjusted for DM additionally, 3-month functional outcome remained significantly worse in patients with AH (mRS:0-2:_adjusted OR=0.58;p=0.004, death:_adjusted OR=1.57;p=0.014 and mRS-shift:_adjusted p=0.004). DM independently predicted recurrent/progressive in-hospital ischaemic stroke (OR=1.71;p=0.043) together with admission NIHSS score (OR=0.95;p=0.005) and AH independently predicted in-hospital symptomatic intracranial haemorrhage (OR=2.21;p=0.001). The association of admission continuous glucose levels and most outcome variables was (inversely) J-shaped.

CONCLUSIONS

AH more than DM was associated with worse 3-month outcome in the patients studied - more likely so in case of moderate/good collaterals and mismatch in admission imaging.

Stress hyperglycemia is associated with in-hospital mortality in patients with diabetes and acute ischemic stroke

Background and Objective

Stress hyperglycemia may occur in diabetic patients with acute severe cerebrovascular disease, but the results regarding its association with stroke outcomes are conflicting. This study aimed to examine the association between stress‐induced hyperglycemia and the occurrence of in‐hospital death in patients with diabetes and acute ischemic stroke.

Research Design and Methods

All data were from the Chinese Stroke Center Alliance (CSCA) database and were collected between 2016 and 2018 from >300 centers across China. Patients’ demographics, clinical presentation, and laboratory data were extracted from the database. The primary endpoint was in‐hospital death. The ratio of fasting blood glucose (FBG) to HbA1c was calculated, that is, the stress‐induced hyperglycemia ratio (SHR), to determine stress hyperglycemia following acute ischemic stroke.

Results

A total of 168,381 patients were included. The mean age was 66.2 ± 10.7, and 77,688 (43.0%) patients were female. The patients were divided into two groups: survivors (n = 167,499) and non‐survivors (n = 882), as well as into four groups according to their SHR quartiles (n = 42,090–42,099/quartile). There were 109 (0.26%), 142 (0.34%), 196 (0.47%), and 435 (1.03%) patients who died in the Q1, Q2, Q3, and Q4 quartiles, respectively. Compared with Q1 patients, the death risk was higher in Q4 patients (odds ratio (OR) = 4.02) (adjusted OR = 1.80, 95% confidence interval [CI] = 1.10–2.92, p = 0.018 after adjustment for traditional cardiovascular risk factors). The ROC analyses showed that SHR (AUC = 0.667, 95% CI: 0.647–0.686) had a better predictive value for mortality than that of fasting blood glucose (AUC = 0.633, 95% CI: 0.613–0.652) and HbA1c (AUC = 0.523, 95% CI: 0.504–0.543).

Conclusions

The SHR may serve as an accessory parameter for the prognosis of patients with diabetes after acute ischemic stroke. Hyperglycemia in stroke patients with diabetes mellitus is associated with a higher risk of in‐hospital death.

Fasting Blood-Glucose Level and Clinical Outcome in Anterior Circulation Ischemic Stroke of Different Age Groups After Endovascular Treatment

OBJECTIVE

We aimed to analyze the association between fasting blood-glucose (FBG) level and 3-month functional outcome in anterior circulation ischemic stroke in different age groups after endovascular treatment (EVT).

METHODS

We retrospectively analyzed the consecutive patients with acute ischemic stroke (AIS) receiving EVT from our department between July 2015 and March 2021. The patients were categorized into the older (≥60 years) and younger (<60 years) groups, and patients in each age group were dichotomized into favorable versus unfavorable outcomes according to the 3-month modified Rankin Scale (mRS) score.

RESULTS

A total of 504 patients (286 males and 218 females) were included in our study. Three hundred ninety-two patients (77.8%) belonged to the group aged ≥60 years, and 112 (22.2%) belonged to the group aged <60 years. At the end of the study, 222 (56.6%) patients developed unfavorable outcomes in the older group and 31 (27.7%) showed unfavorable outcomes in the younger group. FBG level of the younger patients was significantly lower than that of older patients. In the older group, FBG level independently predicted a 3-month clinical unfavorable outcome with an odds ratio of 1.242 (95% confidence interval, 1.096-1.407; p = 0.001). However, the association was not found in the younger group (p = 0.376).

CONCLUSION

Higher FBG level is an independent risk factor for 3-month unfavorable outcome in the AIS patients aged ≥60 years receiving EVT, but no similar effect was seen in the group aged <60 years.

Increased Postoperative Fasting Glucose Is Associated With Unfavorable Outcomes in Patients Treated With Mechanical Thrombectomy Treatment

Background and objective: Hyperglycemia on admission was associated with worse clinical outcomes after mechanical thrombectomy (MT) of acute ischemic stroke (AIS). We evaluated whether increased postoperative fasting glucose (PFG) was also related to poor clinical outcomes in patients who underwent MT treatment.

Methods: Consecutive patients with large vessel occlusion underwent MT in our center were included. Admission glucose and fasting glucose levels after MT treatment were evaluated. Primary outcome was 90-day unfavorable outcomes (modified Rankin Scale score of 3–6). Secondary outcome was the rate of symptomatic intracranial hemorrhage (sICH) after MT treatment. The association of PFG and 90-day clinical outcome after MT treatment was determined using logistic regression analyses.

Results: One hundred twenty seven patients were collected. The median postoperative fasting glucose level was 6.27 mmol/L (IQR 5.59–7.62). Fourteen patients (11.02%) had sICH, and fifty-eight patients (45.67%) had unfavorable outcomes at 90-day after MT. After adjustment for potential confounding factors, PFG level was an independent predictor of 90-day unfavorable outcome (OR 1.265; 95% CI 1.017–1.575; p = 0.035) and sICH (OR 1.523; 95% CI 1.056–2.195; p = 0.024) after MT. In addition, older age, higher baseline NIHSS score, and higher postoperative NLR were also associated with unfavorable outcomes at 90-day after MT treatment.

Conclusions: Increased PFG is associated with unfavorable outcomes at 90-day and an increased risk of sICH in patients underwent MT treatment.

Factors Contributing to an Efficacious Endovascular Treatment for Acute Ischemic Stroke in Asian Population

Although randomized control trials about endovascular treatment (EVT) of emergent large vessel occlusion (LVO) have demonstrated the success of mechanical thrombectomy as the choice of treatment, a wide range of caveats remain unaddressed. Asian patients were rarely included in the trials, thereby raising the question of whether the treatment could be generalized. In addition, there remains a concern on the feasibility of the method with respect to its application against intracranial atherosclerosis (ICAS)-related LVO, frequently observed in the Asian population. It is important to include evidence on ICAS LVO from Asian countries in the future for a comprehensive understanding of LVO etiology. Besides the issues with EVT, prognostic concerns in diabetes patients, acute kidney injury following EVT, neuroprotective management against reperfusion injury, and other peri-EVT issues should be considered in clinical practice. In the current article, we present an in-depth review of the literature that revises information pertaining to such concerns.

Which Glucose Parameter Best Predicts Poor Outcome after Mechanical Thrombectomy for Acute Large Vessel Occlusion Stroke?

BACKGROUND

Hyperglycemia is related to adverse outcomes in patients with acute ischemic stroke treated by mechanical thrombectomy (MT).

AIM

To compare the predictive ability of admission blood glucose (ABG), fasting blood glucose (FBG), and glycated hemoglobin (HbA1c) in patients with acute large vessel occlusion (ALVO) stroke undergoing MT.

METHODS

The study retrospectively analyzed the data of 329 consecutive acute stroke patients treated by MT. Multivariate logistic regression analysis was performed to investigate the predictors of poor functional outcome. Receiver operating characteristic (ROC) analysis was performed to identify the predictive ability of ABG, FBG, and HbA1c for poor functional independence in patients with ALVO stroke undergoing MT. In addition, subgroup analyses were performed for both diabetic and nondiabetic patients.

RESULTS

Multiple logistic regression analysis demonstrated that ABG and FBG were independent predictors of 3-month poor functional outcome; however, HbA1c could not predict poor functional outcome. Receiver operating characteristic (ROC) analysis showed that FBG has a higher predictive ability than ABG (areas under the ROC curve [AUCs]: 0.689 vs. 0.624, P = 0.037) and HbA1c (AUCs: 0.689 vs. 0.541, P<0.001) for poor function outcome.

CONCLUSIONS

ABG and FBG are independent predictors of poor functional outcome in patients with acute ischemic stroke undergoing MT, and FBG has a higher predictive ability than ABG and HbA1c. This article is protected by copyright. All rights reserved.

Symptomatic intracranial hemorrhage in patients with admission hyperglycemia and diabetes after mechanical thrombectomy: A systematic review and meta-analysis

OBJECTIVES

Symptomatic intracranial hemorrhage (sICH) is a severe complication of revascularization therapy. We aimed to investigate the association of admission hyperglycemia and sICH after mechanical thrombectomy in patients with acute ischemic stroke.

METHODS

We systematically searched PubMed, EMBASE and Cochrane Library to identify studies that reported incidence of sICH in patients with admission hyperglycemia and normoglycemia, or with and without a history of diabetes, or glucose level in patients with sICH and non-sICH from inception to December 10, 2019. The estimate effects were pooled by random-effects model.

RESULTS

Twelve eligible studies were included with 4892 patients enrolled. The risk of sICH was significantly higher in admission hyperglycemia patients than that in normoglycemia (OR 2.93, 95% CI 1.34-6.42, p = 0.007; adjusted OR1.95, 95% CI 1.22-3.13; p = 0.006). The admission glucose level was significantly higher in sICH patients than that in non-sICH with a mean difference of 37.49 (95% CI 3.03-71.94, p = 0.03). The risk of sICH increased with elevating glucose level (adjusted OR 1.06, 95% CI 1.01-1.11; p = 0.02). The risk of sICH was not significantly increased in patients with a history of diabetes than that of those without (OR 1.74, 95% CI 1.00-3.03, p = 0.05; adjusted OR 2.26, 95% CI 0.97-5.28; p = 0.06).

CONCLUSIONS

In patients of acute ischemic stroke treated with mechanical thrombectomy, the risk of sICH was associated with admission hyperglycemia but possibly not with a history of diabetes.

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.

Insulin in the Management of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

OBJECTIVE

The role of tight glycemic control in the management of acute ischemic stroke remains uncertain. Our goal is to evaluate the effects of tight glucose control with insulin therapy after acute ischemic stroke.

METHODS

We searched PubMed, CENTRAL, and Embase for randomized controlled trials (RCTs) that evaluated the effects of tight glycemic control (70-135 mg/dL) in acute ischemic stroke. Analysis was performed using fixed-effects and random-effects models. Outcomes were death, independence, and modified Rankin Scale (mRS) score at ≥90 days follow-up, and symptomatic or severe hypoglycemia during treatment.

RESULTS

Twelve RCTs including 2734 patients were included. Compared with conventional therapy or placebo, tight glycemic control was associated with similar rates of mortality at ≥90 days follow-up (pooled odds ratio [pOR], 0.99; 95% confidence interval [CI], 0.79-1.22]; I² = 0%), independence at ≥90 days follow-up (pOR, 0.95; 95% CI, 0.79-1.14; I² = 0%) and mRS scores at ≥90 days follow-up (standardized mean difference, 0.014; 95% CI, -0.15 to 0.17; I² = 0%). In contrast, tight glycemic control was associated with increased rates of symptomatic or severe hypoglycemia during treatment (pOR, 5.2; 95% CI, 1.7-15.9; I² = 28%).

CONCLUSIONS

Tight glucose control after acute ischemic stroke is not associated with improvements in mortality, independence, or mRS score and leads to higher rates of symptomatic or severe hypoglycemia.

Homocysteine, interleukin-1β, and fasting blood glucose levels as prognostic markers for diabetes mellitus complicated with cerebral infarction and correlated with carotid intima-media thickness

Diabetes mellitus complicated with cerebral infarction (DMCI) has a high incidence and disability rate. Therefore, identification of biomarkers for the early prediction of the development and progression of cerebral infarction (CI) is of great significance for the prevention and treatment of this disease. The roles of serum homocysteine (Hey), interleukin-1β (IL-1β), and fasting blood glucose (FBG) in DMCI and their correlations with carotid intima-media thickness (CIMT) were explored. A total of 124 patients with DMCI (DMCI group) and 103 patients with diabetes mellitus (DM) (DM group) admitted to the People's Hospital of Liuhe District of Nanjing were enrolled in this study. A further 100 healthy controls undergoing physical examinations during the same period (HC group) were also enrolled. CIMT value was detected by carotid artery ultrasound. Hey and FBG levels were determined by a fully automatic biochemical analyzer. The IL-1β level was detected by enzyme-linked immunosorbent assay (ELISA). The levels of Hey, IL-1β, and FBG and the CIMT value in the DMCI and DM groups were significantly higher than those in the HC group (P<0.001). The levels and the value in the DMCI group were significantly higher than those in the DM group (P<0.001). Hey, IL-1β, and FBG levels were positively correlated with CIMT value (r=0.542, P<0.001; r=0.522, P<0.001; r=0.402, P<0.001). Receiver operating characteristic (ROC) curves showed that the sensitivity and specificity of Hey for diagnosing DMCI were 86.29 and 80.58%; those of IL-1β were 68.55 and 86.41%; those of FBG were 69.35 and 88.35%. Multivariate logistic regression analysis revealed that systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), Hey, IL-1β, FBG, and CIMT were independent risk factors for DMCI (P<0.05). In conclusion, patients with DMCI have severe atherosclerosis. Hey, IL-1β, and FBG are involved in the development and progression of DMCI, so they can be used as predictive markers for the disease. Hey, IL-1β, FBG, and CIMT are independent risk factors for patients with DMCI.

Elevated blood glucose is associated with aggravated brain edema in acute stroke

BACKGROUND AND PURPOSE

Clinical outcome after endovascular thrombectomy in patients with acute ischemic stroke still varies significantly. Higher blood glucose levels (BGL) have been associated with worse clinical outcome, but the pathophysiological causes are not yet understood. We hypothesized that higher levels of BGL are associated with more pronounced ischemic brain edema and worse clinical outcome mediated by cerebral collateral circulation.

METHODS

178 acute ischemic stroke patients who underwent mechanical thrombectomy were included. Early ischemic brain edema was determined using quantitative lesion water uptake on initial computed tomography (CT) and collateral status was assessed with an established 5-point scoring system in CT-angiography. Good clinical outcome was defined as functional independence (modified Rankin Scale [mRS] score 0-2). Multivariable logistic regression analysis was performed to predict functional independence and linear regression analyses to investigate the impact of BGL and collateral status on water uptake.

RESULTS

The mean BGL at admission was significantly lower in patients with good outcome at 90 days (116.5 versus 138.5 mg/dl; p < 0.001) and early water uptake was lower (6.3% versus 9.6%; p < 0.001). The likelihood for good outcome declined with increasing BGL (odds ratio [OR] per 100 mg/dl BGL increase: 0.15; 95% CI 0.02-0.86; p = 0.039). Worse collaterals (1% water uptake per point, 95% CI 0.4-1.7%) and higher BGL (0.6% per 10 mg/dl BGL, 95% CI 0.3-0.8%) were significantly associated with increased water uptake.

CONCLUSION

Elevated admission BGL were associated with increased early brain edema and poor clinical outcome mediated by collateral status. Patients with higher BGL might be targeted by adjuvant anti-edematous treatment.

Impact of Hyperglycemia According to the Collateral Status on Outcomes in Mechanical Thrombectomy

Background and Purpose- Understanding the influence of hyperglycemia on outcomes in terms of the pretreatment collateral status might contribute to the achievement of case-specific glucose management in acute ischemic stroke. We sought to investigate whether the glucose level can influence the pretreatment collateral status and functional outcomes of endovascular thrombectomy in acute ischemic stroke and whether the impact of hyperglycemia on outcomes can be modified by the pretreatment collateral status. Methods- We analyzed the Triple-S database, which includes individual patient data pooled from 3 prospective Solitaire stent retriever studies (SWIFT [Solitaire With the Intention for Thrombectomy], SWIFT PRIME [SWIFT as Primary Endovascular Treatment], and STAR [Solitaire Flow Restoration Thrombectomy for Acute Revascularization]). Patients were eligible if they had acute ischemic stroke with moderate to severe neurological deficits, harbored angiographically confirmed large vessel occlusion, and were treatable by endovascular thrombectomy within 8 hours of onset. Pretreatment catheter angiograms were scored for collateral grades by a core imaging laboratory. The main outcome was 3-month good outcome (modified Rankin Scale score of 0-2). Results- Angiographic data on collaterals were available in 309 patients (age, 67±12 years; glucose, 131±55 mg/dL). Overall, the glucose level at presentation was not associated with pretreatment collateral status but was significantly lower in patients with a good outcome at 90 days (124 versus 140 mg/dL). Collateral grades modified the effect of glucose on good outcomes at 90 days ( P_int=0.03). Among patients with poor collaterals (collateral grades, 0-2), higher glucose levels did not alter the outcome, whereas among patients with good collaterals (3-4), higher glucose levels reduced the likelihood of a good outcome at 90 days (per 10 mg/dL increase: odds ratio, 0.81; 95% CI, 0.69-0.95). Conclusions- Our study revealed that higher glucose levels reduce the likelihood of a good outcome among patients with good collaterals, but their effects on the outcome are less significant for patients with poor collaterals. The results suggest that good collaterals at presentation may be targets for more intensive glucose control and future studies relating to glucose management.

High Stress Hyperglycemia Ratio Predicts Poor Outcome after Mechanical Thrombectomy for Ischemic Stroke

OBJECTIVE

The present study aimed to evaluate the association between stress hyperglycemia ratio (SHR) and outcome at 3 months after mechanical thrombectomy (MT) for acute occlusion in the anterior circulation.

METHODS

Data from 160 consecutive patients with large vessel occlusion in the anterior circulation who underwent MT from May 2013 to March 2018 were retrospectively reviewed. SHR was calculated as the fasting glucose concentration divided by the estimated average glucose concentration (derived from the glycosylated hemoglobin level). Patients were dichotomized into 2 groups in accordance with the median SHR. Univariate and multivariate analyses were used to identify predictors of functional outcome. Good and poor outcomes were defined as modified Rankin Scale scores of 0-2 and 3-6, respectively.

RESULTS

patients with unfavorable outcome had significantly higher levels of SHR than those with favorable outcome (median in SHR = 1.02 versus .84, P = .000). The median SHR was .96. Univariate analysis showed that significantly more patients with a poor outcome had SHR ≥ .96 compared with those with a good outcome (65.2% versus 31.0%, P = .000). After adjusting for potential covariates, Increased SHR (odds ratio [OR] 6.97, 95% confidence intervals [CI] 1.22-39.65, P = .029, for continuous SHR levels) and SHR ≥ .96 (OR 3.12, 95% CI 1.39-6.96, P = .006) remained independent predictors of poor outcome.

CONCLUSIONS

Increased SHR is strongly correlated with poor outcome at 3 months after MT for proximal artery occlusion in the anterior circulation.

C-R Relationship between Fasting Plasma Glucose and Unfavorable Outcomes in Patients of Ischemic Stroke withoutDiabetes

BACKGROUND

Limited data are available on the impact of fasting plasma glucose (FPG) on outcomes in nondiabetic acute ischemic stroke patients.

METHODS

The prospective, multi-center, and observational study was performed at 8 hospitals in the Liaoning Province between 2015-2016, sought to elucidate the relationship between FPG and the 6-month functional outcomes in nondiabetic acute ischemic stroke patients. The primary effect measure was the adjusted odds ratio for a shift in the direction of unfavorable outcome on the modified Rankin Scale (mRS) score at 6 months, estimated with an ordinal logistic regression, and adjusted for common prognostic factors. Finally, we employed a restricted cubic spline function of linear model to characterize concentration-response (C-R) relationships between FPG and outcomes.

RESULTS

A total of 1260 consecutive patients were enrolled, 48.9% of patients had FPG levels >6.1mmol/L. A total of 282 (22.4%) patients achieved an unfavorable neurologic outcome. Patients achieving an unfavorable neurologic outcome had significantly higher levels of FPG than those achieving a favorable neurologic outcome (6.47mmol/L versus 7.02 mmol/L). FPG was significantly related to an unfavorable neurologic outcome in nondiabetic acute ischemic stroke patients. The C-R curve showed a nonlinear relation between FPG and 6-month mRS with the nadir at 5.9mmol/L. Moreover, the likelihood of unfavorable outcome increased by 8.5% for each 1mmol/L increase in FPG.

CONCLUSIONS

Early identification and prompt hyperglycemia management should be considered to improve the functional outcomes during the early poststroke stage.

Effect of Hyperglycemia at Presentation on Outcomes in Acute Large Artery Occlusion Patients Treated With Solitaire Stent Thrombectomy

Background: Sporadic data showed hyperglycemia at presentation is associated with poor outcomes in patients with acute ischemic stroke (AIS) under mechanical thrombectomy (MT) treatment.

Objective: This study aims to evaluate the relationship of admission hyperglycemia and outcomes in patients treated with solitaire stent thrombectomy.

Methods: This multicenter prospective study registered patients with AIS due to anterior circulation large vessel occlusion (LVO) suitable for MT with Solitaire stent retriever. We analyzed the influence of admission hyperglycemia (≥7.8 mmol/L) and serum glucose on functional independence which is defined as modified Rankin Scale score (mRS) of 0–2, symptomatic intracranial hemorrhage (sICH) and several outcomes of interest using univariable and multiple logistic regression analysis.

Results: This study involved 17 stroke centers across China and consecutively recruited 149 patients. Patients with hyperglycemia at presentation less frequently exhibited a functional independence at 3 months than patients without hyperglycemia (22.2 vs. 66.4%; odds ratio 0.75, 95% confidence interval 0.61–0.92; P = 0.005). Higher glucose levels were correlated with worse outcome (per 1 mmol/L increase in glucose: odds ratio for mRS score 0–2 at 3 months 0.17, 95% confidence interval 0.06–0.45; P < 0.001) at 3 months and sICH (per 1 mmol/L increase in glucose: odds ratio for sICH was 8.2, 95% confidence interval 1.13–29.57; P < 0.001) after thrombectomy.

Conclusions: Higher admission serum glucose and hyperglycemia were independently correlated with lower functional independence at 3 months in patients treated with Solitaire stent thrombectomy of anterior circulation LVO. Higher admission serum glucose was also associated with sICH after thrombectomy.

HbA1c (Glycated Hemoglobin) Levels and Clinical Outcome Post-Mechanical Thrombectomy in Patients With Large Vessel Occlusion

Background and Purpose- We analyzed the relationship between HbA1c (glycated hemoglobin) levels and clinical outcomes in patients with large vessel occlusion treated with mechanical thrombectomy (MT). Methods- A total of 534 patients with acute ischemic stroke (AIS) treated with MT were enrolled in this prospective cohort study. The primary outcome measured was the modified Rankin Scale score at 3 months, according to HbA1c level. High HbA1c levels were defined as a plasma level of HbA1c >6.5%. Favorable outcomes were defined as functional independence, with modified Rankin Scale scores of 0 to 2. Secondary functional outcomes included mortality, early clinical outcomes, and intracranial hemorrhage. Results- The number of patients with a favorable outcome was significantly lower in patients with HbA1c >6.5% than in those with HbA1c ≤6.5% (28.8% versus 42.1%; P=0.006). In multivariate analysis, high HbA1c levels (especially >7.0% HbA1c) were significantly associated with poor functional outcomes 3 months after AIS in patients with large vessel occlusion treated with MT. High HbA1c was also significantly associated with increased mortality and worse early clinical outcomes after AIS in patients treated with MT. Subgroup analyses showed that HbA1c >6.5% was associated with significantly lower odds of functional independence at 3 months after AIS, when comparing the recanalized group with nonrecanalized patients. Conclusions- These results suggest that high HbA1c level is an independent predictor of a poor outcome at 3 months after AIS in patients with large vessel occlusion treated with MT, particularly in those with recanalization, and may augment the risk of mortality and early clinical worsening after AIS.

Factors that may contribute to poor outcome despite good reperfusion after acute endovascular stroke therapy

Endovascular therapy with mechanical thrombectomy is a formidable treatment for severe acute ischemic stroke caused by occlusion of a proximal intracranial artery. Its strong beneficial effect is explained by the high rates of very good and excellent reperfusion achieved with current endovascular techniques. However, there is a sizable proportion of patients who do not experience clinical improvement despite successful recanalization of the occluded artery and reperfusion of the ischemic territory. Factors such as baseline reserve, collateral flow, anesthesia and systemic factors have been identified as potential culprits for lack of improvement in the setting of timely and successful revascularization. Older age, baseline disability and perhaps radiological markers of chronic brain injury can affect the prognosis of patients treated with endovascular therapy. Collateral flow is a major determinant of outcome after endovascular therapy and it is manifested by the size of the core in relation to the volume of the salvageable tissue. Parenchymal and vascular imaging can help assess the quality of collateral flow, but the optimal radiological strategy for daily practice (i.e. the optimal combination of rapid availability and diagnostic precision) has not been established. A sizable body of observational evidence indicates that acute hypertension, hyperglycemia and fever are associated with worse outcomes after a stroke even after optimal reperfusion with endovascular therapy. Lastly, current randomized controlled trials in anesthesia for stroke demonstrate similar rates of good functional outcome between general anesthesia and conscious sedation suggesting equipoise exists.

Clinical Outcome After Mechanical Thrombectomy in Patients with Diabetes with Major Ischemic Stroke of the Anterior Circulation

BACKGROUND

Among patients with acute ischemic stroke treated with mechanical thrombectomy (MT), patients with diabetes (DP) show a poorer outcome compared with patients without diabetes (NDP). This study aims to provide a comprehensive analysis of factors associated with unfavorable outcome in DP receiving MT for stroke of the anterior circulation.

METHODS

This study included 317 of 498 consecutive patients who received interventional treatment for acute ischemic stroke in the terminal internal carotid artery and/or middle cerebral artery, including 46 DP. The study data included pre- and posttreatment stroke computed tomography, including perfusion data, collateral status, treatment data including treatment times, pre-existing cardiovascular risk factors, cerebrovascular events, comorbidities, laboratory parameters, and medication. Neurologic status was assessed at baseline (National Institute of Health Stroke Scale [NIHSS]/modified Rankin Scale [mRS]) and after 90 days (mRS 90).

RESULTS

Compared with NDP, DP showed a significantly poorer outcome (mRS90 >2) (P < 0.05). Collateralization and infarct core size did not differ between groups, whereas the penumbra was significantly smaller in DP than in NDP (P < 0.05). The poorer mRS90 outcome (mRS90 > 2) in DP was associated with poor collaterals (P = 0.01) and hyperglycemia on admission (P < 0.05). Shorter time to reperfusion was associated with favorable mRS90 in the NDP (P < 0.001) but not the DP (P = 0.49) group. In univariate logistic regression, the following parameters were significantly associated with mRS90: diabetes, hyperglycemia at admission, time to reperfusion, and the NIHSS score (P < 0.05 each). In multivariate analyses and partition regression models of all variables, DP with admission hyperglycemia (≥132 mg/dL) and older age (≥66 years) showed a particularly poor outcome.

CONCLUSIONS

The main factors for an unfavorable outcome of DP after MT are admission hyperglycemia, age, and NIHSS score.

Early Prediction of Poor Outcome Despite Successful Recanalization After Endovascular Treatment for Anterior Large Vessel Occlusion Stroke

OBJECTIVE

Successful recanalization (SR) of the occluded artery does not always translate into a good outcome for patients with acute anterior circulation large-vessel occlusion stroke. This study aimed to develop a scale to predict poor outcome early despite SR after endovascular treatment (EVT) for candidates identified using current guidelines.

METHODS

The eligible patients with SR were retrospectively enrolled between 2014 and 2016. Poor outcome was defined as modified Rankin Scale of 3 to 6 at 90 days. Multivariable logistic regression was used to derive a PooR outcomE of enDovascular treatment wIth suCcessful recanalizaTion (PREDICT) scale. The discrimination and calibration of the scale were assessed.

RESULTS

A total of 332 patients were enrolled. The PREDICT scale consisted of 5 items (prior intravenous thrombolysis, collateral status, blood glucose, blood neutrophil-to-lymphocyte ratio, and baseline National Institutes of Health Stroke Scale score). The scale had good discrimination and calibration. The risk of poor outcome was stratified into very low (PREDICT scale score ≤5), low (6-8), moderate (9-11), and high (≥12). Compared with patients with a score of ≤5, patients with a score of ≥12 had an 18.33-fold (95% confidence interval [CI], 6.36-52.89) increased risk of poor outcome.

CONCLUSIONS

The PREDICT scale is a practical tool for early prediction of poor outcome despite SR after EVT in our patients and, if validated in other patient populations, may serve as a scale for identifying which patients are most, and least, likely to benefit from EVT.

A hemorrhagic transformation model of mechanical stroke therapy with acute hyperglycemia in mice

Clinical benefit for mechanical thrombectomy (MT) in stroke was recently demonstrated in multiple large prospective studies. Acute hyperglycemia (HG) is an important risk factor of poor outcome in stroke patients, including those that underwent MT. The aim of this therapy is to achieve a complete reperfusion in a short time, given that reperfusion damage is dependent on the duration of ischemia. Here, we investigated the effects of acute HG in a mouse model of ischemic stroke induced by middle cerebral artery occlusion (MCAO). Hyperglycemic (intraperitoneal [ip] injection of glucose) and control (ip saline injection) 10-week male C57BL6 mice were subjected to MCAO (30, 90, and 180 min) followed by reperfusion obtained by withdrawal of the monofilament. Infarct volume, hemorrhagic transformation (HT), neutrophil infiltration, and neurological scores were assessed at 24 hr by performing vital staining, ELISA immunofluorescence, and behavioral test, respectively. Glucose injection led to transient HG (blood glucose = 250-390 mg/dL) that significantly increased infarct volume, HT, and worsened neurological outcome. In addition, we report that HG promoted blood-brain barrier disruption as shown by hemoglobin accumulation in the brain parenchyma and tended to increase neutrophil extravasation within the infarcted area. Acute HG increased neurovascular damage for all MCAO durations tested. HTs were observed as early as 90 min after ischemia under hyperglycemic conditions. This model mimics MT ischemia/reperfusion and allows the exploration of brain injury in hyperglycemic conditions.

Update on Neurocritical Care of Stroke

PURPOSE OF REVIEW

This review will highlight the recent advancements in acute ischemic stroke diagnosis and treatment, with special attention to new features and recommendations of stroke care in the neurocritical care unit.

RECENT FINDINGS

New studies suggest that pre-hospital treatment of stroke with mobile stroke units and telestroke technology may lead to earlier stroke therapy with intravenous tissue plasminogen activator (tPA), and recent studies show tPA can be given in previously contraindicated situations. More rapid automated CT perfusion and angiography may demonstrate a vascular penumbra for neuroendovascular intervention. Further, the greatest advance in acute stroke treatment since 2014 is the demonstration that neuroendovascular catheter-based thrombectomy with stent retrievers recanalizing intracranial large vessel occlusion (LVO) improves both recanalization and long-term outcomes in several trials. Hemorrhagic transformation and severe large infarct cerebral edema remain serious post-stroke challenges, with new guidelines describing who and when patients should get medical or surgical intervention. The adage "time is brain" directs the most evidence-based approach for rapid stroke diagnosis for tPA eligible and LVO recanalization using an orchestrated team approach. The neurocritical care unit is the appropriate location to optimize stroke outcomes for the most severely affected stroke patients.

Observation of elevated fasting blood glucose and functional outcome after ischemic stroke in patients with and without diabetes

During May 2015 to October 2016, this prospective study enrolled a total of 438 patients with acute ischemic stroke(AIS), meanwhile, records regarding the severity of initial stroke and neurological outcomes at three months, as well as other examination were completed in patients on admission, as well as the measurement and evaluation of fasting blood glucose(FBG) levels. At admission, the median FBG levels in patients with a minor stroke (n=124), [P<0.001]) was significantly lower than that observed in patients with other degrees of stroke. The poor functional outcome distribution across the FBG quartiles ranged from 13.8 % (first quartile) to 59.6% (fourth quartile), with P <0.001. Compared with the reference category (first quartile), patients in the highest quartile had a relative risk of 3.12 (95% confidence interval [CI], 1.88-6.15; P<0.001) while those in the second and third quartiles had relative risks of 1.76 (95% CI, 1.21-3.03; P=0.035) and 2.23 (95% CI, 1.50-3.69; P=0.010), respectively. Furthermore, in the patients without diabetes, FBG level was observed to be increased and indicated an increased risk of disability (odds ratio [OR]: 1.30 (95%CI 1.13-1.61), P=0.002), however, similar result was not detected in patients with prior diabetes (P=0.089). In conclusion, elevated FBG levels after stroke may suggest poor functional outcome at 3-month in patients without a previous history of diabetes.

Admission hyperglycemia and outcomes in large vessel occlusion strokes treated with mechanical thrombectomy

BACKGROUND AND PURPOSE

Higher admission serum glucose levels have been associated with poor outcomes in patients with acute ischemic stroke (AIS) treated with IV thrombolysis. We sought to evaluate the association of admission serum glucose with early outcomes of patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT).

METHODS

Consecutive AIS patients due to ELVO treated with MT in three tertiary stroke centers were evaluated. The following outcomes were documented using standard definitions: symptomatic intracranial hemorrhage (sICH), complete reperfusion, mortality, functional independence (modified Rankin Scale (mRS) score of 0-2), and functional improvement (shift in mRS score) at 3 months. The association of admission serum glucose and admission hyperglycemia (>140 mg/dL) with outcomes was evaluated using univariable and multivariable binary and ordinal logistic regression models.

RESULTS

231 AIS patients with ELVO (mean age 62±14 years, 51% men, median admission National Institute of Health Stroke Scale score 16 points (IQR 12-21), median admission serum glucose 125 mg/dL (IQR 104-162)) were treated with MT. Admission hyperglycemia was associated with a lower likelihood of functional improvement (common OR 0.53; 95% CI 0.31 to 0.97; p=0.027) and higher odds of 3 month mortality (OR 2.76; 95% CI 1.40 to 5.44; p=0.004) in multivariable analyses adjusting for potential confounders. A 10 mg/dL increase in admission blood glucose was associated with a higher likelihood of sICH (OR 1.07; 95% CI 1.01 to 1.13; p=0.033) and 3 month mortality (OR 1.07; 95% CI 1.02 to 1.12; p=0.004) in multivariable models. There was no association between admission serum glucose or hyperglycemia and complete reperfusion.

CONCLUSIONS

Higher admission serum glucose and admission hyperglycemia are independent predictors of adverse outcomes in ELVO patients treated with MT.