Postoperative hyperglycemia predicts symptomatic intracranial hemorrhage after endovascular treatment in patients with acute anterior circulation large artery occlusion

Glycaemia and ischaemia-reperfusion brain injury in patients with ischaemic stroke treated with mechanical thrombectomy (GLIAS-MT): an observational, unicentric, prospective study protocol

INTRODUCTION

Poststroke hyperglycaemia is an independent risk factor for poorer outcomes in patients treated with mechanical thrombectomy (MT) and is associated with a lower probability of functional recovery and higher mortality at 3 months. This study aims to evaluate the association between glucose levels during cerebral reperfusion with MT and functional recovery at 3 months, measured by subcutaneous continuous glucose monitoring (CGM) devices.

METHODS

This prospective observational study aims to recruit 100 patients with ischaemic stroke and large anterior circulation vessel occlusion, in whom MT is indicated. CGM will be performed using a Freestyle Libre ProIQ device (FSL-CGM, Abbott Diabetes Care, Alameda, California, USA), which will be implanted on admission to the emergency department, to monitor glucose levels before, during and after reperfusion. The study's primary endpoint will be the functional status at 3 months, as measured by the dichotomised modified Rankin Scale (0-2 indicating good recovery and 3-6 indicating dependency or death). We will analyse expression profiles of microRNA (miRNA) at the time of reperfusion and 24 hours later, as potential biomarkers of ischaemic-reperfusion injury. The most promising miRNAs include miR-100, miR-29b, miR-339, miR-15a and miR-424. All patients will undergo treatment according to current international recommendations and local protocols for the treatment of stroke, including intravenous thrombolysis if indicated.

ETHICS AND DISSEMINATION

This study (protocol V.1.1, dated 29 October 2021, code 6017) has been approved by the Clinical Research Ethics Committee of La Paz University Hospital (Madrid, Spain) and has been registered in ClinicalTrials.gov (NCT05871502). Study results will be disseminated through peer-reviewed publications in Open Access format and at conference presentations.

TRIAL REGISTRATION NUMBER

NCT05871502.

Stress hyperglycemia increases short-term mortality in acute ischemic stroke patients after mechanical thrombectomy

BACKGROUND AND PURPOSE

Glucose-to-glycated hemoglobin ratio (GAR) is considered a more reliable marker of stress hyperglycemia by correcting for basal blood glucose levels. This study aimed to investigate the extent to which GAR is associated with 3 month and 1 year all-cause mortalities in patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT).

METHODS

We retrospectively followed 553 AIS patients who underwent MT. The degree of stress hyperglycemia was quantified as the GAR, defined as fasting plasma glucose (mmol/L)/hemoglobin A1c (HbA1c) (%) on the second day after admission. According to the GAR quartiles, the patients were further categorized into four groups (group 1-group 4). We assessed the association between GAR and all-cause mortalities, clinical outcomes during hospitalization and function outcomes at 3 months. The associations between stress hyperglycemia and all-cause mortalities were analyzed using a Cox proportional-hazards model, while other outcomes were analyzed using multiple logistic regression analysis.

RESULTS

The follow-up lasted a median of 18 months (range 0-66 months). The 3 month mortality rate was 9.58% (n = 53) and the 1 year mortality rate was 18.62% (n = 103). The Kaplan-Meier analysis revealed a significant inverse relationship between GAR and mortality (P < 0.001). In the Cox proportional-hazards model at 3 months, compared with group1, group 4 of GAR was associated with a significant increase in the risk of 3 month mortality (hazard ratio [HR] = 4.11, 95% confidence interval [CI] 1.41-12.0, P = 0.01) after adjusting for potential covariates. On multivariate logistic regression analysis, GAR was strongly associated with an increased risk of 3 month poor function outcome.

CONCLUSIONS

Stress hyperglycemia, quantified by a higher GAR, is associated with all-cause mortality and poor functional outcomes in patients with AIS who undergo MT. Furthermore, GAR may contribute to improving the predictive efficiency of all-cause mortality in patients with AIS after MT, especially short-term all-cause mortality.

Postoperative blood glucose increase is associated with futile recanalization in patients with successful thrombectomy: a retrospective study

BACKGROUND

Timely recognition of futile recanalization might enable a prompt response and an improved outcome in post-thrombectomy patients. This study aims to evaluate whether postoperative blood glucose increase (BGI) could act as an indicator of futile recanalization in patients receiving a successful thrombectomy.

METHODS

This is a single-center, retrospective analysis of patients with anterior circulation large-vessel occlusion and successful thrombectomy between February 2019 and June 2022. BGI was defined as a higher level of blood glucose at the first postoperative morning than at admission. Futile recanalization was defined as patients with a modified Rankin Scale score of 3-6 at 90 days after onset. Multivariable binary logistic regression was used to assess the association of BGI with futile recanalization.

RESULTS

A total of 276 patients were enrolled, amongst which 120 patients (43.5%) had BGI. Futile recanalization was more prevalent among patients with BGI compared to those without (70.0 vs. 49.4%, P = 0.001). After adjusting for potential confounders, BGI was associated with a higher likelihood of futile recanalization (adjusted OR: 2.97, 95%CI: 1.50-5.86, P = 0.002). This association was consistently observed regardless of diabetes history, occlusion site, time from symptom onset to groin puncture, or reperfusion status.

CONCLUSION

Our findings support BGI serving as an indicator of futile recanalization in patients with anterior circulation large-vessel occlusion and successful thrombectomy.

Anaesthetic and peri-operative management for thrombectomy procedures in stroke patients

PURPOSE

To provide recommendations for the anaesthetic and peri-operative management for thrombectomy procedure in stroke patients DESIGN: A consensus committee of 15 experts issued from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et Réanimation, SFAR), the Association of French-language Neuro-Anaesthetists (Association des Neuro-Anesthésistes Réanimateurs de Langue Francaise, ANARLF), the French Neuro-Vascular Society (Société Francaise de Neuro-Vasculaire, SFNV), the French Neuro-Radiology Society (Société Francaise de Neuro-Radiologie, SFNR) and the French Study Group on Haemostasis and Thrombosis (Groupe Français d'Études sur l'Hémostase et la Thrombose, GFHT) was convened, under the supervision of two expert coordinators from the SFAR and the ANARLF. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were required to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence.

METHODS

Four fields were defined prior to the literature search: (1) Peri-procedural management, (2) Prevention and management of secondary brain injuries, (3) Management of antiplatelet and anticoagulant treatments, (4) Post-procedural management and orientation of the patient. Questions were formulated using the PICO format (Population, Intervention, Comparison, and Outcomes) and updated as needed. Analysis of the literature was then conducted and the recommendations were formulated according to the GRADE methodology.

RESULTS

The SFAR/ANARLF/SFNV/SFNR/GFHT guideline panel drew up 18 recommendations regarding anaesthetic management of mechanical thrombectomy procedures. Due to a lack of data in the literature allowing to conclude with high certainty on relevant clinical outcomes, the experts decided to formulate these guidelines as "Professional Practice Recommendations" (PPR) rather than "Formalized Expert Recommendations". After two rounds of rating and several amendments, a strong agreement was reached on 100% of the recommendations. No recommendation could be formulated for two questions.

CONCLUSIONS

Strong agreement among experts was reached to provide a sizable number of recommendations aimed at optimising anaesthetic management for thrombectomy in patients suffering from stroke.

Prognostic role of dynamic neutrophil-to-lymphocyte ratio in acute ischemic stroke after reperfusion therapy: A meta-analysis

Background

The prognostic role of the neutrophil-to-lymphocyte ratio (NLR), an inflammatory marker, in acute ischemic stroke (AIS) after reperfusion therapy remains controversial. Therefore, this meta-analysis sought to assess the correlation between the dynamic NLR and the clinical outcomes of patients with AIS after reperfusion therapy.

Methods

PubMed, Web of Science, and Embase databases were searched to identify relevant literature from their inception to 27 October 2022. The clinical outcomes of interest included poor functional outcome (PFO) at 3 months, symptomatic intracerebral hemorrhage (sICH), and 3-month mortality. The NLR on admission (pre-treatment) and post-treatment was collected. The PFO was defined as a modified Rankin scale (mRS) of >2.

Results

A total of 17,232 patients in 52 studies were included in the meta-analysis. The admission NLR was higher in the 3-month PFO (standardized mean difference [SMD] = 0.46, 95% confidence interval [CI] = 0.35-0.57), sICH (SMD = 0.57, 95% CI = 0.30-0.85), and mortality at 3 months (SMD = 0.60, 95% CI = 0.34-0.87). An elevated admission NLR was associated with an increased risk of 3-month PFO (odds ratio [OR] = 1.13, 95% CI = 1.09-1.17), sICH (OR = 1.11, 95% CI = 1.06-1.16), and mortality at 3 months (OR = 1.13, 95% CI = 1.07-1.20). The post-treatment NLR was significantly higher in the 3-month PFO (SMD = 0.80, 95% CI = 0.62-0.99), sICH (SMD = 1.54, 95% CI = 0.97-2.10), and mortality at 3 months (SMD = 1.00, 95% CI = 0.31-1.69). An elevated post-treatment NLR was significantly associated with an increased risk of 3-month PFO (OR = 1.25, 95% CI = 1.16-1.35), sICH (OR = 1.14, 95% CI = 1.01-1.29), and mortality at 3 months (OR = 1.28, 95% CI = 1.09-1.50).

Conclusion

The admission and post-treatment NLR can be used as cost-effective and easily available biomarkers to predict the 3-month PFO, sICH, and mortality at 3 months in patients with AIS treated with reperfusion therapy. The post-treatment NLR provides better predictive power than the admission NLR.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022366394.

Predictors of Symptomatic Intracranial Hemorrhage after Endovascular Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

INTRODUCTION

This meta-analysis assessed the predictors of symptomatic intracranial hemorrhage (sICH) after endovascular thrombectomy (EVT) for patients with acute ischemic stroke.

METHODS

PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science were searched for studies published from inception to February 16, 2021. We included studies that evaluated the predictors of sICH after EVT. The random-effect model or fixed-effect model was used to pool the estimates according to the heterogeneity.

RESULTS

A total of 25 cohort studies, involving 15,324 patients, were included in this meta-analysis. The total incidence of sICH was 6.72 percent. Age (MD = 2.57, 95% CI: 1.53-3.61; p < 0.00001), higher initial NIHSS score (MD = 1.71, 95% CI: 1.35-2.08, p < 0.00001), higher initial systolic blood pressure (MD = 7.40, 95% CI: 5.11-9.69, p < 0.00001), diabetes mellitus (OR = 1.36, 95% CI: 1.10-1.69, p = 0.005), poor collaterals (OR = 3.26, 95% CI: 2.35-4.51; p < 0.0001), internal carotid artery occlusion (OR = 1.55, 95% CI: 1.26-1.90; p < 0.0001), longer procedure time (MD = 18.92, 95% CI: 11.49-26.35; p < 0.0001), and passes of retriever >3 (OR = 3.39, 95% CI: 2.45-4.71; p < 0.0001) were predictors of sICH, while modified thrombolysis in cerebral infarction score ≥2b (OR = 0.61, 95% CI: 0.46-0.79; p = 0.0002) was associated with a decreased risk of sICH. There were no significant differences in the female gender, initial serum glucose, initial ASPECT score, atrial fibrillation, oral anticoagulants, antiplatelet therapy, intravenous thrombolysis, general anesthesia, neutrophil-to-lymphocyte ratio, and emergent stenting.

CONCLUSIONS

This study identified many predictors of sICH. Some of the results lack robust evidence given the limitations of the study. Therefore, larger cohort studies are needed to confirm these predictors.

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.

Role of Neutrophil-Lymphocyte Ratio in the Prognosis of Acute Ischaemic Stroke After Reperfusion Therapy: A Systematic Review and Meta-analysis

Background

Inflammation may mediate response to acute reperfusion therapy (RT) in acute cerebral ischaemia. Neutrophil-lymphocyte ratio (NLR), an inflammatory biomarker, may play an important role in acute ischaemic stroke (AIS) prognostication.

Objective

This meta-analysis sought to examine the effect of NLR on functional outcomes, mortality and adverse outcomes in AIS patients receiving RT.

Methods

Individual studies were retrieved from PubMed/Medline, EMBASE and Cochrane databases. Data were extracted using a standardised data sheet and meta-analysis on association of admission (pre-RT) or delayed (post-RT) NLR with clinical/safety outcomes after RT was conducted.

Results

Thirty-five studies (n = 10 308) were identified for the systematic review with 27 (n = 8537) included in the meta-analyses. Lower admission NLR was associated with good functional outcomes (GFOs), defined as 3-month modified Rankin scale (mRS) 0–2 (SMD = −.46; 95% CI = −.62 to −.29; P < .0001), mRS 0–1 (SMD = −.44; 95% CI = −.66 to −.22; P < .0001) and early neurological improvement (ENI) (SMD = −.55; 95 %CI = −.84 to −.25; P < .0001). Lower delayed admission NLR was also associated with GFOs (SMD = −.80; 95%CI = −.91 to −.68; P < .0001). Higher admission NLR was significantly associated with mortality (SMD = .49; 95%CI = .12 to .85; P = .009), intracerebral haemorrhage (ICH) (SMD = .34; 95% CI = .09 to .59; P = .007), symptomatic ICH (sICH) (SMD = .48; 95% CI = .07 to .90; P = .022) and stroke-associated infection or pneumonia (SMD = .85; 95% CI = .50, 1.19; P < .0001). Higher delayed NLR was significantly associated with sICH (SMD = 1.40; 95% CI = .60 to 2.19; P = .001), ICH (SMD = .94; 95% CI = .41 to 1.46; P < .0001) and mortality (SMD = 1.12; 95% CI = .57 to 1.67; P < .0001). There were variations in outcomes across RT groups.

Conclusion

Higher admission or delayed NLR is significantly associated with worse morbidity, mortality and safety outcomes in AIS patients receiving RT.

Predictors of Symptomatic Hemorrhage After Endovascular Treatment for Anterior Circulation Occlusions: Turkish Endovascular Stroke Registry

We evaluated the predictive factors of symptomatic intracranial hemorrhage (SICH) in endovascular treatment of stroke. We included 975 ischemic stroke patients with anterior circulation occlusion. Patients that had hemorrhage and an increase of ≥4 points in their National Institutes of Health Stroke Scale (NIHSS) after the treatment were considered as SICH. The mean age of patients was 65.2±13.1 years and 469 (48.1%) were women. The median NIHSS was 16 (13-18) and Alberta Stroke Program Early CT 9 (8-10). In 420 patients (43.1%), modified Rankin Scale was favorable (0-2) and mortality was observed in 234 (24%) patients at the end of the third month. Patients with high diastolic blood pressure (P<.05) had significantly higher SICH. SICH was significantly higher in those with high NIHSS scores (P<.001), high blood glucose (P<.001), and leukocyte count at admission (P<.05). Diabetes mellitus (DM) (OR 1.90; P<.001), NIHSS (OR 1.07; P<.05), adjuvant intra-arterial thrombolytic therapy (IA-rtPA) (OR, 1.60; P<.05), and puncture-recanalization time (OR 1.01; P<.05) were independent factors of SICH. Higher baseline NIHSS score, longer procedure time, multiple thrombectomy maneuvers, administration of IA-rtPA, and the history of DM are independent predictors of SICH in anterior circulation occlusion.

Prognosis and Predictors of Symptomatic Intracranial Hemorrhage After Endovascular Treatment of Large Vessel Occlusion Stroke

Background

Symptomatic intracranial hemorrhage (sICH) is a devastating complication of endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) and is associated with high risk of disability and mortality. This study intended to evaluate the predictors of sICH after EVT in patients with large vessel occlusion (LVO)-induced AIS.

Methods

We conducted a retrospective review on consecutive AIS patients who underwent EVT in our University hospital between January 2019 and August 2020. The patients were classified into two groups based upon the occurrence of sICH. The main outcomes were the occurrence of sICH using the Heidelberg Bleeding Classification and functional condition at 90 days. Multivariate logistic regression analysis and receiver operating characteristics (ROC) curves were used to identify independent predictors of sICH after EVT.

Results

Three hundred and 69 patients were enrolled in the study, of which 16.8% (n = 62) developed sICH. Favorable neurological outcome was lower in patients with sICH than in patients without sICH (6.5 vs. 43.3%; P < 0.001), with the overall mortality being 112 (30.4%) at 90 days post- EVT. Results from univariate analysis showed significant differences between the two groups in the prevalence of diabetes, initial Alberta Stroke Program Early CT Score (ASPECTS) score, National Institutes of Health Stroke Scale (NIHSS) score after operation, the levels of fasting blood glucose (FBG), neutrophil to lymphocyte ratio (NLR), platelets (PLT), and thrombin time (TT) at admission. Multivariate logistic regression analysis showed that FBG ≥ 7.54 mmol/L (OR: 2.765; 95% confidence interval [CI]: 1.513–5.054), NLR ≥ 5.48 (OR: 2.711; 95% CI: 1.433–5.128), TT at admission ≥ 16.25 s (OR: 2.022; 95% CI: 1.115–3.667), and NIHSS score within 24 h after the operation ≥ 10 (OR: 3.728; 95% CI: 1.516–9.170) were independent predictors of sICH. The combination of NLR ≥ 5.48, FBG ≥ 7.54 mmol/L, TT at admission ≥ 16.25 s, and NIHSS score within 24 h after the operation ≥ 10 generated an optimal prediction model (AUC: 0.723).

Conclusion

Higher levels of FDG, NLR, TT at admission, and NIHSS score after operation were associated with sICH after EVT in patients with LVO-induced AIS.

Clinical and Imaging Indicators of Hemorrhagic Transformation in Acute Ischemic Stroke After Endovascular Thrombectomy

BACKGROUND AND PURPOSE

Prior studies have investigated the clinical and imaging factors for hemorrhagic transformation (HT), especially symptomatic intracranial hemorrhage (sICH); however, whether alteplase increases the risk of HT after endovascular thrombectomy (EVT) is unknown. This study aimed to assess clinical and imaging features associated with HT, sICH, and parenchymal hematoma (PH) in patients with acute ischemic stroke after EVT, with and without intravenous alteplase in DIRECT-MT (Direct Intraarterial Thrombectomy to Revascularize Acute Ischemic Stroke Patients with Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals: a Multicenter Randomized Clinical Trial).

METHODS

The DIRECT-MT trial is a randomized trial of EVT alone versus intravenous thrombolysis combined with EVT. HT, sICH, and PH was evaluated on follow-up computed tomography. Multivariable ordinal logistic regression analysis was used to test the association of stepwise selected determinants with HT, sICH, and PH.

RESULTS

In total, 633 patients were analyzed; 261 (41.2%) had HT; 34 (5.4%) had sICH; and 85 (13.4%) had PH. The median age was 69, and 56.7% were men. The median National Institutes of Health Stroke Scale score was 18, and 320 patients were in combination-therapy group. Symptomatic intracranial hemorrhage was associated with higher baseline National Institutes of Health Stroke Scale score (adjusted odds ratio [OR], 1.06 [95% CI, 1.10-1.12]) and higher glucose level at hospital arrival (adjusted OR, 1.14 [95% CI, 1.00-1.29]). No association was found between alteplase treatment and HT, sICH, or PH. The independent predictor of sICH was higher baseline National Institutes of Health Stroke Scale score (adjusted OR, 1.09 [95% CI, 1.01-1.18]) in EVT alone group, and history of anticoagulant drugs (adjusted OR, 3.75 [95% CI, 1.07-13.06]), higher glucose level at hospital arrival (adjusted OR, 1.19 [95% CI, 1.03-1.38]), >3 passes of device (adjusted OR, 4.42 [95% CI, 1.36-14.32]) in combination-therapy group.

CONCLUSIONS

In DIRECT-MT, independent predictors of sICH were baseline National Institutes of Health Stroke Scale score and glucose level at hospital arrival. Alteplase treatment did not increase the risk of HT, sICH, or PH after EVT. The independent predictor of sICH was different in EVT alone group and combination-therapy group.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03469206.

Neutrophil-lymphocyte ratio in acute ischemic stroke: Immunopathology, management, and prognosis

There is an ongoing need for accurate prognostic biomarkers in the milieu of acute ischemic stroke (AIS) receiving reperfusion therapy. Neutrophil-lymphocyte ratio (NLR) has been implicated in emergency medicine and acute stroke setting as an important biomarker in the prognosis of patients. However, there are ongoing questions around its accuracy and translation into clinical practice given suboptimal sensitivity and specificity results, as well as varying thresholds and lack of clarity around which NLR time points are most clinically indicative. This article provides a comprehensive overview of the role of NLR in AIS patients receiving reperfusion therapy and perspectives on areas of future research. NLR may be an important biomarker in risk stratifying patients in AIS to identify and select those who are more likely to benefit from reperfusion therapy. Appropriate clinical decision-making tools and models are required to harness the predictive value of NLR, which could be useful in identifying and monitoring high-risk patients to guide early treatment and achieve improved outcomes. Our understanding of the role of NLR in the immunopathogenesis of AIS is also suboptimal, which hinders the ability to translate this into clinical practice.

Effect of Intensive Glucose Control on Outcomes of Hyperglycemic Stroke Patients Receiving Mechanical Thrombectomy: Secondary Analysis of the SHINE Trial

BACKGROUND

Hyperglycemia is common among patients presenting with acute ischemic stroke (AIS) and is associated with poor clinical outcomes. We studied the effects of intensive blood glucose control among AIS patients presenting with hyperglycemia treated with mechanical thrombectomy (MT).

METHODS

We analyzed publicly available data from the Stroke Hyperglycemia Insulin Network Effort trial. In this nonpreplanned secondary analysis, we compared hyperglycemic AIS patients treated with MT who received intensive blood glucose control (80 to 130 mg/dL) with those who received standard blood glucose control (80 to 179 mg/dL). Outcomes included rates of favorable 90-day outcome (modified Rankin Scale score ≤2) and death.

RESULTS

This analysis included 146 patients (74 in the intensive treatment group and 72 in the standard treatment group). Intensive blood glucose was not associated with higher rates of 90-day favorable outcomes (intensive 31.1% vs. standard 30.6%, P=1.0; odds ratio 1.025, 95% confidence interval 0.51 to 2.07) or a decrease in rates of death (intensive 20.3% vs. standard 22.2%, P=0.84; odds ratio 0.98, 95% confidence interval 0.40 to 1.97).

CONCLUSIONS

Intensive blood glucose control among AIS patients presenting with hyperglycemia and treated with MT was not associated with lower rates of death or higher rates of long-term favorable outcomes when compared with standard treatment.

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.

Predictors for Failure of Early Neurological Improvement After Successful Thrombectomy in the Anterior Circulation

BACKGROUND AND PURPOSE

Failure of early neurological improvement (fENI) despite successful mechanical thrombectomy in the anterior circulation is a clinically frequent occurrence. Purpose of this analysis was to define independent clinical, radiological, laboratory, or procedural predictors for fENI.

METHODS

Retrospective single-center analysis of patients treated for acute ischemic stroke in the anterior circulation ensuing successful mechanical thrombectomy between January 2014 and April 2019. Patients were compared according to fENI (equal or higher National Institutes of Health Stroke Scale) and ENI (lower National Institutes of Health Stroke Scale at discharge). Thirty-eight variables were examined in multivariable analysis for association with fENI.

RESULTS

Five hundred forty-nine out of 1146 patients experienced successful recanalization (modified Treatment in Cerebral Ischemia 2c-3). fENI occurred in 115/549 (20.9%) patients. Independent predictors of fENI were premorbid modified Rankin Scale (odds ratio [OR] per point [IC], 1.21 [1.00-1.46], P=0.049), end-stage renal failure (OR [IC], 12.18 [2.01-73.63], P=0.007), admission glucose (OR [IC], 1.018 [1.004-1.013] per mg/dL, P=0.001), bridging IV lysis (OR [IC], 0.57 [0.35-0.93], P: 0.024), time from groin puncture to final recanalization (OR [IC], 1.004 [1.001-1.007] per minute, P=0.015), general anesthesia during mechanical thrombectomy (OR, 2.41 [1.43-4.08], P<0.001), symptomatic intracranial hemorrhage (OR [CI], 6.81 [1.84-25.16], P=0.004), and follow-up Alberta Stroke Program Early CT Score (OR [IC], 0.76 [0.69-0.84] per point, P<0.001). In a secondary analysis, involvement of the regions internal capsule, M4 and M5 (motor cortex) were further independent predictors for fENI. Patients with ENI were more likely to experience a good outcome (modified Rankin Scale on day 90, 0-2: n=229/435 [52.8%] versus n=13/115 [11.3%]; P<0.001).

CONCLUSIONS

The extent of infarction and the involvement of motor cortex and internal capsule as well as higher premorbid modified Rankin Scale, end-stage renal failure, high glucose level on admission, absence of bridging IV lysis, general anesthesia, and a longer therapy interval are presumably independent predictors for fENI in patients with successful mechanical thrombectomy.

Intracranial Bleeding After Reperfusion Therapy in Acute Ischemic Stroke

Intracranial hemorrhage is one of the most feared complications following brain infarct. Ischemic tissues have a natural tendency to bleed. Moreover, the first recanalization trials using intravenous thrombolysis have shown an increase in mild to severe intracranial hemorrhage. Symptomatic intracerebral hemorrhage is strongly associated with poor outcomes and is an important factor in recanalization decisions. Stroke physicians have to weigh the potential benefit of recanalization therapies, first, with different risks of intracranial hemorrhage described in randomized controlled trials, and second with numerous risk markers that have been found to be associated with intracranial hemorrhage in retrospective series. These decisions have become quite complex with different intravenous thrombolytics and mechanical thrombectomy. This review aims to outline some elements of the pathophysiological mechanisms and classifications, describe most of the risk factors identified for each reperfusion therapy, and finally suggest future research directions that could help physicians dealing with these complications.

Hypersensitive C-reactive protein-albumin ratio predicts symptomatic intracranial hemorrhage after endovascular therapy in acute ischemic stroke patients

Background

Approximately 10% of patients would develop symptomatic intracranial hemorrhage (sICH) after endovascular therapy. The aim of our study was to explore the ability of hypersensitive C-reactive protein-albumin ratio (HAR) in predicting sICH after endovascular therapy.

Methods

From April 2016 to December 2018, 334 consecutive patients with anterior circulation infarction undergoing endovascular therapy were enrolled in our study. sICH was defined using Heidelberg bleeding classification after endovascular therapy. Multiple regression analysis was used to investigate the potential risk factors of sICH after endovascular therapy. We used receiver operating characteristic curve analysis and nomogram analysis to assess the overall discriminative ability of the HAR in predicting sICH after endovascular therapy.

Results

Among these 334 patients enrolled, 37 (11.1%) patients with anterior circulation infarction were identified with sICH after endovascular therapy. Univariate logistic regression analysis demonstrated that patients with higher levels of HAR may be inclined to develop sICH (odds ratio, 10.994; 95% confidence interval, 4.567–26.463; P = 0.001). This association remained significant even after adjustment for potential confounders. Also, a cutoff value of 0.526× 10^− 3 for HAR was detected in predicting sICH (area under curve, 0.763). Furthermore, nomogram analysis also suggested that HAR was an indicator of sICH (c-index was 0.890, P< 0.001).

Conclusions

This study showed that high levels of HAR could predict sICH after endovascular therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02066-2.

Identification of Predictors for Hemorrhagic Transformation in Patients with Acute Ischemic Stroke After Endovascular Therapy Using the Decision Tree Model

Purpose

This study aimed to identify independent predictors for the risk of hemorrhagic transformation (HT) in arterial ischemic stroke (AIS) patients.

Methods

Consecutive patients with AIS due to large artery occlusion in the anterior circulation treated with mechanical thrombectomy (MT) were enrolled in a tertiary stroke center. Demographic and medical history data, admission lab results, and Circle of Willis (CoW) variations were collected from all patients.

Results

Altogether, 90 patients were included in this study; among them, 34 (37.8%) had HT after MT. The final pruned decision tree (DT) model consisted of collateral score and platelet to lymphocyte ratios (PLR) as predictors. Confusion matrix analysis showed that 82.2% (74/90) were correctly classified by the model (sensitivity, 79.4%; specificity, 83.9%). The area under the ROC curve (AUC) was 81.7%. The DT model demonstrated that participants with collateral scores of 2–4 had a 75.0% probability of HT. For participants with collateral scores of 0–1, if PLR at admission was <302, participants had a 13.0% probability of HT; otherwise, participants had an 75.0% probability of HT. The final adjusted multivariate logistic regression analysis indicated that collateral score 0–1 (OR, 10.186; 95% CI, 3.029–34.248; p < 0.001), PLR (OR, 1.005; 95% CI, 1.001–1.010; p = 0.040), and NIHSS at admission (OR, 1.106; 95% CI, 1.014–1.205; p = 0.022) could be used to predict HT. The AUC for the model was 0.855, with 83.3% (75/90) were correctly classified (sensitivity, 79.4%; specificity, 87.3%). Less patients with HT achieved independent outcomes (mRS, 0–2) in 90 days (20.6% vs. 64.3%, p < 0.001). Rate of poor outcomes (mRS, 4–6) was significantly higher in patients with HT (73.5% vs. 19.6%; p < 0.001).

Conclusion

Both the DT model and multivariate logistic regression model confirmed that the lower collateral status and the higher PLR were significantly associated with an increased risk for HT in AIS patients after MT. PLR may be one of the cost-effective and practical predictors for HT. Further prospective multicenter studies are needed to validate our findings.

Dynamic Hyperglycemic Patterns Predict Adverse Outcomes in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy

BACKGROUND

Admission hyperglycemia impairs outcome in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT). Since hyperglycemia in AIS represents a dynamic condition, we tested whether the dynamic patterns of hyperglycemia, defined as blood glucose levels > 140 mg/dl, affect outcomes in these patients.

METHODS

We retrospectively analyzed data of 200 consecutive patients with prospective follow-up. Based on blood glucose level, patients were distinguished into 4 groups: (1) persistent normoglycemia; (2) hyperglycemia at baseline only; (3) hyperglycemia at 24-h only; and (4) persistent (at baseline plus at 24-h following MT) hyperglycemia.

RESULTS

AIS patients with persistent hyperglycemia have a significantly increased risk of poor functional outcome (OR 6.89, 95% CI 1.98-23.94, p = 0.002, for three-month poor outcome; OR 11.15, 95% CI 2.99-41.52, p = 0.001, for no major neurological improvement), mortality (OR 5.37, 95% CI 1.61-17.96, p = 0.006, for in-hospital mortality; OR 4.43, 95% CI 1.40-13.97, p = 0.01, for three-month mortality), and hemorrhagic transformation (OR 6.89, 95% CI 2.35-20.21, p = 0.001, for intracranial hemorrhage; OR 5.42, 95% CI 1.54-19.15, p = 0.009, for symptomatic intracranial hemorrhage) after endovascular treatment. These detrimental effects were partially confirmed after also excluding diabetic patients. The AUC-ROC showed a very good performance for predicting three-month poor outcome (0.76) in-hospital mortality (0.79) and three-month mortality (0.79).

CONCLUSIONS

Our study suggests that it is useful to perform the prolonged monitoring of glucose levels lasting 24-h after MT.