Prognostic value of admission hyperglycemia on outcomes of thrombolysis in ischemic stroke patients with or without diabetes

Performance comparison of stress hyperglycemia ratio for predicting fatal outcomes in patients with thrombolyzed acute ischemic stroke

BACKGROUND

The stress hyperglycemia ratio (SHR), a newly developed metric, is used to assess adverse outcomes in patients with acute ischemic stroke (AIS). However, the relationship between SHR and fatal outcomes (in-hospital mortality [IHM], malignant cerebral edema [MCE], symptomatic intracerebral hemorrhage [sICH], 3-month mortality, and poor functional outcome) in AIS patients receiving recombinant tissue plasminogen activator (rt-PA) treatment is unclear, and determining the optimal threshold remains incomplete.

MATERIALS AND METHODS

We retrospectively enrolled a total of 345 AIS patients treated with rt-PA during 2015-2022 and collected data on various glucose metrics, including different types of SHR, glycemic gap (GG), random plasma glucose (RPG), fasting plasma glucose (FPG), and hemoglobin A1c (HbA1c). SHR and GG were calculated using these equations: SHR1, [FPG]/[HbA1c]; SHR2, [admission RPG]/[HbA1c]; SHR3, FPG/[(1.59 × HbA1c)-2.59]; SHR4, [admission RPG]/[(1.59 × HbA1c)-2.59]; GG, admission RPG - [(1.59 × HbA1c)-2.59]. We used multivariable logistic regression analysis (MVLR) to identify the association between different glucose metrics and outcomes while comparing their predictive values.

RESULTS

SHR1 had the greatest predictive power and a more significant correlation with fatal outcomes than other continuous glucose metrics. The area under the curve of the SHR1 for IHM, MCE, and sICH, 3-month mortality, and poor functional outcome were 0.75, 0.77, 0.77, 0.76, and 0.73, respectively. SHR1 (per 1-point increases) was independently associated with IHM (Odds ratios [ORs] = 5.80; 95% CI [1.96, 17.17]; p = 0.001), MCE (ORs = 4.73; 95% CI [1.71, 13.04]; p = 0.003), sICH (ORs = 4.68, 95% CI [1.48-14.82]; p = 0.009), 3-month mortality (ORs = 10.87; 95% CI [3.56, 33.21]; p<0.001), and 3-month poor functional outcome (ORs = 8.05; 95% CI [2.77, 23.39]; p<0.001) after adjustment in MVLR. In subgroup analysis, elevated SHR1 was associated with fatal outcomes in patients with non-diabetes, SBP≥ 180 mmHg, and NIHSS <16.

CONCLUSION

SHR1 demonstrates an independent association with fatal outcomes in AIS patients treated with rt-PA, exhibiting superior predictive ability over other glucose metrics.

The impact of stress hyperglycemia ratio on short-term and long-term outcomes for acute basilar artery occlusion underwent endovascular treatment

BACKGROUND

Stress hyperglycemia ratio (SHR) reflects a true acute hyperglycemic state during acute basilar artery occlusion (ABAO). We aimed to investigate the association between SHR and short-term and long-term outcomes in patients with ABAO receiving endovascular treatment (EVT).

METHODS

We selected patients treated with EVT from the BASILAR study, a nationwide prospective registry. A total 250 patients with documented glucose and glycated hemoglobin (HbA1C) values at admission were included. SHR was calculated as the ratio of glucose/HbA1C. All 250 patients completed 90 days of follow-up and 234 patients (93.6%) completed 1 year of follow-up. The primary outcome was the favorable outcome defined as modified Rankin Scale (mRS) score ≤ 3 at 90 days. Safety outcomes included mortality at 90 days and 1 year, and intracranial hemorrhage.

RESULTS

Among the 250 patients included, patients with higher tertiles of SHR were associated with decreased odds of a favorable functional outcome at 90 days (adjusted OR, 0.26; 95% CI, 0.12-0.56; P = 0.001 and adjusted OR, 0.37; 95% CI, 0.18-0.80; P = 0.01; respectively) and 1 year (adjusted OR, 0.34; 95% CI, 0.16-0.73; P = 0.006 and adjusted OR, 0.38; 95% CI, 0.18-0.82; P = 0.01; respectively) after adjusting for confounding covariates. The mortality was comparable across tertiles of SHR groups at 90 days and 1 year.

CONCLUSIONS

Our study showed that SHR was associated with a decreased probability of favorable functional outcome both at 90 days and 1 year after EVT in patients with ABAO. The relationship was more pronounced in non-diabetes patients.

TRIAL REGISTRATION

Clinical Trial Registry Identifier: ChiCTR1800014759 (November 12, 2013).

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.

Role of diabetes in stroke: Recent advances in pathophysiology and clinical management

The increasing prevalence of diabetes and stroke is a major global public health concern. Specifically, acute stroke patients, with pre-existing diabetes, pose a clinical challenge. It is established that diabetes is associated with a worse prognosis after acute stroke and the various biological factors that mediate poor recovery profiles in diabetic patients is unknown. The level of association and impact of diabetes, in the setting of reperfusion therapy, is yet to be determined. This article presents a comprehensive overview of the current knowledge of the role of diabetes in stroke, therapeutic strategies for primary and secondary prevention of cardiovascular disease and/or stroke in diabetes, and various therapeutic considerations that may apply during pre-stroke, acute, sub-acute and post-stroke stages. The early diagnosis of diabetes as a comorbidity for stroke, as well as tailored post-stroke management of diabetes, is pivotal to our efforts to limit the burden. Increasing awareness and involvement of neurologists in the management of diabetes and other cardiovascular risk factors is desirable towards improving stroke prevention and efficacy of reperfusion therapy in acute stroke patients with diabetes.

Diabetes, Vascular Aging and Stroke: Old Dogs, New Tricks?

BACKGROUND

Stroke remains a leading cause of death and disability throughout the world. It is well established that Diabetes Mellitus (DM) is a risk factor for stroke, while other risk factors include dyslipidaemia and hypertension. Given that the global prevalence of diabetes steadily increases, the need for adequate glycaemic control and prevention of DM-related cardiovascular events remains a challenge for the medical community. Therefore, a re-examination of the latest data related to this issue is of particular importance.

OBJECTIVE

This review aims to summarise the latest data on the relationship between DM and stroke, including epidemiology, risk factors, pathogenesis, prevention and biomarkers.

METHODS

For this purpose, comprehensive research was performed on the platforms PubMed, Google Scholar and EMBASE with a combination of the following keywords: diabetes mellitus, stroke, macrovascular complications, diabetic stroke, cardiovascular disease.

CONCLUSIONS

Much progress has been made in stroke in people with DM in terms of prevention and early diagnosis. In the field of prevention, the adaptation of the daily habits and the regulation of co-morbidity of individuals play a particularly important role. Simultaneously, the most significant revolution has been brought by the relatively new treatment options that offer protection to the cardiovascular system. Moreover, many prognostic and diagnostic biomarkers have been identified, paving the way for early and accurate diagnoses. However, to date, there are crucial points that remain controversial and need further clarification.

Fasting Normoglycemia after Intravenous Thrombolysis Predicts Favorable Long-Term Outcome in Non-Diabetic Patients with Acute Ischemic Stroke

BACKGROUND

Only a few studies evaluated the role of fasting glucose levels after intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS). Importantly, formal analysis concerning the prognostic role of fasting glucose levels in these patients with and without diabetes mellitus (DM) was not performed. Therefore, we assessed whether fasting normoglycemia (FNG) next morning after AIS treated with IVT was associated with 90-day functional outcome in diabetic and non-diabetic patients.

METHODS

We retrospectively analyzed 362 AIS patients treated with IVT at The University Hospital in Krakow. FNG was defined as glucose below 5.5 mmol/L. A favorable outcome was defined as modified Rankin score (mRS) of 0-2 at day 90 after AIS onset.

RESULTS

At 3-month follow-up, FNG was associated with favorable outcome (87.5% vs. 60.8%, p < 0.001) and decreased risk of death (3.1% vs. 18.1%, p = 0.002). Independent predictors of a favorable outcome for the whole group were: younger age (HR 0.92, 95%CI 0.89-0.95), lower NIHSS score after IVT (HR 0.70, 95%CI 0.65-0.76), lower maximal systolic blood pressure within 24 h after IVT (HR 0.92, 95%CI 0.89-0.95) and FNG (HR 4.12, 95%CI 1.38-12.35). Association between FNG and mortality was found in univariable (HR 1.47, 95%CI 0.04-0.62) but not in multivariable analysis (HR 0.23, 95%CI 0.03-1.81). In subgroup analyses, FNG was an independent predictor of favorable outcome (HR 5.96, 95%CI 1.42-25.1) only in patients without DM.

CONCLUSIONS

FNG next morning after IVT is an independent protective factor for a favorable long-term outcome in non-diabetic AIS patients.