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Aziz YN, Vagal V, Mehta TV, Siegler JE, Mistry AM, Yaghi S, Khatri P, Mistry EA. Higher blood glucose is associated with the severity of hemorrhagic transformation after endovascular therapy for stroke. J Stroke Cerebrovasc Dis 2024; 33:107823. [PMID: 38880367 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 06/09/2024] [Accepted: 06/13/2024] [Indexed: 06/18/2024] Open
Abstract
OBJECTIVES Hyperglycemia is associated with poor outcome in large vessel occlusion (LVO) stroke, with mechanism for this effect unknown. MATERIALS AND METHODS We used our prospective, multicenter, observational study, Blood Pressure After Endovascular Stroke Therapy (BEST), of anterior circulation LVO stroke undergoing endovascular therapy (EVT) from 11/2017-7/2018 to determine association between increasing blood glucose (BG) and intracerebral hemorrhage (ICH). Our primary outcome was degree of ICH, classified as none, asymptomatic ICH, or symptomatic ICH (≥4-point increase in National Institutes of Health Stroke Scale [NIHSS] at 24 h with any hemorrhage on imaging). Secondary outcomes included 24 h NIHSS, early neurologic recovery (ENR, NIHSS 0-1 or NIHSS reduction by ≥8 within 24 h), and 90-day modified Rankin Scale (mRS) using univariate and multivariable regression. RESULTS Of 485 enrolled patients, increasing BG was associated with increasing severity of ICH (adjusted OR, aOR 1.06, 95 % CI 1.02-1.1, p < 0.001), higher 24 h NIHSS (aOR 1.22, 95 % CI 1.11-1.34, p < 0.001), ENR (aOR 0.90, 95 % CI 0.82-1.00, p < 0.002), and 90-day mRS (aOR 1.06, 95 % CI 1.03-1.09, p < 0.001) when adjusted for age, presenting NIHSS, ASPECTS, 24-hour peak systolic blood pressure, time from last known well, and successful recanalization. CONCLUSIONS In the BEST study, increasing BG was associated with greater odds of increasing ICH severity. Further study is warranted to determine whether treatment of will decrease ICH severity following EVT.
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Affiliation(s)
- Yasmin N Aziz
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States.
| | - Vaibhav Vagal
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States.
| | | | - James E Siegler
- Department of Neurology, University of Chicago, Chicago, IL, United States.
| | - Akshitkumar M Mistry
- Department of Neurosurgery, University of Louisville, Louisville, KY, United States.
| | - Shadi Yaghi
- Brown University, Division of Biology and Medicine, Providence, RI, United States.
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States.
| | - Eva A Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States.
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Klapproth S, Meyer L, Kniep H, Bechstein M, Kyselyova A, Hanning U, Schön G, Rimmele L, Fiehler J, Broocks G. Effect of short- versus long-term serum glucose levels on early ischemic water homeostasis and functional outcome in patients with large vessel occlusion stroke. Eur J Neurol 2024; 31:e16166. [PMID: 38015448 PMCID: PMC11235831 DOI: 10.1111/ene.16166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND PURPOSE In ischemic stroke, the impact of short- versus long-term blood glucose level (BGL) on early lesion pathophysiology and functional outcome has not been assessed. The purpose of this study was to directly compare the effect of long-term blood glucose (glycated hemoglobin [HbA1c]) versus serum BGL on early edema formation and functional outcome. METHODS Anterior circulation ischemic stroke patients who underwent mechanical thrombectomy after multimodal computed tomography (CT) on admission were analyzed. Endpoints were early ischemic cerebral edema, measured by quantitative net water uptake (NWU) on initial CT and functional independence at Day 90. RESULTS A total of 345 patients were included. Patients with functional independence had significantly lower baseline NWU (3.1% vs. 8.3%; p < 0.001) and lower BGL (113 vs. 123 mg/dL; p < 0.001) than those without functional independence, while HbA1c levels did not differ significantly (5.7% vs. 5.8%; p = 0.15). A significant association was found for NWU and BGL (ß = 0.02, 95% confidence interval [CI] 0.006-0.03; p = 0.002), but not for HbA1c and NWU (ß = -0.16, 95% CI -0.53-0.21; p = 0.39). Mediation analysis showed that 67% of the effect of BGL on functional outcome was mediated by early edema formation. CONCLUSION Aggravated early edema and worse functional outcome was associated with elevated short-term serum BGL, but not with HbA1c levels. Hence, the link between short-term BGL and early edema development might be used as a target for adjuvant therapy in patients with ischemic stroke.
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Affiliation(s)
- Susan Klapproth
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Lukas Meyer
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Helge Kniep
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Anna Kyselyova
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Uta Hanning
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Gerhard Schön
- Institute of Medical Biometry and EpidemiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Leander Rimmele
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Jens Fiehler
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
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Sun J, Lam C, Christie L, Blair C, Li X, Werdiger F, Yang Q, Bivard A, Lin L, Parsons M. Risk factors of hemorrhagic transformation in acute ischaemic stroke: A systematic review and meta-analysis. Front Neurol 2023; 14:1079205. [PMID: 36891475 PMCID: PMC9986457 DOI: 10.3389/fneur.2023.1079205] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/31/2023] [Indexed: 02/22/2023] Open
Abstract
Background Hemorrhagic transformation (HT) following reperfusion therapies for acute ischaemic stroke often predicts a poor prognosis. This systematic review and meta-analysis aims to identify risk factors for HT, and how these vary with hyperacute treatment [intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT)]. Methods Electronic databases PubMed and EMBASE were used to search relevant studies. Pooled odds ratio (OR) with 95% confidence interval (CI) were estimated. Results A total of 120 studies were included. Atrial fibrillation and NIHSS score were common predictors for any intracerebral hemorrhage (ICH) after reperfusion therapies (both IVT and EVT), while a hyperdense artery sign (OR = 2.605, 95% CI 1.212-5.599, I 2 = 0.0%) and number of thrombectomy passes (OR = 1.151, 95% CI 1.041-1.272, I 2 = 54.3%) were predictors of any ICH after IVT and EVT, respectively. Common predictors for symptomatic ICH (sICH) after reperfusion therapies were age and serum glucose level. Atrial fibrillation (OR = 3.867, 95% CI 1.970-7.591, I 2 = 29.1%), NIHSS score (OR = 1.082, 95% CI 1.060-1.105, I 2 = 54.5%) and onset-to-treatment time (OR = 1.003, 95% CI 1.001-1.005, I 2 = 0.0%) were predictors of sICH after IVT. Alberta Stroke Program Early CT score (ASPECTS) (OR = 0.686, 95% CI 0.565-0.833, I 2 =77.6%) and number of thrombectomy passes (OR = 1.374, 95% CI 1.012-1.866, I 2 = 86.4%) were predictors of sICH after EVT. Conclusion Several predictors of ICH were identified, which varied by treatment type. Studies based on larger and multi-center data sets should be prioritized to confirm the results. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=268927, identifier: CRD42021268927.
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Affiliation(s)
- Jiacheng Sun
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Christina Lam
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Lauren Christie
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,Allied Health Research Unit, St Vincent's Health Network Sydney, Sydney, NSW, Australia.,Faculty of Health Sciences, Australian Catholic University, North Sydney, NSW, Australia
| | - Christopher Blair
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.,Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, NSW, Australia
| | - Xingjuan Li
- Queensland Department of Agriculture and Fisheries, Brisbane, QLD, Australia
| | - Freda Werdiger
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Qing Yang
- Apollo Medical Imaging Technology Pty Ltd., Melbourne, VIC, Australia
| | - Andrew Bivard
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Longting Lin
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Mark Parsons
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.,Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, NSW, Australia
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Xu T, Yang J, Han Q, Wu Y, Gao X, Xu Y, Huang Y, Wang A, Parsons MW, Lin L. Net water uptake, a neuroimaging marker of early brain edema, as a predictor of symptomatic intracranial hemorrhage after acute ischemic stroke. Front Neurol 2022; 13:903263. [PMID: 35968283 PMCID: PMC9363701 DOI: 10.3389/fneur.2022.903263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/27/2022] [Indexed: 11/15/2022] Open
Abstract
Objective We hypothesized that quantitative net water uptake (NWU), a novel neuroimaging marker of early brain edema, can predict symptomatic intracranial hemorrhage (sICH) after acute ischemic stroke (AIS). Methods We enrolled patients with AIS who completed admission multimodal computed tomography (CT) within 24 h after stroke onset. NWU within the ischemic core and penumbra was calculated based on admission CT, namely NWU-core and NWU-penumbra. sICH was defined as the presence of ICH in the infarct area within 7 days after stroke onset, accompanied by clinical deterioration. The predictive value of NWU-core and NWU-penumbra on sICH was evaluated by logistic regression analyses and the receiver operating characteristic (ROC) curve. A pure neuroimaging prediction model was built considering imaging markers, which has the potential to be automatically quantified with an artificial algorithm on image workstation. Results 154 patients were included, of which 93 underwent mechanical thrombectomy (MT). The median time from symptom onset to admission CT was 262 min (interquartile range, 198–368). In patients with MT, NWU-penumbra (OR =1.442; 95% CI = 1.177–1.766; P < 0.001) and NWU-core (OR = 1.155; 95% CI = 1.027–1.299; P = 0.016) were independently associated with sICH with adjustments for age, sex, time from symptom onset to CT, hypertension, lesion volume, and admission National Institutes of Health Stroke Scale (NIHSS) score. ROC curve showed that NWU-penumbra had better predictive performance than NWU-core on sICH [area under the curve (AUC): 0.773 vs. 0.673]. The diagnostic efficiency of the predictive model was improved with the containing of NWU-penumbra (AUC: 0.853 vs. 0.760). A pure imaging model also presented stable predictive power (AUC = 0.812). In patients without MT, however, only admission NIHSS score (OR = 1.440; 95% CI = 1.055–1.965; P = 0.022) showed significance in predicting sICH in multivariate analyses. Conclusions NWU-penumbra may have better predictive performance than NWU-core on sICH after MT. A pure imaging model showed potential value to automatically screen patients with sICH risk by image recognition, which may optimize treatment strategy.
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Affiliation(s)
- Tianqi Xu
- Department of Neurology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Jianhong Yang
- Department of Neurology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Qing Han
- Department of Neurology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Yuefei Wu
- Department of Neurology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Xiang Gao
- Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Yao Xu
- Department of Neurology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Yi Huang
- Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
- Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, China
| | - Aiju Wang
- Department of Neurology, Ningbo Fourth Hospital, Ningbo, China
| | - Mark W. Parsons
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
- Department of Neurology, Liverpool Hospital, Sydney, NSW, Australia
- Mark W. Parsons
| | - Longting Lin
- Department of Neurology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
- *Correspondence: Longting Lin
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