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Wu S, Mao Y, Chen S, Pan P, Zhang H, Chen S, Liu J, Mi D. Safety and efficacy of tight versus loose glycemic control in acute stroke patients: A meta-analysis of randomized controlled trials. Int J Stroke 2024; 19:727-734. [PMID: 38472157 DOI: 10.1177/17474930241241994] [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] [Indexed: 03/14/2024]
Abstract
BACKGROUND Hyperglycemia is associated with worse stroke outcomes, but it is uncertain whether tight glycemic control during the acute stroke period is associated with a better outcome. We conducted a meta-analysis to compare the effect of tight glycemic control versus loose glycemic control in the acute phase of stroke patients. METHODS A literature search was performed to identify randomized controlled trials comparing the safety and efficacy of tight glycemic control with a relatively loose control of blood glucose of acute stroke (ischemic or hemorrhagic) patients within 24 h after stroke onset. We required that the blood glucose level of the patients should not be lower than 6.11 mmol/L at the time of enrollment, and for the intensive blood glucose control range, we defined the blood glucose level as lower than that of the control group. The primary efficacy outcome measure was deaths from any cause at 90 days. Secondary efficacy outcomes comprised the number of participants with modified Rankin score (mRS). We define mRS scores 0-2 as favorable scores, recurrent stroke, and the National Institute of Health Stroke Scale or the European Stroke Scale scores. We defined the number of participants with hypoglycemia as our primary safety outcome. Subgroup analysis was performed according to age, the variety of interventions, maintained glucose level, and status of hypoglycemia on National Institute of Health Stroke Scale (NIHSS) scores or European Stroke Scale (ESS) scores. RESULTS Fifteen randomized controlled trials (RCTs) with 2957 participants meeting the including criteria were identified and included in this meta-analysis, although not all included data on every outcome measure. Data on the primary efficacy endpoint, mortality at 90 days, was available in 11 RCTs, a total of 2575 participants. There was no significant difference between the intervention and control groups (odds ratio (OR): 1.00; 95% confidence interval (CI): 0.81-1.23; P = 0.99). For secondary endpoints, there was no difference between intervention and control groups for a mRS from 0 to 2 (OR: 0.96; 95% CI: 0.80-1.15; P = 0.69; data from 9 RCTs available), or recurrent stroke (OR: 1.34; 95% CI: 0.92-1.96; P = 0.13; data from 3 RCTs available). For NIHSS scores or ESS scores, there was a small difference in favor of intensive controls (standardized mean difference: -0.29; 95% CI: -0.54 to -0.04; P = 0.02). There was a marked increase in hypoglycemia with tight control: (OR of 9.46 (95% CI: 4.59-19.50; P < 0.00001; data from 9 RCTs available). CONCLUSION There was no difference between tight and loose glycemic control on mortality, independence, or recurrent stroke outcome in acute stroke, but an increase in hypoglycemia. There was a small effect improvement on neurological scales, but the relevance of this needs to be confirmed in future adequately powered studies.
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Affiliation(s)
- Shuangzhe Wu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuke Mao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Sijia Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peiyan Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huiying Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Siqi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jue Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Donghua Mi
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Pan H, Xiong Y, Huang Y, Zhao J, Wan H. Association between stress hyperglycemia ratio with short-term and long-term mortality in critically ill patients with ischemic stroke. Acta Diabetol 2024; 61:859-868. [PMID: 38499778 DOI: 10.1007/s00592-024-02259-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 02/11/2024] [Indexed: 03/20/2024]
Abstract
AIMS Hyperglycemia on admission is associated with poor prognosis in ischemic stroke (IS) patients. We aimed to investigate the relationship between stress hyperglycemia ratio (SHR) and short-term or long-term mortality in IS patients in the ICU and to explore whether this relationship is influenced by diabetes status. MATERIALS AND METHODS We collected patients with severe IS requiring ICU admission in the Medical Information Mart for Intensive Care (MIMIC-IV) database and calculated SHR. Outcomes included 30-day, 90-day, and 1-year mortality. The association between SHR and mortality in patients with critical IS was elucidated using Multivariate Cox regression and subgroup analysis for diabetes. RESULTS A total of 1376 patients were recruited. After adjusting for potential confounders, patients in the third and fourth quartiles had a significantly increased risk of death at 30 days, 90 days, and 1 year compared to the first quartile of SHR (Q3 vs. Q1: HR 1.56-1.80, all p < 0.02; Q4 vs. Q1: HR 1.75-2.15, all p < 0.001; all p for trend < 0.001). In addition, the highest quartile of SHR was significantly associated with short-term or long-term mortality compared with the first quartile, regardless of diabetes status. CONCLUSIONS Our results suggest that stress hyperglycemia, defined by the glucose/HbA1c ratio, is associated with increased short-term and long-term mortality in patients with ischemic stroke, independent of the patient's diabetes status.
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Affiliation(s)
- Haowei Pan
- Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yiqun Xiong
- Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yanming Huang
- Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
- Department of Anesthesiology, Hangzhou Red Cross Hospital, 208 East Huancheng Road, Hangzhou, 310003, China
| | - Jie Zhao
- Department of Anesthesiology, Hangzhou Red Cross Hospital, 208 East Huancheng Road, Hangzhou, 310003, China
| | - Haifang Wan
- Department of Anesthesiology, Hangzhou Red Cross Hospital, 208 East Huancheng Road, Hangzhou, 310003, China.
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Bladin CF, Wah Cheung N, Dewey HM, Churilov L, Middleton S, Thijs V, Ekinci E, Levi CR, Lindley R, Donnan GA, Parsons MW, Meretoja A, Tiainen M, Choi PM, Cordato D, Brown H, Campbell BC, Davis SM, Cloud G, Grimley R, Lee-Archer M, Ghia D, Sanders L, Markus R, Muller C, Salvaris P, Wu T, Fink J. Management of Poststroke Hyperglycemia: Results of the TEXAIS Randomized Clinical Trial. Stroke 2023; 54:2962-2971. [PMID: 38011235 PMCID: PMC10664794 DOI: 10.1161/strokeaha.123.044568] [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] [Indexed: 11/29/2023]
Abstract
BACKGROUND Hyperglycemia in acute ischemic stroke reduces the efficacy of stroke thrombolysis and thrombectomy, with worse clinical outcomes. Insulin-based therapies are difficult to implement and may cause hypoglycemia. We investigated whether exenatide, a GLP-1 (glucagon-like peptide-1) receptor agonist, would improve stroke outcomes, and control poststroke hyperglycemia with minimal hypoglycemia. METHODS The TEXAIS trial (Treatment With Exenatide in Acute Ischemic Stroke) was an international, multicenter, phase 2 prospective randomized clinical trial (PROBE [Prospective Randomized Open Blinded End-Point] design) enrolling adult patients with acute ischemic stroke ≤9 hours of stroke onset to receive exenatide (5 µg BID subcutaneous injection) or standard care for 5 days, or until hospital discharge (whichever sooner). The primary outcome (intention to treat) was the proportion of patients with ≥8-point improvement in National Institutes of Health Stroke Scale score (or National Institutes of Health Stroke Scale scores 0-1) at 7 days poststroke. Safety outcomes included death, episodes of hyperglycemia, hypoglycemia, and adverse event. RESULTS From April 2016 to June 2021, 350 patients were randomized (exenatide, n=177, standard care, n=173). Median age, 71 years (interquartile range, 62-79), median National Institutes of Health Stroke Scale score, 4 (interquartile range, 2-8). Planned recruitment (n=528) was stopped early due to COVID-19 disruptions and funding constraints. The primary outcome was achieved in 97 of 171 (56.7%) in the standard care group versus 104 of 170 (61.2%) in the exenatide group (adjusted odds ratio, 1.22 [95% CI, 0.79-1.88]; P=0.38). No differences in secondary outcomes were observed. The per-patient mean daily frequency of hyperglycemia was significantly less in the exenatide group across all quartiles. No episodes of hypoglycemia were recorded over the treatment period. Adverse events of mild nausea and vomiting occurred in 6 (3.5%) exenatide patients versus 0 (0%) standard care with no withdrawal. CONCLUSIONS Treatment with exenatide did not reduce neurological impairment at 7 days in patients with acute ischemic stroke. Exenatide did significantly reduce the frequency of hyperglycemic events, without hypoglycemia, and was safe to use. Larger acute stroke trials using GLP-1 agonists such as exenatide should be considered. REGISTRATION URL: www.australianclinicaltrials.gov.au; Unique identifier: ACTRN12617000409370. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03287076.
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Affiliation(s)
- Christopher F. Bladin
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Department of Neurology, Monash University, Clayton, Victoria, Australia (C.F.B., H.M.D., P.M.C.C.)
- The Florey Institute of Neuroscience and Mental Health (C.F.B., V.T., B.C.V.C.), University of Melbourne, Parkville, Australia
| | - Ngai Wah Cheung
- Faculty of Medicine and Health, Westmead Hospital (N.W.C.), University of Sydney, New South Wales, Australia
| | - Helen M. Dewey
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Department of Neurology, Monash University, Clayton, Victoria, Australia (C.F.B., H.M.D., P.M.C.C.)
| | - Leonid Churilov
- Department of Medicine (L.C.), University of Melbourne, Parkville, Australia
- Australian Centre for Accelerating Diabetes Innovations (L.C., E.E.), University of Melbourne, Parkville, Australia
- Austin Health, Australia (L.C., E.E.)
| | - Sandy Middleton
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne and School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia (S.M.)
| | - Vincent Thijs
- The Florey Institute of Neuroscience and Mental Health (C.F.B., V.T., B.C.V.C.), University of Melbourne, Parkville, Australia
| | - Elif Ekinci
- Australian Centre for Accelerating Diabetes Innovations (L.C., E.E.), University of Melbourne, Parkville, Australia
- Austin Health, Australia (L.C., E.E.)
| | - Christopher R. Levi
- Department of Neurology, Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, Australia (C.R.L.)
| | - Richard Lindley
- Faculty of Medicine and Health, Sydney Medical School (R.L.), University of Sydney, New South Wales, Australia
- George Institute for Global Health, Sydney, Australia (R.L.)
| | - Geoffrey A. Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital (G.A.D., B.C.V.C., S.M.D), University of Melbourne, Parkville, Australia
| | - Mark W. Parsons
- Department of Neurology, Ingham Institute for Applied Medical Research, Liverpool Hospital, University of New South Wales, Sydney, Australia (M.W.P., D.C.)
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Finland (A.M., M.T.)
| | - Marjaana Tiainen
- Department of Neurology, Helsinki University Hospital, Finland (A.M., M.T.)
| | - Philip M.C. Choi
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Department of Neurology, Monash University, Clayton, Victoria, Australia (C.F.B., H.M.D., P.M.C.C.)
| | - Dennis Cordato
- Department of Neurology, Ingham Institute for Applied Medical Research, Liverpool Hospital, University of New South Wales, Sydney, Australia (M.W.P., D.C.)
| | - Helen Brown
- Princess Alexandra Hospital, Brisbane, Queensland, Australia (H.B.)
| | - Bruce C.V. Campbell
- The Florey Institute of Neuroscience and Mental Health (C.F.B., V.T., B.C.V.C.), University of Melbourne, Parkville, Australia
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital (G.A.D., B.C.V.C., S.M.D), University of Melbourne, Parkville, Australia
| | - Stephen M. Davis
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital (G.A.D., B.C.V.C., S.M.D), University of Melbourne, Parkville, Australia
| | - Geoffrey Cloud
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Department of Neurology, Monash University, Clayton, Victoria, Australia (C.F.B., H.M.D., P.M.C.C.)
- Department of Medicine (L.C.), University of Melbourne, Parkville, Australia
- The Florey Institute of Neuroscience and Mental Health (C.F.B., V.T., B.C.V.C.), University of Melbourne, Parkville, Australia
- Australian Centre for Accelerating Diabetes Innovations (L.C., E.E.), University of Melbourne, Parkville, Australia
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital (G.A.D., B.C.V.C., S.M.D), University of Melbourne, Parkville, Australia
- Faculty of Medicine and Health, Westmead Hospital (N.W.C.), University of Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Sydney Medical School (R.L.), University of Sydney, New South Wales, Australia
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne and School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia (S.M.)
- Austin Health, Australia (L.C., E.E.)
- Department of Neurology, Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, Australia (C.R.L.)
- George Institute for Global Health, Sydney, Australia (R.L.)
- Department of Neurology, Ingham Institute for Applied Medical Research, Liverpool Hospital, University of New South Wales, Sydney, Australia (M.W.P., D.C.)
- Department of Neurology, Helsinki University Hospital, Finland (A.M., M.T.)
- Princess Alexandra Hospital, Brisbane, Queensland, Australia (H.B.)
- Department of Neurology, Fiona Stanley Hospital, Perth, Western Australia, Australia (D.G.)
- Department of Medicine, St John of God Midland Public and Private Hospitals, Perth, Western Australia (P.S.)
- Department of Neurology, Launceston General Hospital, Tasmania, Australia (M.L.-A.)
- Department of Neurology, Christchurch Hospital, New Zealand (T.W., J.F.)
- Department of Neurosciences, St Vincent’s Hospital, Melbourne, Australia (L.S.)
- Department of Neurology, St Vincent’s Hospital, Sydney, Australia (R.M.)
- School of Medicine and Dentistry, Griffith University, Birtinya, Queensland, Australia (R.G.)
- Department of Neurology, Royal Brisbane and Women’s Hospital, University of Queensland, Brisbane, Australia (C.M.)
| | - Rohan Grimley
- School of Medicine and Dentistry, Griffith University, Birtinya, Queensland, Australia (R.G.)
| | - Matthew Lee-Archer
- Department of Neurology, Launceston General Hospital, Tasmania, Australia (M.L.-A.)
| | - Darshan Ghia
- Department of Neurology, Fiona Stanley Hospital, Perth, Western Australia, Australia (D.G.)
| | - Lauren Sanders
- Department of Neurosciences, St Vincent’s Hospital, Melbourne, Australia (L.S.)
| | - Romesh Markus
- Department of Neurology, St Vincent’s Hospital, Sydney, Australia (R.M.)
| | - Claire Muller
- Department of Neurology, Royal Brisbane and Women’s Hospital, University of Queensland, Brisbane, Australia (C.M.)
| | - Patrick Salvaris
- Department of Medicine, St John of God Midland Public and Private Hospitals, Perth, Western Australia (P.S.)
| | - Teddy Wu
- Department of Neurology, Christchurch Hospital, New Zealand (T.W., J.F.)
| | - John Fink
- Department of Neurology, Christchurch Hospital, New Zealand (T.W., J.F.)
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Mannismäki L, Martinez-Majander N, Sibolt G, Suomalainen OP, Bäcklund K, Abou Elseoud A, Järveläinen J, Forss N, Curtze S. Association of admission plasma glucose level and cerebral computed tomographic perfusion deficit volumes. J Neurol Sci 2023; 451:120722. [PMID: 37393736 DOI: 10.1016/j.jns.2023.120722] [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: 04/12/2023] [Revised: 06/19/2023] [Accepted: 06/24/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION Hyperglycemia in acute ischemic stroke (AIS) is frequent and associated with worse outcome. Yet, strict glycemic control in AIS patients has failed to yield beneficial outcome. So far, the underlying pathophysiological mechanisms of admission hyperglycemia in AIS have remained not fully understood. We aimed to evaluate the yet equivocal association of hyperglycemia with computed tomographic perfusion (CTP) deficit volumes. PATIENTS AND METHODS We included 832 consecutive AIS and transient ischemic attack (TIA) patients who underwent CTP as a part of screening for recanalization treatment (stroke code) between 3/2018 and 10/2020, from the prospective cohort of Helsinki Stroke Quality Registry. Associations of admission glucose level (AGL) and CTP deficit volumes, namely ischemic core, defined as relative cerebral blood flow <30%, and hypoperfusion lesions Time-to-maximum (Tmax) >6 s and Tmax >10s, as determined with RAPID® software, were analyzed with a linear regression model adjusted for age, sex, C-reactive protein, and time from symptom onset to imaging. RESULTS AGL median was 6.8 mmol/L (interquartile range 5.9-8.0 mmol/L), and 222 (27%) patients were hyperglycemic (glucose >7.8 mmol/L) on admission. In non-diabetic patients (643 [77%]), AGL was significantly associated with volume of Tmax. >6 s (regression coefficient [RC] 4.8, 95% confidence interval [CI] 0.49-9.1), of Tmax >10s (RC 4.6, 95% CI 1.2-8.1), and of ischemic core (RC 2.6, 95% CI 0.64-4.6). No significant associations were shown in diabetic patients. CONCLUSION Admission hyperglycemia appears to be associated with both larger volume of hypoperfusion lesions and of ischemic core in non-diabetic stroke code patients with AIS and TIA.
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Affiliation(s)
- Laura Mannismäki
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland.
| | - Nicolas Martinez-Majander
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Gerli Sibolt
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Olli P Suomalainen
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Katariina Bäcklund
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Ahmed Abou Elseoud
- Helsinki Medical Imaging Centre, Helsinki University Hospital, Helsinki, Finland
| | - Juha Järveläinen
- Helsinki Medical Imaging Centre, Helsinki University Hospital, Helsinki, Finland
| | - Nina Forss
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland; Department of Neuroscience and Biomedical Engineering, Aalto University, Espoo, Finland
| | - Sami Curtze
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
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Christou MA, Christou PA, Kyriakopoulos C, Christou GA, Tigas S. Effects of Hypoglycemia on Cardiovascular Function in Patients with Diabetes. Int J Mol Sci 2023; 24:ijms24119357. [PMID: 37298308 DOI: 10.3390/ijms24119357] [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: 04/25/2023] [Revised: 05/21/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
Hypoglycemia is common in patients with type 1 and type 2 diabetes (T1D, T2D), treated with insulin or sulfonylureas, and has multiple short- and long-term clinical implications. Whether acute or recurrent, hypoglycemia significantly affects the cardiovascular system with the potential to cause cardiovascular dysfunction. Several pathophysiological mechanisms have been proposed linking hypoglycemia to increased cardiovascular risk, including hemodynamic changes, myocardial ischemia, abnormal cardiac repolarization, cardiac arrhythmias, prothrombotic and proinflammatory effects, and induction of oxidative stress. Hypoglycemia-induced changes can promote the development of endothelial dysfunction, which is an early marker of atherosclerosis. Although data from clinical trials and real-world studies suggest an association between hypoglycemia and cardiovascular events in patients with diabetes, it remains uncertain whether this association is causal. New therapeutic agents for patients with T2D do not cause hypoglycemia and have cardioprotective benefits, whereas increasing the use of new technologies, such as continuous glucose monitoring devices and insulin pumps, has the potential to reduce hypoglycemia and its adverse cardiovascular outcomes in patients with T1D.
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Affiliation(s)
- Maria A Christou
- Department of Endocrinology, University of Ioannina Faculty of Medicine, 45500 Ioannina, Greece
| | - Panagiota A Christou
- Department of Endocrinology, University of Ioannina Faculty of Medicine, 45500 Ioannina, Greece
| | - Christos Kyriakopoulos
- Department of Respiratory Medicine, University of Ioannina Faculty of Medicine, 45500 Ioannina, Greece
| | - Georgios A Christou
- Laboratory of Physiology, University of Ioannina Faculty of Medicine, 45500 Ioannina, Greece
| | - Stelios Tigas
- Department of Endocrinology, University of Ioannina Faculty of Medicine, 45500 Ioannina, Greece
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Landman TRJ, Schoon Y, Warlé MC, Meijer FJA, Leeuw FED, Thijssen DHJ. The effect of repeated remote ischemic postconditioning after an ischemic stroke (REPOST): A randomized controlled trial. Int J Stroke 2023; 18:296-303. [PMID: 35593677 PMCID: PMC9941800 DOI: 10.1177/17474930221104710] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS A potential strategy to treat ischemic stroke may be the application of repeated remote ischemic postconditioning (rIPostC). This consists of several cycles of brief periods of limb ischemia followed by reperfusion, which can be applied by inflating a simple blood pressure cuff and subsequently could result in neuroprotection after stroke. METHODS Adult patients admitted with an ischemic stroke in the past 24 h were randomized 1:1 to repeated rIPostC or sham-conditioning. Repeated rIPostC was performed by inflating a blood pressure cuff around the upper arm (4 × 5 min at 200 mm Hg), which was repeated twice daily during hospitalization with a maximum of 4 days. Primary outcome was infarct size after 4 days or at discharge. Secondary outcomes included the modified Rankin Scale (mRS)-score after 12 weeks and the National Institutes of Health Stroke Scale (NIHSS) at discharge. RESULTS The trial was preliminarily stopped after we included 88 of the scheduled 180 patients (average age: 70 years, 68% male) into rIPostC (n = 40) and sham-conditioning (n = 48). Median infarct volume was 2.19 mL in rIPostC group and 5.90 mL in sham-conditioning, which was not significantly different between the two groups (median difference: 3.71; 95% CI: -0.56 to 6.09; p = 0.31). We found no significant shift in the mRS score distribution between groups. The adjusted common odds ratio was 2.09 (95% CI: 0.88-5.00). We found no significant difference in the NIHSS score between groups (median difference: 1.00; 95% CI: -0.99 to 1.40; p = 0.51). CONCLUSION This study found no significant improvement in infarct size or clinical outcome in patients with an acute ischemic stroke who were treated with repeated remote ischemic postconditioning. However, due to a lower-than-expected inclusion rate, no definitive conclusions about the effectiveness of rIPostC can be drawn.
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Affiliation(s)
- Thijs RJ Landman
- Department of Physiology, Radboud
Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The
Netherlands,Thijs RJ Landman, Department of Physiology,
Radboud Institute for Health Sciences, Radboud University Medical Center, Geert
Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands.
| | - Yvonne Schoon
- Department of Geriatric Medicine,
Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen,
The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - Frederick JA Meijer
- Department of Medical Imaging, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - Frank-Erik De Leeuw
- Donders Center for Medical
Neuroscience, Department of Neurology, Radboud University Medical Center, Nijmegen,
The Netherlands
| | - Dick HJ Thijssen
- Department of Physiology, Radboud
Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The
Netherlands
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Kersten CJBA, Zandbergen AAM, Fokkert MJ, Slingerland RJ, den Hertog HM. Continuous glucose monitoring in acute ischemic stroke patients treated with endovascular therapy: A pilot study to assess feasibility and accuracy. PLoS One 2023; 18:e0280153. [PMID: 36758045 PMCID: PMC9910721 DOI: 10.1371/journal.pone.0280153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/18/2022] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION Hyperglycemia is common in acute ischemic stroke and is associated with larger infarct volume and unfavorable functional outcome, also in patients who undergo reperfusion therapy. Hyperglycemia during reperfusion may be a therapeutic target. However, previous randomized trials on the effect of glucose lowering in the acute phase of ischemic stroke failed to demonstrate effects on clinical outcome. Inaccurate glucose measurements and not focussing on patients who undergo reperfusion therapy are possible explanations. Our aim was to study the feasibility and accuracy of continuous glucose monitoring (CGM) in patients with acute ischemic stroke undergoing endovascular treatment (EVT). METHODS All consecutive patients with ischemic stroke and large vessel occlusion (LVO) of the anterior circulation who were eligible for endovascular therapy within 24 hours of symptom onset and presenting at the emergency department of Isala Hospital Zwolle, the Netherlands, were enrolled in this study. CGM was performed using a Freestyle Libre Flash 2 device (FSL-CGM, Abbot Diabetes Care, Alameda, California, USA) which was implanted on arrival at the emergency department. Feasibility was defined as the number of patients who could be registered for 24 hours and delay in door-to-groin time because of sensor implantation. Accuracy of CGM versus capillary and venous based plasma glucose values was determined with the Parkes error grid analysis. RESULTS Twenty-three patients were included of whom 20 completed 24 hours monitoring (87%). One patient did not give permission to use the data; one sensor broke during implantation and one meter was broken after a sensor was shot in so no measurements could be recorded. There was no significant delay in treatment due to implantation of the sensor and no adverse events. One hundred percent of CGM data are in zones A and B of the Parkes error grid analysis so data out of the sensor can be interpreted as accurate. CONCLUSION In this study, we showed that continuous glucose monitoring in patients with acute ischemic stroke due to large vessel occlusion of the anterior circulation in patients who were treated with endovascular therapy is feasible, safe and accurate.
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Affiliation(s)
- C. J. B. A. Kersten
- Department of Neurology, Medisch Spectrum Twente, Enschede, The Netherlands
- * E-mail:
| | - A. A. M. Zandbergen
- Department of Internal Medicine, Erasmus Medisch Centrum, Rotterdam, The Netherlands
| | - M. J. Fokkert
- Department of Clinical Chemistry, Isala, Zwolle, The Netherlands
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Moulton E, Valabregue R, Piotin M, Marnat G, Saleme S, Lapergue B, Lehericy S, Clarencon F, Rosso C. Interpretable deep learning for the prognosis of long-term functional outcome post-stroke using acute diffusion weighted imaging. J Cereb Blood Flow Metab 2023; 43:198-209. [PMID: 36169033 PMCID: PMC9903217 DOI: 10.1177/0271678x221129230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 08/19/2022] [Accepted: 09/04/2022] [Indexed: 01/24/2023]
Abstract
Advances in deep learning can be applied to acute stroke imaging to build powerful and explainable prediction models that could supersede traditionally used biomarkers. We aimed to evaluate the performance and interpretability of a deep learning model based on convolutional neural networks (CNN) in predicting long-term functional outcome with diffusion-weighted imaging (DWI) acquired at day 1 post-stroke. Ischemic stroke patients (n = 322) were included from the ASTER and INSULINFARCT trials as well as the Pitié-Salpêtrière registry. We trained a CNN to predict long-term functional outcome assessed at 3 months with the modified Rankin Scale (dichotomized as good [mRS ≤ 2] vs. poor [mRS ≥ 3]) and compared its performance to two logistic regression models using lesion volume and ASPECTS. The CNN contained an attention mechanism, which allowed to visualize the areas of the brain that drove prediction. The deep learning model yielded a significantly higher area under the curve (0.83 95%CI [0.78-0.87]) than lesion volume (0.78 [0.73-0.83]) and ASPECTS (0.77 [0.71-0.83]) (p < 0.05). Setting all classifiers to the specificity as the deep learning model (i.e., 0.87 [0.82-0.92]), the CNN yielded a significantly higher sensitivity (0.67 [0.59-0.73]) than lesion volume (0.48 [0.40-0.56]) and ASPECTS (0.50 [0.41-0.58]) (p = 0.002). The attention mechanism revealed that the network learned to naturally attend to the lesion to predict outcome.
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Affiliation(s)
- Eric Moulton
- Institut du Cerveau et de la Moelle épinière, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France
| | - Romain Valabregue
- Institut du Cerveau et de la Moelle épinière, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France
- Centre de Neuro-Imagerie de Recherche, CENIR, ICM, Paris, France
| | - Michel Piotin
- Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Suzana Saleme
- Diagnostic and Interventional Neuroradiology, University Hospital of Limoges, Limoges, France
| | - Bertrand Lapergue
- Department of Stroke Center and Diagnostic and Interventional Neuroradiology, University of Versailles and Saint Quentin en Yvelines, Foch Hospital, Suresnes, France
| | - Stephane Lehericy
- Institut du Cerveau et de la Moelle épinière, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France
- Centre de Neuro-Imagerie de Recherche, CENIR, ICM, Paris, France
- AP-HP Service de Neuroradiologie diagnostique, Hôpital Pitié-Salpêtrière, Paris, France
| | - Frederic Clarencon
- Institut du Cerveau et de la Moelle épinière, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France
- AP-HP Service de Neuroradiologie interventionelle Hôpital Pitié-Salpêtrière, Paris, France
- ICM iCRIN team: STAR (Stroke Therapy And Registries)
| | - Charlotte Rosso
- Institut du Cerveau et de la Moelle épinière, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France
- ICM iCRIN team: STAR (Stroke Therapy And Registries)
- AP-HP, Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
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9
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Yao M, Hao Y, Wang T, Xie M, Li H, Feng J, Feng L, Ma D. A review of stress-induced hyperglycaemia in the context of acute ischaemic stroke: Definition, underlying mechanisms, and the status of insulin therapy. Front Neurol 2023; 14:1149671. [PMID: 37025208 PMCID: PMC10070880 DOI: 10.3389/fneur.2023.1149671] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 02/21/2023] [Indexed: 04/08/2023] Open
Abstract
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.
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Affiliation(s)
- Mengyue Yao
- Department of Neurology and Neuroscience Centre, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yulei Hao
- Department of Neurology and Neuroscience Centre, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Tian Wang
- Department of Neurology and Neuroscience Centre, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Meizhen Xie
- Department of Neurology and Neuroscience Centre, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Hui Li
- Department of Neurology and Neuroscience Centre, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jiachun Feng
- Department of Neurology and Neuroscience Centre, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Liangshu Feng
- Stroke Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China
- Liangshu Feng
| | - Di Ma
- Department of Neurology and Neuroscience Centre, The First Hospital of Jilin University, Changchun, Jilin, China
- *Correspondence: Di Ma
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10
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Peters A, Sprengell M, Kubera B. The principle of 'brain energy on demand' and its predictive power for stress, sleep, stroke, obesity and diabetes. Neurosci Biobehav Rev 2022; 141:104847. [PMID: 36067964 DOI: 10.1016/j.neubiorev.2022.104847] [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: 01/08/2022] [Revised: 08/10/2022] [Accepted: 08/26/2022] [Indexed: 12/01/2022]
Abstract
Does the brain actively draw energy from the body when needed? There are different schools of thought regarding energy metabolism. In this study, the various theoretical models are classified into one of two categories: (1) conceptualizations of the brain as being purely passively supplied, which we call 'P-models,' and (2) models understanding the brain as not only passively receiving energy but also actively procuring energy for itself on demand, which we call 'A-models.' One prominent example of such theories making use of an A-model is the selfish-brain theory. The ability to make predictions was compared between the A- and P-models. A-models were able to predict and coherently explain all data examined, which included stress, sleep, caloric restriction, stroke, type-1-diabetes mellitus, obesity, and type-2-diabetes, whereas the predictions of P-models failed in most cases. The strength of the evidence supporting A-models is based on the coherence of accurate predictions across a spectrum of metabolic states. The theory test conducted here speaks to a brain that pulls its energy from the body on-demand.
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Affiliation(s)
- Achim Peters
- Medical Clinic 1, Center of Brain, Behavior and Metabolism, University of Lübeck, Ratzeburger Allee 160, D-23538 Lübeck, Germany.
| | - Marie Sprengell
- Medical Clinic 1, Center of Brain, Behavior and Metabolism, University of Lübeck, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - Britta Kubera
- Medical Clinic 1, Center of Brain, Behavior and Metabolism, University of Lübeck, Ratzeburger Allee 160, D-23538 Lübeck, Germany
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11
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Muscari A, Falcone R, Recinella G, Faccioli L, Forti P, Pastore Trossello M, Puddu GM, Spinardi L, Zoli M. Prognostic significance of diabetes and stress hyperglycemia in acute stroke patients. Diabetol Metab Syndr 2022; 14:126. [PMID: 36038896 PMCID: PMC9422130 DOI: 10.1186/s13098-022-00896-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/17/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Hyperglycemic non-diabetic stroke patients have a worse prognosis than both normoglycemic and diabetic patients. Aim of this study was to assess whether hyperglycemia is an aggravating factor or just an epiphenomenon of most severe strokes. METHODS In this retrospective study, 1219 ischemic or hemorrhagic stroke patients (73.7 ± 13.1 years) were divided into 4 groups: 0 = non-hyperglycemic non-diabetic, 1 = hyperglycemic non-diabetic, 2 = non-hyperglycemic diabetic and 3 = hyperglycemic diabetic. Hyperglycemia was defined as fasting blood glucose ≥ 126 mg/dl (≥ 7 mmol/l) measured the morning after admission, while the diagnosis of diabetes was based on a history of diabetes mellitus or on a glycated hemoglobin ≥ 6.5% (≥ 48 mmol/mol), independently of blood glucose levels. All diabetic patients, except 3, had Type 2 diabetes. The 4 groups were compared according to clinical history, stroke severity indicators, acute phase markers and main short term stroke outcomes (modified Rankin scale ≥ 3, death, cerebral edema, hemorrhagic transformation of ischemic lesions, fever, oxygen administration, pneumonia, sepsis, urinary infection and heart failure). RESULTS Group 1 patients had more severe strokes, with larger cerebral lesions and higher inflammatory markers, compared to the other groups. They also had a high prevalence of atrial fibrillation, prediabetes, previous stroke and previous arterial revascularizations. In this group, the highest frequencies of cerebral edema, hemorrhagic transformation, pneumonia and oxygen administration were obtained. The prevalence of dependency at discharge and in-hospital mortality were equally high in Group 1 and Group 3. However, in multivariate analyses including stroke severity, cerebral lesion diameter, leukocytes and C-reactive protein, Group 1 was only independently associated with hemorrhagic transformation (OR 2.01, 95% CI 0.99-4.07), while Group 3 was independently associated with mortality (OR 2.19, 95% CI 1.32-3.64) and disability (OR 1.70, 95% CI 1.01-2.88). CONCLUSIONS Hyperglycemic non-diabetic stroke patients had a worse prognosis than non-hyperglycemic or diabetic patients, but this group was not independently associated with mortality or disability when size, severity and inflammatory component of the stroke were accounted for.
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Affiliation(s)
- Antonio Muscari
- Stroke Unit, Medical Department of Continuity of Care and Disability, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138, Bologna, Italy.
| | - Roberta Falcone
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138, Bologna, Italy
| | - Guerino Recinella
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138, Bologna, Italy
| | - Luca Faccioli
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paola Forti
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138, Bologna, Italy
| | - Marco Pastore Trossello
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giovanni M Puddu
- Stroke Unit, Medical Department of Continuity of Care and Disability, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Spinardi
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Zoli
- Stroke Unit, Medical Department of Continuity of Care and Disability, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138, Bologna, Italy
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12
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Kersten CJBA, Zandbergen AAM, Berkhemer OA, Borst J, Haalboom M, Roos YBWEM, Dippel DWJ, van Oostenbrugge RJ, van der Lugt A, van Zwam WH, Majoie CB, den Hertog HM. Association of hyperglycemia and computed tomographic perfusion deficits in patients who underwent endovascular treatment for acute ischemic stroke caused by a proximal intracranial occlusion: A subgroup analysis of a randomized phase 3 trial (MR CLEAN). J Neurol Sci 2022; 440:120333. [PMID: 35834861 DOI: 10.1016/j.jns.2022.120333] [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: 01/29/2022] [Revised: 06/23/2022] [Accepted: 06/27/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Hyperglycemia is highly prevalent in patients with acute ischemic stroke and is associated with increased risk of symptomatic intracranial hemorrhage, larger infarct size and unfavorable outcome. Furthermore, glucose may modify the effect of endovascular treatment (EVT) in patients with ischemic stroke. Hyperglycemia might lead to accelerated conversion of penumbra into infarct core. However, it remains uncertain whether hyperglycemia on admission is associated with the size of penumbra or infarct core in acute ischemic stroke. In this study, we aimed to assess the association between hyperglycemia and Computed Tomographic Perfusion (CTP) derived parameters in patients who underwent EVT for acute ischemic stroke. METHODS We used data from the MR CLEAN study (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands). Hyperglycemia was defined as admission serum glucose of >7.8 mmol/L. Dichotomized and quantiles of glucose levels were related to size of core, penumbra and core penumbra ratio. Hypoperfused area is mean transient time 45% higher than that of the contralateral hemisphere. Core is the area with cerebral blood volume of <2 mL/100 g and penumbra is the area with cerebral blood volume > 2 mL/100 g. Core-penumbra ratio is the ischemic core divided by the total volume of hypoperfused tissue (core plus penumbra) multiplied by 100. Adjustments were made for age, sex, NIHSS on admission, onset-imaging time and diabetes mellitus. RESULTS Hundred seventy-three patients were included. Median glucose level on admission was 6.5 mmol/L (IQR 5.8-7.5 mmol/L) and thirty-five patients (20%) were hyperglycemic. Median core volume was 33.3 mL (IQR 13.6-62.4 mL), median penumbra volume was 80.2 mL (IQR 36.3-123.5 mL) and median core-penumbra ratio was 28.5% (IQR 18.6-45.8%). Patients with hyperglycemia on admission had larger core volumes and core penumbra ratio than normoglycemic patients with a regression coefficient of 15.1 (95% confidence interval (CI), 1.8 to 28.3) and 11.5 (95% confidence interval (CI), 3.4 to 19.7) respectively. CONCLUSION Hyperglycemia on admission was associated with larger ischemic core volume and larger core-penumbra ratio in patients with acute ischemic stroke who underwent endovascular treatment.
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Affiliation(s)
- C J B A Kersten
- Department of Neurology, Medisch Spectrum Twente, Enschede, the Netherlands.
| | - A A M Zandbergen
- Department of Internal Medicine, Erasmus Medisch Centrum, Rotterdam, the Netherlands
| | - O A Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - J Borst
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - M Haalboom
- Medical School Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Y B W E M Roos
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - D W J Dippel
- Department of Neurology, Erasmus Medisch Centrum, Rotterdam, the Netherlands
| | - R J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - A van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus Medisch Centrum, Rotterdam, the Netherlands
| | - W H van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - C B Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
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13
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Dhamanaskar R, Feldman WB, Merz JF. Practicalities of Impracticability: An Interim Review of Randomized Controlled Trials. J Empir Res Hum Res Ethics 2022; 17:329-345. [PMID: 35440213 DOI: 10.1177/15562646221092663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Impracticability is an ethical standard for waiver of informed consent in research. We examine how well the criterion of impracticability appears to have been fulfilled in a set of 36 completed randomized controlled trials (RCTs) that secured consent from some subjects or LARs and employed waivers to enroll others. These trials were identified among 155 RCTs using waivers of consent in a convenience sample drawn from 7 systematic reviews. Recruitment data were available for 19 of the 36 trials, revealing an average of 41.6% of subjects (range 0.2-98.7%, 95% CI: 24.8-58.4%) were enrolled without consent. Six trials enrolled less than 10% of subjects without consent and an overlapping set of 9 trials sought consent from all subjects or LARs at some sites while waiving consent at other sites. We question whether these trials were practicable without waivers and identify issues for consideration by investigators and ethics review boards.
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Affiliation(s)
- Roma Dhamanaskar
- Department of Health Research Methods, Evidence and Impact, 152969McMaster University Medical Centre, 1280 Main Street West, 2C Area, Hamilton, Ontario, Canada L8S 4K1
| | - William B Feldman
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, 1861Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120, USA
| | - Jon F Merz
- Department of Medical Ethics & Health Policy, 14640Perelman School of Medicine at the University of Pennsylvania, Blockley Hall Floor 14, 423 Guardian Drive, Philadelphia, Pennsylvania 19104-4884, USA
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14
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Baudu J, Gerbaud E, Catargi B, Montaudon M, Beauvieux MC, Sagnier S, Debruxelles S, Renou P, Poli M, Olindo S, Couture M, Marnat G, Sibon I. High glycemic variability: An underestimated determinant of stroke functional outcome following large vessel occlusion. Rev Neurol (Paris) 2022; 178:732-740. [DOI: 10.1016/j.neurol.2021.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 12/19/2022]
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15
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Ferrari F, Moretti A, Villa RF. Hyperglycemia in acute ischemic stroke: physiopathological and therapeutic complexity. Neural Regen Res 2022; 17:292-299. [PMID: 34269190 PMCID: PMC8463990 DOI: 10.4103/1673-5374.317959] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/31/2020] [Accepted: 02/26/2021] [Indexed: 11/17/2022] Open
Abstract
Diabetes mellitus and associated chronic hyperglycemia enhance the risk of acute ischemic stroke and lead to worsened clinical outcome and increased mortality. However, post-stroke hyperglycemia is also present in a number of non-diabetic patients after acute ischemic stroke, presumably as a stress response. The aim of this review is to summarize the main effects of hyperglycemia when associated to ischemic injury in acute stroke patients, highlighting the clinical and neurological outcomes in these conditions and after the administration of the currently approved pharmacological treatment, i.e. insulin. The disappointing results of the clinical trials on insulin (including the hypoglycemic events) demand a change of strategy based on more focused therapies. Starting from the comprehensive evaluation of the physiopathological alterations occurring in the ischemic brain during hyperglycemic conditions, the effects of various classes of glucose-lowering drugs are reviewed, such as glucose-like peptide-1 receptor agonists, DPP-4 inhibitors and sodium glucose cotransporter 2 inhibitors, in the perspective of overcoming the up-to-date limitations and of evaluating the effectiveness of new potential therapeutic strategies.
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Affiliation(s)
- Federica Ferrari
- Department of Biology and Biotechnology, Laboratory of Pharmacology and Molecular Medicine of Central Nervous System, University of Pavia, Via Ferrata, Pavia, Italy
| | - Antonio Moretti
- Department of Biology and Biotechnology, Laboratory of Pharmacology and Molecular Medicine of Central Nervous System, University of Pavia, Via Ferrata, Pavia, Italy
| | - Roberto Federic Villa
- Department of Biology and Biotechnology, Laboratory of Pharmacology and Molecular Medicine of Central Nervous System, University of Pavia, Via Ferrata, Pavia, Italy
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16
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Bradley SA, Spring KJ, Beran RG, Chatzis D, Killingsworth MC, Bhaskar SMM. Role of diabetes in stroke: Recent advances in pathophysiology and clinical management. Diabetes Metab Res Rev 2022; 38:e3495. [PMID: 34530485 DOI: 10.1002/dmrr.3495] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/28/2021] [Accepted: 08/31/2021] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Sian A Bradley
- University of New South Wales (UNSW), South Western Sydney Clinical School, Liverpool, New South Wales, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Kevin J Spring
- University of New South Wales (UNSW), South Western Sydney Clinical School, Liverpool, New South Wales, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, New South Wales, Australia
- Medical Oncology Group, Liverpool Clinical School, Western Sydney University & Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Roy G Beran
- University of New South Wales (UNSW), South Western Sydney Clinical School, Liverpool, New South Wales, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital and South Western Sydney Local Health District, Sydney, New South Wales, Australia
- Medical School, Griffith University, Southport, Queensland, Australia
- Sechenov Moscow First State University, Moscow, Russia
| | | | - Murray C Killingsworth
- University of New South Wales (UNSW), South Western Sydney Clinical School, Liverpool, New South Wales, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, New South Wales, Australia
- Department of Anatomical Pathology, Correlatively Microscopy Facility, NSW Health Pathctology, Sydney, New South Wales, Australia
| | - Sonu M M Bhaskar
- University of New South Wales (UNSW), South Western Sydney Clinical School, Liverpool, New South Wales, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, New South Wales, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital and South Western Sydney Local Health District, Sydney, New South Wales, Australia
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17
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Sabir Rashid A, Huang-Link Y, Johnsson M, Wetterhäll S, Gauffin H. Predictors of Early Neurological Deterioration and Functional Outcome in Acute Ischemic Stroke: The Importance of Large Artery Disease, Hyperglycemia and Inflammatory Blood Biomarkers. Neuropsychiatr Dis Treat 2022; 18:1993-2002. [PMID: 36097537 PMCID: PMC9464020 DOI: 10.2147/ndt.s365758] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Early neurological deterioration (END) in acute ischemic stroke (AIS) can be associated with poor outcome. The aim of this study was to investigate the association between infarction subtypes, biomarkers and END, and to identify patients with risk of unfavorable functional outcome. MATERIALS AND METHODS This prospective study enrolled 101 patients with AIS. Neurological status was evaluated according to NIHSS at acute onset, on days 2, 3, and 90. END was defined as ≥2-point increase of NIHSS within 72 hours. Functional outcome was assessed using NIHSS and the modified Rankin Scale (mRS) at day 90. RESULTS END was observed in 20, 8%. Patients with large artery disease had higher risk of developing END compared with patients with cardioembolism or small vessel disease (p <0.01). Significant higher blood glucose level and leukocytes were observed in the END group. Patients with END had higher scores of mRS at day 90 (p <0.01). Levels of NSE, IL-6, hsCRP and NT-proBNP were higher in the patients with unfavorable compared with favorable functional outcome. CONCLUSION Large artery disease, high blood glucose and leukocytes levels are associated with END. Elevated levels of blood markers NSE, IL-6, HsCRP and NT-proBNP indicate poor functional outcome at 90 days after AIS. These patients must be identified and be offered treatment immediately in order to improve the functional outcome after AIS.
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Affiliation(s)
- Avan Sabir Rashid
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Yumin Huang-Link
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Marcus Johnsson
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Simon Wetterhäll
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Helena Gauffin
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
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18
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Du LZ, Liu PY, Ge CY, Li Y, Li YY, Tang MF, Chen JJ. Continuous Intravenous versus Subcutaneous Administration of Insulin for Glycemic Variability in Acute Ischemic Stroke. Neuropsychiatr Dis Treat 2022; 18:1309-1314. [PMID: 35799799 PMCID: PMC9255991 DOI: 10.2147/ndt.s370776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/23/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Continuous intravenous infusion (IV) or subcutaneous injection (SC) of insulin was widely applied to control hyperglycemia after ischemic stroke. However, the impact of different administration modes on glycemic variability was unknown. METHODS Consecutive stroke patients treated with intravenous thrombolysis were screened. Subjects who received insulin treatment were included and entered into the IV or SC group according to the respective administration mode. Blood glucose was closely monitored within the first 72 hours, and the target range of glucose was from 7.7 to 10.0 mmol/L for all patients. The variabilities of glucose, assessed using standard deviation of the mean, variable coefficient and range from the maximum to the minimum value, were compared between the two groups. RESULTS A total of 130 patients were enrolled with 66 in the IV groups and 64 in the SC group. Compared with the SC group, the IV group had higher glycemic variability evaluated as either standard deviation (2.7 ± 0.7 mmol/L vs 2.2 ± 0.9 mmol/L, p = 0.002), variable coefficient (0.26 ± 0.06 vs 0.23 ± 0.08, p = 0.011) or range (10.0 ± 3.6 mmol/L vs 8.1 ± 3.1 mmol/L, p = 0.001). Multivariate logistic regression analyses found that continuous intravenous infusion was associated with higher level of the standard deviation (adjusted OR 3.01, 95% CI 1.29-7.28, p = 0.011), variable coefficient (adjusted OR 5.97, 95% CI 2.55-13.96, p < 0.001) and range (adjusted OR 6.08, 95% CI 2.63-14.05, p < 0.001). CONCLUSION Continuous intravenous infusion of insulin was associated with higher glycemic variability than subcutaneous injection in acute stroke patients receiving thrombolysis.
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Affiliation(s)
- Lin-Zhe Du
- Department of Clinical Pharmacy, Nanjing First Hospital, Nanjing, People's Republic of China
| | - Pei-Yan Liu
- Department of Clinical Pharmacy, Nanjing First Hospital, Nanjing, People's Republic of China
| | - Chen-Yan Ge
- Department of Clinical Pharmacy, Nanjing First Hospital, Nanjing, People's Republic of China
| | - Yang Li
- Department of Clinical Pharmacy, Nanjing First Hospital, Nanjing, People's Republic of China
| | - Yuan-Yuan Li
- Department of Clinical Pharmacy, Nanjing First Hospital, Nanjing, People's Republic of China
| | - Mu-Fei Tang
- Department of Clinical Pharmacy, Nanjing First Hospital, Nanjing, People's Republic of China
| | - Jin-Jin Chen
- Department of Clinical Pharmacy, Nanjing First Hospital, Nanjing, People's Republic of China
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19
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Duloquin G, Graber M, Baptiste L, Mohr S, Garnier L, Ndiaye M, Blanc-Labarre C, Hervieu-Bègue M, Osseby GV, Giroud M, Béjot Y. [Management of ischemic stroke in the acute phase]. Rev Med Interne 2021; 43:286-292. [PMID: 34481684 DOI: 10.1016/j.revmed.2021.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/01/2021] [Indexed: 12/24/2022]
Abstract
Ischemic stroke accounts for 80% of overall stroke, and is one of the leading causes of death, disability and dementia in worldwide. Management of patients with acute ischemic stroke dramatically improved over time with the implementation of intensive care stroke units, the development of acute recanalization strategies, the optimization of the management of post-stroke complications, and the prevention of early stroke recurrence. The objective of this article is to provide a general overview of the current management of patients with acute ischemic stroke aiming at improving post-stroke outcome.
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Affiliation(s)
- G Duloquin
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Graber
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - L Baptiste
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - S Mohr
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - L Garnier
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Ndiaye
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - C Blanc-Labarre
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Hervieu-Bègue
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - G-V Osseby
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Giroud
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - Y Béjot
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France.
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20
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Sprengell M, Kubera B, Peters A. Proximal Disruption of Brain Energy Supply Raises Systemic Blood Glucose: A Systematic Review. Front Neurosci 2021; 15:685031. [PMID: 34248487 PMCID: PMC8264130 DOI: 10.3389/fnins.2021.685031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/28/2021] [Indexed: 12/17/2022] Open
Abstract
This work joins a series that methodically tests the predictions of the Selfish-Brain theory. The theory postulates a vital ability of the mammalian brain, namely to give priority to its own energy metabolism. The brain behaves “selfishly” in this respect. For the cerebral artery occlusion studied here, the theory predicts an increase in blood glucose concentration, what becomes the hypothesis to be tested. We conducted a systematic review of cerebral-artery-occlusion papers to test whether or not the included studies could confirm this hypothesis. We identified 239 records, screened 231 works by title or abstract, and analyzed 89 by full text. According to strict selection criteria (set out in our PROSPERO preregistration, complying with PRISMA guidelines), 7 papers provided enough information to decide on the hypothesis. Our hypothesis could be fully confirmed for the 3 to 24 h after the onset of a transient 2 h or permanent occlusion. As for the mechanism, the theory predicts that the energy-deprived brain suppresses insulin secretion via the sympathoadrenal system, thereby preventing insulin-mediated glucose uptake into muscle and fat and, as a result, enhancing insulin-independent glucose uptake via the blood-brain barrier. Evidence from our included studies actually demonstrated cerebral insulin suppression. In all, the current work confirms the second major prediction of the Selfish-Brain theory that relates to a proximal bottleneck of the cerebral supply chain, cerebral artery occlusion. Its first major prediction relates to a distal supply bottleneck, caloric restriction, and is fulfilled as shown by our previous work, whereas the prediction of the long held gluco-lipostatic theory, which sees the brain as only passively supplied, is violated (Sprengell et al., 2021). The crucial point was that caloric restriction elicits smaller changes in mass (energy) in the brain than in the body. Taken together, the evidence from the current and previous work clearly shows that the most accurate predictions are possible with a theory that views the brain as an independently self-regulating energy compartment occupying a primary position in energy metabolism.
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Affiliation(s)
- Marie Sprengell
- Medical Clinic 1, Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Lübeck, Germany
| | - Britta Kubera
- Medical Clinic 1, Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Lübeck, Germany
| | - Achim Peters
- Medical Clinic 1, Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Lübeck, Germany
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21
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Broocks G, Fiehler J, Hanning U. In Reply: Early Prediction of Malignant Cerebellar Edema in Posterior Circulation Stroke Using Quantitative Lesion Water Uptake. Neurosurgery 2021; 88:E476-E477. [PMID: 33555009 DOI: 10.1093/neuros/nyab032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/20/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg, Germany
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22
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Strong B, Pudar J, Thrift AG, Howard VJ, Hussain M, Carcel C, de Los Campos G, Reeves MJ. Sex Disparities in Enrollment in Recent Randomized Clinical Trials of Acute Stroke: A Meta-analysis. JAMA Neurol 2021; 78:666-677. [PMID: 33900363 DOI: 10.1001/jamaneurol.2021.0873] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance The underenrollment of women in randomized clinical trials represents a threat to the validity of the evidence supporting clinical guidelines and potential disparities in access to novel treatments. Objective To determine whether women were underenrolled in contemporary randomized clinical trials of acute stroke therapies published in 9 major journals after accounting for their representation in underlying stroke populations. Data Sources MEDLINE was searched for acute stroke therapeutic trials published between January 1, 2010, and June 11, 2020. Study Selection Eligible articles reported the results of a phase 2 or 3 randomized clinical trial that enrolled patients with stroke and/or transient ischemic attack and examined a therapeutic intervention initiated within 1 month of onset. Data Extraction Data extraction was performed by 2 independent authors in duplicate. Individual trials were matched to estimates of the proportion of women in underlying stroke populations using the Global Burden of Disease database. Main Outcomes and Measures The primary outcome was the enrollment disparity difference (EDD), the absolute difference between the proportion of trial participants who were women and the proportion of strokes in the underlying disease populations that occurred in women. Random-effects meta-analyses of the EDD were performed, and multivariable metaregression was used to explore the associations of trial eligibility criteria with disparity estimates. Results The search returned 1529 results, and 115 trials (7.5%) met inclusion criteria. Of 121 105 randomized patients for whom sex was reported, 52 522 (43.4%) were women. The random-effects summary EDD was -0.053 (95% CI, -0.065 to -0.040), indicating that women were underenrolled by 5.3 percentage points. This disparity persisted across virtually all geographic regions, intervention types, and stroke types, apart from subarachnoid hemorrhage (0.117 [95% CI, 0.084 to 0.150]). When subarachnoid hemorrhage trials were excluded, the summary EDD was -0.067 (95% CI, -0.078 to -0.057). In the multivariable metaregression analysis, an upper age limit of 80 years as an eligibility criterion was associated with a 6-percentage point decrease in the enrollment of women. Conclusions and Relevance Further research is needed to understand the causes of the underenrollment of women in acute stroke trials. However, to maximize representation, investigators should avoid imposing age limits on enrollment.
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Affiliation(s)
- Brent Strong
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Julia Pudar
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham
| | - Murtaza Hussain
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Cheryl Carcel
- George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Gustavo de Los Campos
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
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23
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Katsiki N, Kotsa K, Stoian AP, Mikhailidis DP. Hypoglycaemia and Cardiovascular Disease Risk in Patients with Diabetes. Curr Pharm Des 2021; 26:5637-5649. [PMID: 32912117 DOI: 10.2174/1381612826666200909142658] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/09/2020] [Indexed: 12/12/2022]
Abstract
Hypoglycaemia represents an important side effect of insulin therapy and insulin secretagogues. It can occur in both type 1 and type 2 diabetes mellitus patients. Also, some associations between hypoglycaemia and cardiovascular (CV) risk have been reported. Several mechanisms may be involved, including the sympathoadrenal system, hypokalaemia, endothelial dysfunction, coagulation, platelets, inflammation, atherothrombosis and impaired autonomic cardiac reflexes. This narrative review discusses the associations of hypoglycaemia with CV diseases, including coronary heart disease (CHD), cardiac arrhythmias, stroke, carotid disease and peripheral artery disease (PAD), as well as with dementia. Severe hypoglycaemia has been related to CHD, CV and all-cause mortality. Furthermore, there is evidence supporting an association between hypoglycaemia and cardiac arrhythmias, potentially predisposing to sudden death. The data linking hypoglycaemia with stroke, carotid disease and PAD is limited. Several factors may affect the hypoglycaemia-CV relationships, such as the definition of hypoglycaemia, patient characteristics, co-morbidities (including chronic kidney disease) and antidiabetic drug therapy. However, the association between hypoglycaemia and dementia is bilateral. Both the disorders are more common in the elderly; thus, glycaemic goals should be carefully selected in older patients. Further research is needed to elucidate the impact of hypoglycaemia on CV disease.
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Affiliation(s)
- Niki Katsiki
- Division of Endocrinology and Metabolism, Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism, Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Anca P Stoian
- Diabetes, Nutrition and Metabolic diseases Department, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, United Kingdom
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24
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Guenego A, Lucas L, Gory B, Richard S, Aubertin M, Weisenburger-Lile D, Labreuche J, Dargazanli C, Benali A, Bourcier R, Detraz L, Vannier S, Guillen M, Eugene F, Walker G, Lun R, Wormsbecker A, Ducroux C, Piotin M, Blanc R, Consoli A, Lapergue B, Fahed R. Thrombectomy for Comatose Patients with Basilar Artery Occlusion : A Multicenter Study. Clin Neuroradiol 2021; 31:1131-1140. [PMID: 33704508 DOI: 10.1007/s00062-021-01001-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/04/2021] [Indexed: 12/27/2022]
Abstract
PURPOSE Acute ischemic stroke (AIS) secondary to a basilar artery occlusion (BAO) carries a poor prognosis, especially in cases of severe symptoms, such as coma at presentation. Despite a lack of evidence, mechanical thrombectomy (MT) is often performed as the procedural risks are felt to be minimal compared to the natural history. We sought to evaluate MT efficacy and safety in comatose BAO patients. METHODS We performed a retrospective analysis of a multicenter prospective cohort of consecutive AIS patients with BAO who underwent MT. We compared baseline characteristics between comatose and noncomatose BAO patients, as well as clinical outcomes (modified Rankin scale, mRS 0-3 at 3 months). Using a multivariate logistic regression, we examined the population of comatose patients for baseline predictive factors of mortality. RESULTS We included 269 patients, 72 (27%) comatose and 197 (73%) non-comatose. Despite similar recanalization rates between comatose and non-comatose patients (83% vs. 90% p = 0.221), comatose patient long-term outcomes were dramatically worse (11% mRS 0-3 vs. 54%, p < 0.0001) and mortality was higher (64% vs. 34%, p < 0.0001). Baseline predictors of mortality at 3 months among comatose BAO patients after multivariate analysis were the following: male sex (odds ratio, OR 31.20, 2.57-378.52, p = 0.007), older age (OR 1.13, 1.04-1.24, p = 0.007) and higher serum glucose levels (OR 1.54, 1.07-2.21, p = 0.019). CONCLUSION Thrombectomy is technically effective for BAO patients presenting with coma; however, the long-term favorable outcome remains poor. Male sex, old age and hyperglycemia were predictors of mortality in these patients.
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Affiliation(s)
- Adrien Guenego
- Interventional Neuroradiology Department, Foundation Rothschild Hospital, Paris, France.,Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Ludovic Lucas
- Neurovascular Unit, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Benjamin Gory
- Department of Diagnostic, Université de Lorraine, CHRU-Nancy, 54000, Nancy, France.,Therapeutic Neuroradiology, Université de Lorraine, IADI, INSERM U1254, 54000, Nancy, France.,INSERM U1116, CHRU-Nancy, 54000, Nancy, France
| | - Sébastien Richard
- INSERM U1116, CHRU-Nancy, 54000, Nancy, France.,Department of Neurology, Stroke Unit, Université de Lorraine, CHRU-Nancy, 54000, Nancy, France
| | - Mathilde Aubertin
- Interventional Neuroradiology Department, Foundation Rothschild Hospital, Paris, France
| | | | - Julien Labreuche
- ULR 2694-METRICS: évaluation des technologies de santé et des pratiques médicales, Univ. Lille, CHU Lille, 59000, Lille, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Centre Hospitalier Universitaire Gui de Chauliac, Montpellier, France
| | - Amel Benali
- Department of Neuroradiology, Centre Hospitalier Universitaire Gui de Chauliac, Montpellier, France
| | - Romain Bourcier
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, L'institut du thorax, Inserm 1087, CNRS, UNIV Nantes, Nantes, France
| | - Lili Detraz
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, L'institut du thorax, Inserm 1087, CNRS, UNIV Nantes, Nantes, France
| | - Stéphane Vannier
- Neurovascular Unit, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - Maud Guillen
- Neurovascular Unit, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - François Eugene
- Department of Neuroradiology, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - Gregory Walker
- Department of Medicine - Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa-Civic Campus, 1053 Carling Avenue, K1Y4E9, Ottawa, ON, Canada.,Department of Medicine-Division of Neurology; Royal Columbian Hospital, New Westminster, University of British Columbia, British Columbia, Canada
| | - Ronda Lun
- Department of Medicine - Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa-Civic Campus, 1053 Carling Avenue, K1Y4E9, Ottawa, ON, Canada
| | - Andrew Wormsbecker
- Department of Critical Care and Internal Medicine; Royal Columbian Hospital, New Westminster, University of British Columbia, British Columbia, Canada
| | - Célina Ducroux
- Interventional Neuroradiology Department, Foundation Rothschild Hospital, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Foundation Rothschild Hospital, Paris, France
| | - Raphael Blanc
- Interventional Neuroradiology Department, Foundation Rothschild Hospital, Paris, France
| | - Arturo Consoli
- Department of Neuroradiology, Foch Hospital, Suresnes, France
| | | | - Robert Fahed
- Interventional Neuroradiology Department, Foundation Rothschild Hospital, Paris, France. .,Department of Medicine - Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa-Civic Campus, 1053 Carling Avenue, K1Y4E9, Ottawa, ON, Canada.
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25
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Pico F, Lapergue B, Ferrigno M, Rosso C, Meseguer E, Chadenat ML, Bourdain F, Obadia M, Hirel C, Duong DL, Deltour S, Aegerter P, Labreuche J, Cattenoy A, Smadja D, Hosseini H, Guillon B, Wolff V, Samson Y, Cordonnier C, Amarenco P. Effect of In-Hospital Remote Ischemic Perconditioning on Brain Infarction Growth and Clinical Outcomes in Patients With Acute Ischemic Stroke: The RESCUE BRAIN Randomized Clinical Trial. JAMA Neurol 2021; 77:725-734. [PMID: 32227157 DOI: 10.1001/jamaneurol.2020.0326] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Treatment with remote ischemic perconditioning has been reported to reduce brain infarction volume in animal models of stroke. Whether this neuroprotective effect was observed in patients with acute ischemic stroke remains unknown. Objective To determine whether treatment with remote ischemic perconditioning administered to the leg of patients with acute ischemic stroke can reduce brain infarction volume growth. Design, Setting, and Participants This proof-of-concept multicenter prospective randomized open-label with blinded end point clinical trial was performed from January 12, 2015, to May 2, 2018. Patients were recruited from 11 stroke centers in France. Of the 188 patients who received magnetic resonance imaging within 6 hours of symptom onset and were confirmed to have carotid ischemic stroke, 93 were randomized to receive treatment with lower-limb remote ischemic perconditioning in addition to standard care (the intervention group), and 95 were randomized to receive standard care alone (the control group). Interventions Randomization on a 1:1 ratio to receive treatment with remote ischemic perconditioning (4 cycles of 5-minute inflations and 5-minute deflations to the thigh to 110 mm Hg above systolic blood pressure) in addition to standard care or standard care alone. Main Outcomes and Measures The change in brain infarction volume growth between baseline and 24 hours, measured by a diffusion-weighted sequence of magnetic resonance imaging scans of the brain. Results A total of 188 patients (mean [SD] age, 67.2 [15.7] years; 98 men [52.1%]) were included in this intention-to-treat analysis. At hospital admission, the median National Institutes of Health Stroke Scale score was 10 (interquartile range [IQR], 6-16) and the median brain infarction volume was 11.4 cm3 (IQR, 3.6-35.8 cm3); 164 patients (87.2%) received intravenous thrombolysis, and 64 patients (34.0%) underwent mechanical thrombectomy. The median increase in brain infarction growth was 0.30 cm3 (IQR, 0.11-0.48 cm3) in the intervention group and 0.37 cm3 (IQR, 0.19-0.55 cm3) in the control group (mean between-group difference on loge-transformed change, -0.07; 95% CI, -0.33 to 0.18; P = .57). An excellent outcome (defined as a score of 0-1 on the 90-day modified Rankin Scale or a score equal to the prestroke modified Rankin Scale score) was observed in 46 of 90 patients (51.1%) in the intervention group and 37 of 91 patients (40.7%) in the control group (P = .12). No significant differences in 90-day mortality were observed between the intervention and control groups (14 of 90 patients; Kaplan-Meier estimate, 15.8% vs 10 of 91 patients; Kaplan-Meier estimate, 10.4%, respectively; P = .45) or with symptomatic intracerebral hemorrhage (4 of 88 patients [4.5%] in both groups; P = .97). Conclusions and Relevance In this study, treatment with remote ischemic perconditioning, during or after reperfusion therapies, had no significant effect on brain infarction volume growth at 24 hours after symptom onset. Trial Registration ClinicalTrials.gov Identifier: NCT02189928.
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Affiliation(s)
- Fernando Pico
- Department of Neurology and Stroke Center, Versailles Mignot Hospital, Versailles, France.,University of Versailles Saint-Quentin-en-Yvelines and Paris-Saclay University, Saint-Aubin, France.,Laboratoire de Recherche Vasculaire Translationnelle, Inserm U1148, Paris, France
| | - Bertrand Lapergue
- University of Versailles Saint-Quentin-en-Yvelines and Paris-Saclay University, Saint-Aubin, France.,Neurology and Stroke Center, Hôpital Foch, Suresnes, France
| | - Marc Ferrigno
- Department of Degenerative and Vascular Cognitive Disorders, Inserm U1171, Université de Lille, Lille, France.,Department of Neurology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Charlotte Rosso
- Assistance Publique-Hopitaux de Paris, Service des Urgences Cerebro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France.,Centre National de la Recherche Scientifique, Inserm U1127, Unite Mixte de Recherche 7225, Institut du Cerveau et de la Moelle Epiniere, Sorbonne Universite, Paris, France
| | - Elena Meseguer
- Assistance Publique-Hôpitaux de Paris, Department of Neurology and Stroke Center, Bichat University Hospital, Universite Paris Diderot, Sorbonne Cite, Paris, France
| | - Marie-Laure Chadenat
- Department of Neurology and Stroke Center, Versailles Mignot Hospital, Versailles, France
| | | | - Michael Obadia
- Neurology and Stroke Center, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Catherine Hirel
- Department of Neurology and Stroke Center, Versailles Mignot Hospital, Versailles, France.,University of Versailles Saint-Quentin-en-Yvelines and Paris-Saclay University, Saint-Aubin, France
| | - Duc Long Duong
- Department of Neurology and Stroke Center, Versailles Mignot Hospital, Versailles, France
| | - Sandrine Deltour
- Assistance Publique-Hopitaux de Paris, Service des Urgences Cerebro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
| | - Philippe Aegerter
- Assistance Publique-Hôpitaux de Paris, Vieillissement et Maladies Chroniques, IndianaSERM, Unité Mixte de Recherche 1168, Universite de Versailles Saint-Quentin-en-Yvelines, Versailles, France.,Department of Biostatistics, Université de Lille, Lille, France
| | - Julien Labreuche
- Unité de Recherche EA 2694-Sante Publique: Epidemiologie et Qualite des Soins, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Amina Cattenoy
- Délégation à la Recherche Clinique, Versailles Mignot Hospital, Versailles, France
| | - Didier Smadja
- Stroke Unit, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - Hassan Hosseini
- Assistance Publique-Hopitaux de Paris, Stroke Center, Henri Mondor Hospital, Université Paris-Est Créteil, Creteil, France
| | - Benoit Guillon
- Department of Neurology, University Hospital of Nantes, Nantes, France
| | - Valérie Wolff
- Stroke Unit, Strasbourg University Hospital, Strasbourg, France
| | - Yves Samson
- Assistance Publique-Hopitaux de Paris, Service des Urgences Cerebro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
| | - Charlotte Cordonnier
- Department of Degenerative and Vascular Cognitive Disorders, Inserm U1171, Université de Lille, Lille, France.,Department of Neurology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Pierre Amarenco
- Laboratoire de Recherche Vasculaire Translationnelle, Inserm U1148, Paris, France.,Assistance Publique-Hôpitaux de Paris, Department of Neurology and Stroke Center, Bichat University Hospital, Universite Paris Diderot, Sorbonne Cite, Paris, France
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26
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Intensive Versus Standard Glucose Control in Patients with Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2020; 136:e487-e495. [DOI: 10.1016/j.wneu.2020.01.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 01/07/2020] [Indexed: 12/27/2022]
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Yao RQ, Ren C, Wu GS, Zhu YB, Xia ZF, Yao YM. Is intensive glucose control bad for critically ill patients? A systematic review and meta-analysis. Int J Biol Sci 2020; 16:1658-1675. [PMID: 32226310 PMCID: PMC7097913 DOI: 10.7150/ijbs.43447] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/27/2020] [Indexed: 02/07/2023] Open
Abstract
Background: The monitoring and management of blood glucose concentration are standard practices in critical settings as hyperglycaemia has been shown close association with poorer outcomes. Several meta-analyses have revealed that intensive glucose control has no benefit in decreasing short-term mortality among critically ill patients, while the studies these meta-analyses have incorporated have been largely divergent. We aim to perform a more comprehensive meta-analysis addressing this problem to provide stronger evidence. Methods: We conducted comprehensive searches for relevant randomized controlled studies in online databases, including the Cochrane Library, EMBASE, and PubMed databases, up to September 1, 2018. The clinical data, which included all-cause mortality, severe hypoglycemia, need for RRT, infection resulting in sepsis, ICU mortality, 90-day mortality, 180-day mortality, and hospital and ICU lengths of stay, were screened and analyzed after data extraction. We applied odds ratios (ORs) to analyze dichotomous outcomes and mean differences for continuous outcomes with a random effects model. Results: A total of 57 RCTs involving a total of 21840 patients were finally included. Patients admitted to the ICU who underwent intensive glucose control showed significantly reduced all-cause mortality (OR: 0.89; 95% CI: 0.80-1.00; P=0.04; I2=32%), reduced infection rate (OR: 0.65, 95% CI: 0.51-0.82, P=0.0002; I2=47%), a lower occurrence of acquired sepsis (OR: 0.80, 95% CI: 0.65-0.99, P=0.04; I2=0%) and shortened length of ICU stay (MD: -0.70, 95% CI: -1.21--0.19, P=0.007, I2=70%) when compared to the same parameters as those treated with the usual care strategy. However, patients in the intensive glucose control group presented with a significantly higher risk of severe hypoglycemia (OR: 5.63, 95% CI: 4.02-7.87, P<0.00001; I2=67%). Conclusions: Critically ill patients undergoing intensive glucose control showed significantly reduced all-cause mortality, length of ICU stay and incidence of acquired infection and sepsis compared to the same parameters in patients treated with the usual care strategy, while the intensive glucose control strategy was associated with higher occurrence of severe hypoglycemic events.
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Affiliation(s)
- Ren-qi Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, People's Republic of China
- Department of Burn Surgery, Changhai Hospital, the Second Military Medical University, Shanghai 200433, People's Republic of China
| | - Chao Ren
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, People's Republic of China
| | - Guo-sheng Wu
- Department of Burn Surgery, Changhai Hospital, the Second Military Medical University, Shanghai 200433, People's Republic of China
| | - Yi-bing Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing 100038, People's Republic of China
| | - Zhao-fan Xia
- Department of Burn Surgery, Changhai Hospital, the Second Military Medical University, Shanghai 200433, People's Republic of China
| | - Yong-ming Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, People's Republic of China
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Insulin in the Management of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. World Neurosurg 2020; 136:e514-e534. [PMID: 31954893 DOI: 10.1016/j.wneu.2020.01.056] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/08/2020] [Indexed: 01/04/2023]
Abstract
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.
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Larsson M, Castrén M, Lindström V, Euler M, Patrone C, Wahlgren N, Nathanson D. Prehospital exenatide in hyperglycemic stroke-A randomized trial. Acta Neurol Scand 2019; 140:443-448. [PMID: 31518433 DOI: 10.1111/ane.13166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/06/2019] [Accepted: 09/10/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Hyperglycemia is a predictor for poor stroke outcome. Hyperglycemic stroke patients treated with thrombolysis have an increased risk of intracranial hemorrhage. Insulin is the gold standard for treating hyperglycemia but comes with a risk of hypoglycemia. Glucagon-like peptide-1 receptor agonists (GLP-1RA) are drugs used in type 2 diabetes that have a low risk of hypoglycemia and have been shown to exert neuroprotective effects. The primary objective was to determine whether prehospital administration of the GLP-1RA exenatide could lower plasma glucose in stroke patients. Secondary objective was to study tolerability and safety. MATERIALS & METHODS Randomized controlled trial comparing exenatide administrated prehospitally with a control group receiving standard care for hyperglycemia. Patients with Face Arm Speech Test ≥1 and glucose ≥8 mmol/L were randomized. Glucose was monitored for 24 hours. All adverse events were recorded. RESULTS Nineteen patients were randomized, eight received exenatide. An interim recruitment failure analysis with subsequent changes of the protocol was made. The study was stopped prematurely due to slow inclusion. No difference was observed in the main outcome of plasma glucose at 4 hours, control vs exenatide (mean, SD); 7.0 ± 1.9 vs 7.6 ± 1.6; P = .56). No major adverse events were reported. CONCLUSIONS We found no evidence that prehospital exenatide had effect on hyperglycemia. However, it was given without adverse events in this study with limited sample size that was prematurely stopped due to slow inclusion.
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Affiliation(s)
- Martin Larsson
- Department of Clinical Science and Education at Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Maaret Castrén
- Department of Clinical Science and Education at Södersjukhuset Karolinska Institutet Stockholm Sweden
- Department of Diabetes and Metabolism Karolinska University Hospital, Huddinge Stockholm Sweden
| | - Veronica Lindström
- Department of Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
- Department of Neurobiology, Care Sciences and Society Section of Nursing Karolinska Institutet Stockholm Sweden
| | - Mia Euler
- Department of Clinical Science and Education at Södersjukhuset Karolinska Institutet Stockholm Sweden
- Academic Emergency Medical Service Region Stockholm Stockholm Sweden
| | - Cesare Patrone
- Department of Clinical Science and Education at Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Nils Wahlgren
- Depatment of Medicine Solna Karolinska Institutet Stockholm Sweden
| | - David Nathanson
- Department of Clinical Science and Education at Södersjukhuset Karolinska Institutet Stockholm Sweden
- Depatment of Clinical Neuroscience Karolinska Institutet Stockholm Sweden
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30
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Abstract
PURPOSE OF REVIEW To provide an update of glycemic management during metabolic stress related to surgery or critical illness. RECENT FINDINGS There is a clear association between severe hyperglycemia, hypoglycemia, and high glycemic variability and poor outcomes of postoperative or critically ill patients. However, the impressive beneficial effects of tight glycemic management (TGM) by intensive insulin therapy reported in one study were never reproduced. Hence, the recommendation of TGM is now replaced by more liberal blood glucose (BG) targets (< 180 mg/dL or 10 mM). Recent data support the concept of targeting individualized blood glucose (BG) values according to the presence of diabetes mellitus/chronic hyperglycemia, the presence of brain injury, and the time from injury. A more liberal glycemic management goal is currently advised during metabolic stress and could be switched to individualized glycemic management once validated by prospective trials.
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Affiliation(s)
- Wasineenart Mongkolpun
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Bruna Provenzano
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
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31
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Broocks G, Kemmling A, Aberle J, Kniep H, Bechstein M, Flottmann F, Leischner H, Faizy TD, Nawabi J, Schön G, Sporns P, Thomalla G, Fiehler J, Hanning U. Elevated blood glucose is associated with aggravated brain edema in acute stroke. J Neurol 2019; 267:440-448. [PMID: 31667625 DOI: 10.1007/s00415-019-09601-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 10/20/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Andre Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Jens Aberle
- Department of Endocrinology and Diabetology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Jawed Nawabi
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.,Department of Radiology, Charité University Medical Center, Berlin, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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32
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Palaiodimou L, Lioutas VA, Lambadiari V, Paraskevas GP, Voumvourakis K, Tsivgoulis G. Glycemia management in acute ischemic stroke: current concepts and novel therapeutic targets. Postgrad Med 2019; 131:423-437. [DOI: 10.1080/00325481.2019.1651206] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Vaia Lambadiari
- Second Department of Internal Medicine, Research Institute and Diabetes Center, Athens University Medical School, “Attikon” University Hospital, Haidari, Greece
| | - George P. Paraskevas
- Cognitive and Movement Disorders Unit and Unit of Neurochemistry and Biological Markers, First Department of Neurology, “Eginition” University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, “Attikon” University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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33
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Johnston KC, Bruno A, Pauls Q, Hall CE, Barrett KM, Barsan W, Fansler A, Van de Bruinhorst K, Janis S, Durkalski-Mauldin VL. Intensive vs Standard Treatment of Hyperglycemia and Functional Outcome in Patients With Acute Ischemic Stroke: The SHINE Randomized Clinical Trial. JAMA 2019; 322:326-335. [PMID: 31334795 PMCID: PMC6652154 DOI: 10.1001/jama.2019.9346] [Citation(s) in RCA: 229] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Hyperglycemia during acute ischemic stroke is common and is associated with worse outcomes. The efficacy of intensive treatment of hyperglycemia in this setting remains unknown. OBJECTIVES To determine the efficacy of intensive treatment of hyperglycemia during acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS The Stroke Hyperglycemia Insulin Network Effort (SHINE) randomized clinical trial included adult patients with hyperglycemia (glucose concentration of >110 mg/dL if had diabetes or ≥150 mg/dL if did not have diabetes) and acute ischemic stroke who were enrolled within 12 hours from stroke onset at 63 US sites between April 2012 and August 2018; follow-up ended in November 2018. The trial included 1151 patients who met eligibility criteria. INTERVENTIONS Patients were randomized to receive continuous intravenous insulin using a computerized decision support tool (target blood glucose concentration of 80-130 mg/dL [4.4-7.2 mmol/L]; intensive treatment group: n = 581) or insulin on a sliding scale that was administered subcutaneously (target blood glucose concentration of 80-179 mg/dL [4.4-9.9 mmol/L]; standard treatment group: n = 570) for up to 72 hours. MAIN OUTCOMES AND MEASURES The primary efficacy outcome was the proportion of patients with a favorable outcome based on the 90-day modified Rankin Scale score (a global stroke disability scale ranging from 0 [no symptoms or completely recovered] to 6 [death]) that was adjusted for baseline stroke severity. RESULTS Among 1151 patients who were randomized (mean age, 66 years [SD, 13.1 years]; 529 [46%] women, 920 [80%] with diabetes), 1118 (97%) completed the trial. Enrollment was stopped for futility based on prespecified interim analysis criteria. During treatment, the mean blood glucose level was 118 mg/dL (6.6 mmol/L) in the intensive treatment group and 179 mg/dL (9.9 mmol/L) in the standard treatment group. A favorable outcome occurred in 119 of 581 patients (20.5%) in the intensive treatment group and in 123 of 570 patients (21.6%) in the standard treatment group (adjusted relative risk, 0.97 [95% CI, 0.87 to 1.08], P = .55; unadjusted risk difference, -0.83% [95% CI, -5.72% to 4.06%]). Treatment was stopped early for hypoglycemia or other adverse events in 65 of 581 patients (11.2%) in the intensive treatment group and in 18 of 570 patients (3.2%) in the standard treatment group. Severe hypoglycemia occurred only among patients in the intensive treatment group (15/581 [2.6%]; risk difference, 2.58% [95% CI, 1.29% to 3.87%]). CONCLUSIONS AND RELEVANCE Among patients with acute ischemic stroke and hyperglycemia, treatment with intensive vs standard glucose control for up to 72 hours did not result in a significant difference in favorable functional outcome at 90 days. These findings do not support using intensive glucose control in this setting. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01369069.
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Affiliation(s)
| | - Askiel Bruno
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta
| | - Qi Pauls
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Christiana E. Hall
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, Texas
| | | | - William Barsan
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Amy Fansler
- Brain Institute, University of Virginia, Charlottesville
| | | | - Scott Janis
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
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Landman T, Schoon Y, Warlé M, De Leeuw FE, Thijssen D. The effect of repeated remote ischemic postconditioning on infarct size in patients with an ischemic stroke (REPOST): study protocol for a randomized clinical trial. Trials 2019; 20:167. [PMID: 30876432 PMCID: PMC6419836 DOI: 10.1186/s13063-019-3264-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 02/27/2019] [Indexed: 01/28/2023] Open
Abstract
Background Remote ischemic postconditioning (rIPostC) refers to the observation that repeated, short periods of ischemia protect remote areas against tissue damage during and after prolonged ischemia. Based on previous observations of a potential neuroprotective effect of rIPostC, the aim of this study is to evaluate whether repeated rIPostC after an ischemic stroke can reduce infarct size, which could be translated to an improvement in clinical outcomes. Methods/design We will enroll 200 ischemic stroke patients to daily rIPostC or sham conditioning during hospitalization into a randomized single-blind placebo-controlled trial. The intervention consists of twice daily exposure to four cycles of 5-min cuff inflation around the upper arm to > 20 mmHg above systolic blood pressure (i.e., rIPostC) or 50 mmHg (i.e., control), followed by 5 minutes of deflation. The primary outcome is infarct size, measured using an MRI diffusion-weighted image at the end of hospitalization. Secondary outcomes include the Modified Rankin Scale, National Institutes of Health Stroke Scale, quality of life, and cardiovascular and cerebrovascular morbidity and mortality. To explore possible underlying mechanisms of rIPostC, venous blood will be sampled to assess biomarkers of inflammation and vascular health. Discussion Previous studies in animals and humans, using a single bout of remote ischemic conditioning, report a potential effect of rIPostC in attenuating neural damage. Although repeated rIPostC has been investigated for cardiovascular disease patients and preclinical stroke models, no previous study has explored the potential physiological and clinical effects of repeatedly applying rIPostC during the hospitalization phase after a stroke. Trial registration Netherlands Trial Register, NTR6880. Registered on 8 December 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3264-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thijs Landman
- Department of Physiology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands.
| | - Yvonne Schoon
- Department of Geriatric Medicine, Radboud University Medical Centre, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands
| | - Michiel Warlé
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands
| | - Frank-Erik De Leeuw
- Centre for Cognitive Neuroscience, Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands
| | - Dick Thijssen
- Department of Physiology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands
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35
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Sato K, Toda T, Iwata A. Fragility Index in Randomized Controlled Trials of Ischemic Stroke. J Stroke Cerebrovasc Dis 2019; 28:1290-1294. [PMID: 30765294 DOI: 10.1016/j.jstrokecerebrovasdis.2019.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/19/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE The fragility index (FI), a minimum number of events in 1 arm of a clinical trial required to revert the statistically significant result to nonsignificant, has recently been developed as an easy-to-understand novel metric to evaluate the robustness of randomized controlled trials (RCTs). Here, we evaluated the FI of RCTs in the field of neurology, particularly in studies of ischemic stroke. METHODS Previous literature published between June 1, 2012 and May 31, 2018 were reviewed from the MEDLINE database by the authors. The original article reporting the significant RCT result, of which a dichotomous outcome was set as its primary outcome measure, was included to evaluate the robustness of the result by calculating the FI. In addition, recent studies examining FI in other clinical fields were reviewed and summarized. RESULTS In the 25 eligible RCT studies, the median total number of study participants was 206 (inter quartile range: 144-450) and the median FI was 7 (inter quartile range: 4-15.0). The FI showed a strong negative correlation with the observed P value. There was no significant difference in the FI between RCTs with and without acute settings. Our median FI was higher than the median FI of 2.5 of previous studies examining FI in other clinical fields, as only 20% (5 of 25) of studies included in our study had an FI less than 2.5. CONCLUSION Our results suggest that many RCTs in the field of ischemic stroke have a fair robustness, when compared to those in other clinical fields.
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Affiliation(s)
- Kenichiro Sato
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsushi Toda
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Atsushi Iwata
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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36
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Kongwad LI, Hegde A, Menon G, Nair R. Influence of Admission Blood Glucose in Predicting Outcome in Patients With Spontaneous Intracerebral Hematoma. Front Neurol 2018; 9:725. [PMID: 30210444 PMCID: PMC6121104 DOI: 10.3389/fneur.2018.00725] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 08/09/2018] [Indexed: 01/08/2023] Open
Abstract
Background and Aims: Hyperglycemia or elevated blood glucose levels have been associated with poor outcomes in patients with ischemic stroke yet control of hyperglycemia has not resulted in good outcomes. High admission blood glucose (ABG) values have been mitigated by other poor prognosticators like large hematoma volume, intraventricular extension (IVE) of hematoma and poor GCS. The aim of this study was to evaluate the effects of blood glucose levels at admission, on mortality and functional outcomes at discharge and 3 months follow up. Methods: This was a retrospective observational study conducted at a tertiary care. Patients with spontaneous SICH were enrolled from a prospective SICH register maintained at our hospital. Blood glucose values were recorded on admission. Patients with traumatic hematomas, vascular malformations, aneurysms, and coagulation abnormalities were excluded from our study. Results: A total of 510 patients were included in the study. We dichotomised our cohort into two groups, group A with ABG>160 mg/dl and group B with ABG<160 mg/dl. Mean blood glucose levels in these two groups were 220.73 mg/dl and 124.37 mg/dl respectively, with group A having twice the mortality. mRS at discharge and 3 months was better in Group B (p ≤ 0.001) as compared to Group A. Age, GCS, volume of hematoma, ABG, IVE and Hydrocephalus were significant predictors of mortality and poor outcome on univariate analysis with a p < 0.05. The relationship between ABG and mortality (P = 0.249, 95% CI 0.948-1.006) and outcome (P = 0.538, 95% CI 0.997-1.005) failed to reach statistical significance on multivariate logistic regression. Age, Volume of hematoma and GCS were stronger predictors of mortality and morbidity. Conclusion: Admission blood glucose levels was not an independent predictor of mortality in our study when adjusted with age, GCS, and hematoma volume. The effect of high ABG on SICH outcome is probably multifactorial and warrants further research.
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Affiliation(s)
| | - Ajay Hegde
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
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37
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Muller C, Cheung NW, Dewey H, Churilov L, Middleton S, Thijs V, Ekinci EI, Levi C, Lindley R, Donnan G, Parsons M, Bladin C. Treatment with exenatide in acute ischemic stroke trial protocol: A prospective, randomized, open label, blinded end-point study of exenatide vs. standard care in post stroke hyperglycemia. Int J Stroke 2018; 13:857-862. [PMID: 30019627 DOI: 10.1177/1747493018784436] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Rationale Post-stroke hyperglycemia occurs in up to 50% of patients presenting with acute ischemic stroke. It reduces the efficacy of thrombolysis, increases infarct size, and worsens clinical outcomes. Insulin-based therapies have generally not been beneficial in treating post-stroke hyperglycemia as they are difficult to implement, may cause hypoglycaemia, possibly increase mortality and worsen clinical outcomes. Exenatide may be a safer, simpler, and more effective alternative to insulin in acute ischemic stroke. Design TEXAIS is a three year, Phase 2, multi-center, prospective, randomized, open label, blinded end-point trial comparing exenatide to standard of care. It aims to recruit 528 patients with a primary end point of major neurological improvement at 7 days defined as a ≥8-point improvement in NIHSS score, or NIHSS 0-1. Secondary outcomes of hyper- and hypoglycaemia at 5 days and NIHSS and mRS at 90 days will be measured. The treatment arm will receive exenatide 5 µg subcutaneously twice daily. The control arm will receive standard stroke unit care. Continuous glucose monitors will track the dynamic variability of glucose. Conclusion TEXAIS aims to show that exenatide is safe and effective in the treatment of post-stroke hyperglycemia. It has been designed to be highly generalizable with an ability to enroll a large percentage of patients with acute ischemic stroke, regardless of admission blood glucose level, diabetes status, or stroke severity, with very low risk of hypoglycemia. Trial registration: ClinicalTrials.gov/ANZCTR NTA1127.
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Affiliation(s)
- Claire Muller
- 1 Monash University Eastern Health Clinical School, Melbourne, VIC, Australia
- 2 The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - N Wah Cheung
- 3 Centre for Diabetes and Endocrinology Research Westmead, Westmead Hospital & University of Sydney, NSW, Australia
| | - Helen Dewey
- 1 Monash University Eastern Health Clinical School, Melbourne, VIC, Australia
- 4 Faculty of Medicine, Nursing and Health Sciences, Monash University, VIC, Australia
| | - Leonid Churilov
- 5 Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Sandy Middleton
- 6 Nursing Research Institute, St Vincent's & Health Australia (Sydney) and Australian Catholic University, St Vincent's Hospital, NSW, Australia
| | - Vincent Thijs
- 5 Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Elif I Ekinci
- 7 Department of Medicine, and Department of Endocrinology, University of Melbourne, Austin Health, Heidelberg, VIC, Australia
| | - Chris Levi
- 8 Priority Research Centre for Stroke and Brain Injury, Hunter Medical Research Institute, University of Newcastle, John Hunter Hospital, Newcastle, NSW, Australia
- 9 Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Richard Lindley
- 10 Sydney Medical School, Westmead Hospital Clinical School (C24) Sydney, The University of Sydney, NSW, Australia
- 11 George Institute for Global Health, Sydney, NSW, Australia
| | - Geoffrey Donnan
- 5 Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Mark Parsons
- 8 Priority Research Centre for Stroke and Brain Injury, Hunter Medical Research Institute, University of Newcastle, John Hunter Hospital, Newcastle, NSW, Australia
- 9 Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Christopher Bladin
- 1 Monash University Eastern Health Clinical School, Melbourne, VIC, Australia
- 5 Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
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Wang F, Jiang B, Kanesan L, Zhao Y, Yan B. Higher admission fasting plasma glucose levels are associated with a poorer short-term neurologic outcome in acute ischemic stroke patients with good collateral circulation. Acta Diabetol 2018; 55:703-714. [PMID: 29651557 DOI: 10.1007/s00592-018-1139-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/30/2018] [Indexed: 12/15/2022]
Abstract
AIMS In this retrospective study, we sought to delineate the collateral circulation status of acute ischemic stroke patients by CT perfusion and evaluate 90-day modified Rankin Scale (mRS) scores of patients with good or poor collaterals and its correlation with admission fasting plasma glucose (FPG). METHODS We enrolled acute ischemic stroke patients who presented to our hospital 4.5 h within an onset of the first episode between January 2009 and December 2015. Neurological assessment was performed using the 90-day mRS scores (0-2 for a favorable and 3-6 for an unfavorable neurologic outcome). Relative filling time delay (rFTD) was evaluated by CT perfusion scan. The primary outcomes were 90-day mRS scores stratified by good (rFTD ≤ 4 s) versus poor collateral circulation (rFTD > 4 s). RESULTS Totally 270 patients were included, and 139 (51.5%) patients achieved a favorable neurologic outcome. One hundred eighty-five (68.5%) patients had good collateral circulation. Significantly greater portions of patients with good collateral circulation (60.5%, 112/185) achieved a favorable neurologic outcome compared to those with poor collateral circulation (31.8%, 27/85) (P < 0.05). Patients with good collateral circulation achieving a favorable neurologic outcome had significantly lower baseline FPG (6.6 ± 1.96) than those with good collateral circulation achieving an unfavorable neurologic outcome (8.12 ± 4.02; P = 0.002). Spearman correlation analysis showed that rFTD significantly correlated with 90-day mRS scores (adjusted r = 0.258; P < 0.001) and admission FPG (r = 0.286; P < 0.001). CONCLUSION Higher admission FPG levels are associated with significantly higher rates of unfavorable neurologic outcome of acute ischemic stroke patients with good collateral circulation. FPG and rFTD may serve as useful predictors of short-term patient outcome and could be used for risk stratification in clinical decision making.
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Affiliation(s)
- Feng Wang
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
- Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, 3050, Australia
| | - Beisi Jiang
- Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, 3050, Australia
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Lasheta Kanesan
- Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, 3050, Australia
| | - Yuwu Zhao
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
| | - Bernard Yan
- Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, 3050, Australia.
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The silver effect of admission glucose level on excellent outcome in thrombolysed stroke patients. J Neurol 2018; 265:1684-1689. [PMID: 29777362 PMCID: PMC6022525 DOI: 10.1007/s00415-018-8896-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/02/2018] [Accepted: 05/03/2018] [Indexed: 11/25/2022]
Abstract
Higher admission glucose levels (AGL) are associated with less favorable outcome in thrombolysis. But, could AGL’s impact on outcome vary by onset-to-treatment (OTT) time? Is hyperglycemia associated with a shorter therapeutic time window for excellent outcome for thrombolysed stroke patients? We assessed predictive values of AGL, baseline NIHSS, age, and OTT time quartiles on excellent outcome (3-month modified Rankin score of 0–1) in 773 patients treated by rt-Pa. We added the AGL × OTT time quartile interaction in the model and separately analyzed the predictive values of AGL, age, and NIHSS for each OTT time quartile if the interaction was significant. AGL, baseline NIHSS, age, and OTT time quartiles were significant predictors. When added in the model, the AGL × OTT interaction was significant (OR: 0.96, 95% CI: 0.94–0.99, p: 0.0009). AGL was predictive only during the third OTT time quartile (181–224 min). During this period, the predicted rate of excellent outcome was 16% for AGL = 6.5 mmol/L and 8% for AGL = 8 mmol/L. The rate of excellent outcome was not decreased in hyperglycemic patients for OTT time ≤ 180 min (20 vs. 24.5% p: 0.37), but was decreased for OTT time > 180 min (9.6 vs. 26.7% p: 0.00001). Similar results were found in patients with MCA recanalization, but not in patients without recanalization. The therapeutic time window for excellent outcome is shortened in hyperglycemic patients. This would support the design of “freezing penumbra” randomized trials based on ultra-early AGL control.
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Impaired fasting glucose is associated with unfavorable outcome in ischemic stroke patients treated with intravenous alteplase. J Neurol 2018; 265:1426-1431. [PMID: 29666986 DOI: 10.1007/s00415-018-8866-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/07/2018] [Accepted: 04/10/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Hyperglycemia on admission and diabetes mellitus type II are associated with unfavorable outcome in stroke patients. We studied whether impaired fasting glucose (IFG) is associated with unfavorable outcome in ischemic stroke patients treated with intravenous alteplase as well and if IFG is a stronger prognostic factor than hyperglycemia on admission. METHODS We studied 220 consecutive patients with ischemic stroke treated with intravenous alteplase. In all nondiabetic patients, fasting glucose was determined on day 2-5. IFG was defined as fasting glucose level of ≥ 5.6 mmol/L, hyperglycemia on admission as glucose levels ≥ 7.9 mmol/L. The primary effect measure was the adjusted common odds ratio (acOR) for a shift in the direction of worse outcome on the modified Rankin Scale at 3 months, estimated with ordinal logistic regression, and adjusted for common prognostic factors. RESULTS The fasting glucose levels were available in 194 and admission glucose levels in 215 patients. Sixty-three (32.5%) had IFG, 58 (27%) hyperglycemia on admission and 32 (14.6%) pre-existent diabetes. Patients with IFG showed a shift towards worse functional outcome compared with patients with normal fasting glucose levels (acOR 2.77; 95% CI 1.54-4.97), which was stronger than hyperglycemia on admission (acOR 1.75; 95% CI 0.91-3.4). CONCLUSIONS IFG is associated with unfavorable outcome after treatment with intravenous alteplase for acute ischemic stroke. IFG predicts unfavorable outcome better than hyperglycemia on admission.
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Fuentes B, Ntaios G, Putaala J, Thomas B, Turc G, Díez-Tejedor E. European Stroke Organisation (ESO) guidelines on glycaemia management in acute stroke. Eur Stroke J 2017; 3:5-21. [PMID: 31008333 DOI: 10.1177/2396987317742065] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 10/14/2017] [Indexed: 12/19/2022] Open
Abstract
Background Hyperglycaemia is a frequent complication in acute stroke that has been shown to be independently associated with larger infarct size, haematoma growth, poor clinical outcome and mortality. This Guideline Document presents the European Stroke Organisation (ESO) Guidelines for the management of blood glucose levels in patients with acute ischemic or haemorrhagic stroke. Methods The working group identified related questions and developed its recommendations based on evidence from randomised controlled trials following the standard operating procedure of the ESO. This Guideline Document was reviewed and approved by the European Stroke Organisation Guidelines Committee and the European Stroke Organisation Executive Committee. Results We found low-quality evidence from clinical trials in ischemic or haemorrhagic stroke exploring the use of intravenous insulin aimed to achieve a tight glycaemic control with different glucose level targets and several other sources of heterogeneity. None of these trials neither the meta-analysis of them have demonstrated any significant benefit of tight glycaemic control with intravenous insulin in acute ischemic or haemorrhagic stroke patients on functional outcome or in survival and they have shown an increased risk for hypoglycaemia. Conclusions We suggest against the routine use of tight glycaemic control with intravenous insulin as a means to improve outcomes. The currently available data about the management of glycaemia in patients with acute stroke are limited and the strengths of the recommendations are therefore weak. Nevertheless, this does not prevent that hyperglycaemia in acute stroke patients could be treated as any other hospitalised patient.
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Affiliation(s)
- Blanca Fuentes
- 1Department of Neurology and Stroke Center, La Paz University Hospital, Autonoma University of Madrid, IdiPaz Health Research Institute, Madrid, Spain
| | - George Ntaios
- 2Department of Medicine, University of Thessaly, Larissa, Greece
| | - Jukka Putaala
- 3Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Brenda Thomas
- Centre for Clinical Brain Sciences (CCBS), University of Edinburgh, Edinburgh, Scotland
| | - Guillaume Turc
- Department of Neurology, Sainte-Anne Hospital & INSERM U894, Paris, France
| | - Exuperio Díez-Tejedor
- 1Department of Neurology and Stroke Center, La Paz University Hospital, Autonoma University of Madrid, IdiPaz Health Research Institute, Madrid, Spain
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Klingbeil KD, Koch S, Dave KR. Potential link between post-acute ischemic stroke exposure to hypoglycemia and hemorrhagic transformation. Int J Stroke 2017; 15:477-483. [PMID: 29134928 DOI: 10.1177/1747493017743797] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Hemorrhagic transformation is a severe complication of acute ischemic stroke owing to its limited treatment options and poor prognosis. In the last decade, the rates of hemorrhagic transformation incidence have been associated with blood glucose levels. In particular, hyperglycemia at the time of admission has been associated with increased rates of hemorrhagic transformation in acute ischemic stroke patients. Recent pilot clinical trials have attempted to use intensive insulin therapy during stroke treatment to reduce the severity of cerebral infarction and possibly alleviate the risk of hemorrhagic transformation. However, the results of these studies have shown no clear clinical benefit. In addition, intensive insulin therapy has increased rates of hypoglycemia which may be associated with larger infarct growth. We hypothesize that hypoglycemia, similarly to hyperglycemia, is a risk factor for worse outcomes in acute ischemic stroke by promoting hemorrhagic transformation. This review serves to call attention to patterns present within intensive insulin therapy trials and shed light into the pathophysiological effects of hypoglycemia. It is critical that efforts be directed toward the prevention of hemorrhagic transformation by optimizing insulin therapy during the treatment of acute ischemic stroke.
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Affiliation(s)
- Kyle D Klingbeil
- Cerebral Vascular Disease Research Laboratories, Miller 12235 School of Medicine, University of Miami , Miami, FL, USA.,Department of Neurology, Miller 12235 School of Medicine, University of Miami , Miami, FL, USA
| | - Sebastian Koch
- Department of Neurology, Miller 12235 School of Medicine, University of Miami , Miami, FL, USA
| | - Kunjan R Dave
- Cerebral Vascular Disease Research Laboratories, Miller 12235 School of Medicine, University of Miami , Miami, FL, USA.,Department of Neurology, Miller 12235 School of Medicine, University of Miami , Miami, FL, USA.,Neuroscience Program, Miller 12235 School of Medicine, University of Miami , Miami, FL, USA
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Mi D, Wang P, Yang B, Pu Y, Yang Z, Liu L. Correlation of hyperglycemia with mortality after acute ischemic stroke. Ther Adv Neurol Disord 2017; 11:1756285617731686. [PMID: 29399044 PMCID: PMC5784549 DOI: 10.1177/1756285617731686] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 06/29/2017] [Indexed: 01/04/2023] Open
Abstract
Background: Hyperglycemia has been considered a predictor of stroke outcomes. In this article we study the correlation between blood glucose levels within the first 24 h after stroke onset and patients’ outcomes in mortality and hemorrhagic transformations. Methods: Ninety-one non-diabetic patients with acute ischemic stroke admitted to a neurological intensive unit were recruited. Their blood glucose was measured twice within 6 h (baseline) and at every hour after stroke onset. Patients were collected into four groups as follows: those in which normoglycemia and no hyperglycemia were observed at either baseline or 24 h; those with baseline hyperglycemia and hyperglycemia only at baseline; those with 24 h hyperglycemia and hyperglycemia only at 24 h after stroke; and those with persistent hyperglycemia and hyperglycemia at both baseline and at 24 h. Endpoints were designated as the patient’s death within 30 days and/or hemorrhagic transformation under computerized tomography within the first 7 days after stroke onset. Results: Persistent hyperglycemia was correlated with an increased risk of mortality within 30 days (OR = 24.0; 95% CI = 2.8–199.3) and it was also correlated with hemorrhagic transformation (OR = 13.3; 95% CI = 2.7–66.1). Baseline or delayed hyperglycemia were not correlated with any outcome. Conclusions: Persistent hyperglycemia was correlated with mortality after acute ischemic stroke.
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Affiliation(s)
- Donghua Mi
- Beijing Tiantan Hospital, Beijing, China
| | - Pingli Wang
- Wenzhou Hospital of Integrated Traditional and Western Medicine, China
| | - Bo Yang
- Beijing Tiantan Hospital, Beijing, China
| | - Yuehua Pu
- Beijing Tiantan Hospital, Beijing, China
| | | | - Liping Liu
- Beijing Tiantan Hospital, Dongcheng District Tiantan Xili 6#, Beijing, 100050, China
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Yang CJ, Liao WI, Wang JC, Tsai CL, Lee JT, Peng GS, Lee CH, Hsu CW, Tsai SH. Usefulness of glycated hemoglobin A1c-based adjusted glycemic variables in diabetic patients presenting with acute ischemic stroke. Am J Emerg Med 2017; 35:1240-1246. [DOI: 10.1016/j.ajem.2017.03.049] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 03/18/2017] [Accepted: 03/21/2017] [Indexed: 12/11/2022] Open
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Fuentes B, Sanz-Cuesta BE, Gutiérrez-Fernández M, Martínez-Sánchez P, Lisbona A, Madero-Jarabo R, Delgado-Mederos R, Gállego-Cullere J, Rodríguez-Yáñez M, Martínez-Zabaleta M, Freijo M, Alonso de Leciñana M, Portilla JC, Gil-Núñez A, Díez-Tejedor E. Glycemia in Acute Stroke II study: a call to improve post-stroke hyperglycemia management in clinical practice. Eur J Neurol 2017; 24:1091-1098. [PMID: 28707377 DOI: 10.1111/ene.13354] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 06/01/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE The aim of the study was to analyze the effect of conventional glucose management, which aimed to maintain glucose levels <155 mg/dL (8.5 mmol/L), on glucose control and the outcomes of patients with acute ischaemic stroke (IS) in a clinical practice setting. METHODS This was a multicenter, prospective cohort study of patients with acute IS. Patients were classified into four groups based on their initial 48-h capillary glucose levels and the administration of and response to corrective treatment: (i) untreated and maximum glucose levels <155 mg/dL (8.5 mmol/L) within the first 48 h; (ii) treated and good responders [glucose levels persistently <155 mg/dL (8.5 mmol/L)]; (iii) treated and non-responders [any glucose values ≥155 mg/dL (8.5 mmol/L) during the 24 h after the start of corrective treatment]; and (iv) untreated with any glucose value ≥155 mg/dL (8.5 mmol/L). The primary outcome was death or dependence at 3 months (blinded rater). RESULTS A total of 213 patients were included. Ninety-seven (45.5%) patients developed glucose levels ≥155 mg/dL (8.5 mmol/L), 69 (71.1%) underwent corrective treatment and 31 patients underwent no corrective treatment at the physician's discretion [28 of whom had isolated values ≥155 mg/dL (8.5 mmol/L)]. Only 11 (16%) patients responded to conventional treatment, whereas 58 (84%) patients were non-responsive. Non-responders showed a twofold higher risk of death or dependence at 3 months (odds ratio, 2.472; 95% confidence interval, 1.096-5.576; P = 0.029). CONCLUSIONS Lack of response to conventional treatment for glucose management in acute IS is frequent and associated with poor outcomes.
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Affiliation(s)
- B Fuentes
- Department of Neurology and Stroke Center, Neuroscience and Cerebrovascular Research Laboratory, La Paz University Hospital, Autonoma University of Madrid, Madrid, Spain
| | - B E Sanz-Cuesta
- Department of Neurology and Stroke Center, Neuroscience and Cerebrovascular Research Laboratory, La Paz University Hospital, Autonoma University of Madrid, Madrid, Spain
| | - M Gutiérrez-Fernández
- Department of Neurology and Stroke Center, Neuroscience and Cerebrovascular Research Laboratory, La Paz University Hospital, Autonoma University of Madrid, Madrid, Spain
| | - P Martínez-Sánchez
- Department of Neurology and Stroke Center, Neuroscience and Cerebrovascular Research Laboratory, La Paz University Hospital, Autonoma University of Madrid, Madrid, Spain
| | - A Lisbona
- Department of Endocrinology, La Paz University Hospital, Madrid, Spain
| | - R Madero-Jarabo
- Department of Biostatistics, La Paz University Hospital, Madrid, Spain
| | - R Delgado-Mederos
- Department of Neurology, Santa Creu I Sant Pau Hospital, Barcelona, Spain
| | | | - M Rodríguez-Yáñez
- Department of Neurology, University Hospital Clinic, Santiago de Compostela, Spain
| | | | - M Freijo
- Department of Neurology, Basurto Hospital, Bilbao, Spain
| | - M Alonso de Leciñana
- Department of Neurology and Stroke Center, Neuroscience and Cerebrovascular Research Laboratory, La Paz University Hospital, Autonoma University of Madrid, Madrid, Spain.,Department of Neurology, Ramón y Cajal University Hospital, Madrid, Spain
| | - J C Portilla
- Department of Neurology, San Pedro de Alcántara Hospital, Cáceres, Spain
| | - A Gil-Núñez
- Department of Neurology, Gregorio Marañón University Hospital, Madrid, Spain
| | - E Díez-Tejedor
- Department of Neurology and Stroke Center, Neuroscience and Cerebrovascular Research Laboratory, La Paz University Hospital, Autonoma University of Madrid, Madrid, Spain
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Revisiting ‘progressive stroke’: incidence, predictors, pathophysiology, and management of unexplained early neurological deterioration following acute ischemic stroke. J Neurol 2017; 265:216-225. [DOI: 10.1007/s00415-017-8490-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/07/2017] [Accepted: 04/07/2017] [Indexed: 12/22/2022]
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Guillon B, Bourcier R, Toulgoat F, de Gaalon S, Gaultier-Lintia A, Sévin M. Gestione dell’infarto cerebrale acuto. Neurologia 2016. [DOI: 10.1016/s1634-7072(16)80382-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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49
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Glycemic control, mortality, and hypoglycemia in critically ill patients: a systematic review and network meta-analysis of randomized controlled trials. Intensive Care Med 2016; 43:1-15. [DOI: 10.1007/s00134-016-4523-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 08/23/2016] [Indexed: 12/14/2022]
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Velly L, Simeone P, Bruder N. Postoperative Care of Neurosurgical Patients. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0175-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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