Natural history of blood glucose within the first 48 hours after ischemic stroke

Fasting blood glucose-to-glycated hemoglobin ratio for evaluating clinical outcomes in patients with ischemic stroke

Background

Stress hyperglycemia frequently occurs in patients with acute ischemic stroke (AIS). The influence of stress hyperglycemia on the outcomes of patients with AIS remains ambiguous.

Methods

Data from our institution on patients with AIS between June 2020 and June 2021 were retrospectively analyzed. The severity of the stroke was assessed using the National Institutes of Health Stroke Scale (NIHSS) at admission, and the primary endpoint was functional outcomes. Stress hyperglycemia was measured by the glucose-to-HbA1c ratio. In the multivariable analysis, two models that retained or excluded the NIHSS were adopted to explore the relationship between stress hyperglycemia and outcomes. The receiver operating characteristic curve (ROC) was calculated to determine an optimized cutoff value.

Results

The optimal cutoff value was 1.135. When all patients were included, model 1 did not find an association between the glucose-to-HbA1c ratio and functional outcomes. In model 2, the glucose-to-HbA1c ratio^×10 (Glucose-to-HbA1c ratio ×10) was the independent predictor of functional outcomes (OR 1.19, 95% CI 1.07-1.33, p < 0.01). Separately, in patients without diabetes, the glucose-to-HbA1c ratio^×10 was the independent predictor of functional outcomes in both model 1 (OR 1.37, 95% CI 1.08-1.73, p = 0.01) and model 2 (OR 1.48, 95% CI 1.22-1.79, p < 0.01), but not in patients with diabetes. In addition, the glucose-to-HbA1c ratio^×10 was the independent predictor of stroke severity (OR 1.16, 95% CI 1.05-1.28, p < 0.01).

Conclusion

The glucose-to-HbA1c ratio was associated with more severe AIS. Specifically, the glucose-to-HbA1c ratio was associated with the functional outcomes in patients without diabetes but not in patients with diabetes.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association of hyperglycemia, systolic and diastolic hypertension, and hyperthermia relative to baseline in the acute phase of stroke with poor outcome after intravenous thrombolysis

: In the acute phase of ischemic stroke, the trend of some physiological variables, such as blood glucose (BG), blood pressure, and body temperature (BT), might influence outcome. We aimed to assess the association of hyperglycemia, systolic and diastolic hypertension, and hyperthermia relative to baseline BG, systolic blood pressure, diastolic blood pressure and BT, respectively, in the first 12 h with poor outcome after intravenous thrombolysis (IVT). We conducted a retrospective analysis of data prospectively collected from 200 consecutive anterior ischemic stroke patients treated with IVT. Outcome measures were no neurological improvement at 24 h (National Institutes of Health Stroke Scale (NIHSS) score at 24 h ≥NIHSS score at baseline), and unfavorable functional outcome [modified Rankin Scale (mRS) score 3-6] at 3 months. No neurological improvement at 24 h was noted in 52 (26%) patients and mRS 3-6 at 3 months in 68 (34%) patients. The multivariate analyses showed that odds ratios (ORs) for no neurological improvement at 24 h were higher in patients with hyperglycemia relative to baseline [OR 3.50, 95% confidence interval (CI) 1.43-8.57, P = 0.006], and hyperthermia relative to baseline (OR 2.88, 95% CI 1.20-6.91, P = 0.018). OR for 3-month mRS score 3-6 was higher in patients with hyperthermia relative to baseline (OR 3.05, 95% CI 1.20-7.74, P = 0.019). Hyperglycemia and hyperthermia relative to baseline in the first 12 h after IVT are associated with no neurological improvement at 24 h. Hyperthermia relative to baseline is also associated with unfavorable functional outcome at 3 months.

Stress hyperglycemia and acute ischemic stroke in-hospital outcome

BACKGROUND AND AIMS

Stress hyperglycemia is frequent in patients with acute ischemic stroke. However, it is unclear whether stress hyperglycemia only reflects stroke severity or if it is directly associated with adverse outcome. We aimed to evaluate the prognostic significance of stress hyperglycemia in acute ischemic stroke.

METHODS

We prospectively studied 790 consecutive patients who were admitted with acute ischemic stroke (41.0% males, age 79.4±6.8years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). Stress hyperglycemia was defined as fasting serum glucose levels at the second day after admission ≥126mg/dl in patients without type 2 diabetes mellitus (T2DM). The outcome was assessed with adverse outcome rates at discharge (modified Rankin scale between 2 and 6) and with in-hospital mortality.

RESULTS

In the total study population, 8.6% had stress hyperglycemia. Patients with stress hyperglycemia had more severe stroke. Independent predictors of adverse outcome at discharge were age, prior ischemic stroke and NIHSS at admission whereas treatment with statins prior to stroke was associated with favorable outcome. When the NIHSS was removed from the multivariate model, independent predictors of adverse outcome were age, heart rate at admission, prior ischemic stroke, log-triglyceride (TG) levels and stress hyperglycemia, whereas treatment with statins prior to stroke was associated with favorable outcome. Independent predictors of in-hospital mortality were atrial fibrillation (AF), diastolic blood pressure (DBP), serum log-TG levels and NIHSS at admission. When the NIHSS was removed from the multivariate model, independent predictors of in-hospital mortality were age, AF, DBP, log-TG levels and stress hyperglycemia.

CONCLUSION

Stress hyperglycemia does not appear to be directly associated with the outcome of acute ischemic stroke. However, given that patients with stress hyperglycemia had higher prevalence of cardiovascular risk factors than patients with normoglycemia and that glucose tolerance was not evaluated, more studies are needed to validate our findings.

The Stroke Hyperglycemia Insulin Network Effort (SHINE) trial protocol: a randomized, blinded, efficacy trial of standard vs. intensive hyperglycemia management in acute stroke

RATIONALE

Patients with acute ischemic stroke and hyperglycemia have worse outcomes than those without hyperglycemia. Intensive glucose control during acute stroke is feasible and can be accomplished safely but has not been fully assessed for efficacy.

AIMS

The Stroke Hyperglycemia Insulin Network Effort trial aims to determine the safety and efficacy of standard vs. intensive glucose control with insulin in hyperglycemic acute ischemic stroke patients.

DESIGN

This is a randomized, blinded, multicenter, phase III trial of approximately 1400 hyperglycemic patients who receive either standard sliding scale subcutaneous insulin (blood glucose range 80-179 mg/dL, 4·44-9·93 mmol/L) or continuous intravenous insulin (target blood glucose 80-130 mg/dL, 4·44-7·21 mmol/L) for up to 72 h, starting within 12 h of stroke symptom onset. The acute treatment phase is single blind (for the patients), but the final outcome assessment is double blind. The study is powered to detect a 7% absolute difference in favorable outcome at 90 days.

STUDY OUTCOMES

The primary outcome is a baseline severity adjusted 90-day modified Rankin Scale score, defined as 0, 0-1, or 0-2, if the baseline National Institutes of Health Stroke Scale score is 3-7, 8-14, or 15-22, respectively. The primary safety outcome is the rate of severe hypoglycemia (<40 mg/dL, <2·22 mmol/L).

DISCUSSION

This trial will provide important novel information about preferred management of acute ischemic stroke patients with hyperglycemia. It will determine the potential benefits and risks of intensive glucose control during acute stroke.

High glucose induces apoptosis and suppresses proliferation of adult rat neural stem cells following in vitro ischemia

Background

Post-stroke hyperglycemia appears to be associated with poor outcome from stroke, greater mortality, and reduced functional recovery. Focal cerebral ischemia data support that neural stem cells (NSCs) play an important role in post-ischemic repair. Here we sought to evaluate the negative effects of hyperglycemia on the cellular biology of NSCs following anoxia, and to test whether high glucose affects NSC recovery from ischemic injury.

Results

In this study, we used immortalized adult neural stem cells lines and we induced in vitro ischemia by 6 h oxygen and glucose deprivation (OGD) in an anaerobic incubator. Reperfusion was performed by returning cells to normoxic conditions and the cells were then incubated in experimental medium with various concentrations of glucose (17.5, 27.75, 41.75, and 83.75 mM) for 24 h. We found that high glucose (≥27.75 mM) exposure induced apoptosis of NSCs in a dose-dependent manner after exposure to OGD, using an Annexin V/PI apoptosis detection kit. The cell viability and proliferative activity of NSCs following OGD in vitro, evaluated with both a Cell Counting kit-8 (CCK-8) assay and a 5-ethynyl-2’-deoxyuridine (EdU) incorporation assay, were inhibited by high glucose exposure. Cell cycle analysis showed that high glucose exposure increased the percentage of cells in G0/G1-phase, and reduced the percentage of cells in S-phase. Furthermore, high glucose exposure was found to significantly induce the activation of c-Jun N-terminal protein kinase (JNK) and p38 mitogen-activated protein kinase (MAPK) and suppress extracellular signal-regulated kinase 1/2 (ERK1/2) activity.

Conclusions

Our results demonstrate that high glucose induces apoptosis and inhibits proliferation of NSCs following OGD in vitro, which may be associated with the activation of JNK/p38 MAPK pathways and the delay of G1-S transition in the cells.

Higher Blood Glucose within the Normal Range Is Associated with More Severe Strokes

Background. Higher fasting blood glucose (FBG) concentrations in the hyperglycemic range are associated with more severe strokes. Whether this association also extends into patients with FBG in the normoglycemic range is unclear. We studied the association of stroke severity and FBG in normoglycemic patients with ischemic stroke in a median of 7 days after stroke when the initial glycemic stress response has resolved. Method and Material. Included were 361 nondiabetic ischemic stroke patients with admission fasting blood glucose within 70–130 mg/dL admitted into an acute stroke rehabilitation unit in a median of 7 days after stroke. Data including neuroimaging, vital signs, cardiovascular risk factors, and admission functional independence measure (AFIM) were recorded prospectively. Results. FBG correlated with stroke severity in the normoglycemic 70–130 mg/dL range (FBG-AFIM correlation coefficient −0.17; P = 0.003). Odds ratio for more severe injury (below average AFIM score) was 2.02 for patients with FBG 110–130 mg/dL compared to FBG 70–90 mg/dL (95% confidence interval 1.10–3.73, P = 0.022). Each mg/dL increase in FBG was associated with an average decrease of 0.25 FIM points. In a multiple linear regression model, FBG was associated with more severe stroke (P = 0.002). Conclusion. One week after ischemic stroke, FBG within the normoglycemic range was associated with stroke severity.

Hyperglycemia in acute ischemic stroke: pathophysiology and clinical management

Patients with acute ischemic stroke frequently test positive for hyperglycemia, which is associated with a poor clinical outcome. This association between poor glycemic control and an unfavorable prognosis is particularly evident in patients with persistent hyperglycemia, patients without a known history of diabetes mellitus, and patients with cortical infarction. To date, however, only one large clinical trial has specifically investigated the effect of glycemic control on stroke outcome. This trial failed to show a clinical benefit, but had several limitations. Despite a lack of clinical evidence supporting the use of glycemic control in the treatment of patients with stroke, international guidelines recommend treating this subset of critically ill patients for hyperglycemia in the hospital setting. This treatment regime is, however, particularly challenging in patients with stroke, and is associated with an increased risk of the patient developing hypoglycemia. Here we review the available evidence linking hyperglycemia to a poor clinical outcome in patients with ischemic stroke. We highlight the pathophysiological mechanisms that might underlie the deleterious effects of hyperglycemia on acute stroke prognosis and systematically review the literature concerning tight glycemic control after stroke. Finally, we provide directions on the use of insulin treatment strategies to control hyperglycemia in this patient group.

Blood glucose in acute stroke

Blood glucose is often elevated in acute stroke, and higher admission glucose levels are associated with larger lesions, greater mortality and poorer functional outcome. In patients treated with thrombolysis, hyperglycemia is associated with an increased risk of hemorrhagic transformation of infarcts. For a number of years, tight glycemic control has been regarded as beneficial in critically illness, but recent research has been unable to support this notion. The only completed randomized study on glucose-lowering therapy in stroke has failed to demonstrate effect, and concerns relating to the risk of inducing potentially harmful hypoglycemia has been raised. Still, basic and observational research is overwhelmingly in support of a causal relationship between blood glucose and stroke outcome and further research on glucose-lowering therapy in acute stroke is highly warranted.