Increased glycemic variability associated with a poor 30-day functional outcome in acute intracerebral hemorrhage

Glycemic Variability and Prognosis of Patients with Intracerebral Hemorrhage: A Meta-Analysis

Glycemic disorder may affect the outcomes of patients with intracerebral hemorrhage (ICH). However, the association between glycemic variability (GV) and prognosis in these patients remains to be determined. We performed a meta-analysis to compressive the influence of GV on functional outcome and mortality in patients with ICH. Observational studies comparing the risks of poor functional outcome (defined as modified Rankin Scale>2) and all-cause mortality between ICH patients with higher versus lower acute GV were retrieved by systematic search of Medline, Web of Science, Embase, CNKI, and Wanfang databases. A random-effect model was used to pool the data after incorporating the between-study heterogeneity. Sensitivity analyses were performed to evaluate the stability of the findings. Eight cohort studies involving 3400 patients with ICH were included in the meta-analysis. The follow-up duration was within 3 months after admission. All of the included studies used standard deviation of blood glucose (SDBG) as the indicator of acute GV. Pooled results showed that ICH patients with higher SDBG were associated with a higher risk of poor functional outcome as compared to those with lower SDBG [risk ratio (RR): 1.84, 95% confidence interval (CI): 1.41 to 2.42, p<0.001, I2=0%]. In addition, patients with higher category of SDBG were also associated with a higher mortality risk (RR: 2.39, 95% CI: 1.79 to 3.19, p<0.001, I2=0%). In conclusion, high acute GV may be a predictor of poor functional outcome and mortality of patients with ICH.

Prognostic value of glycemic gap in patients with spontaneous intracerebral hemorrhage

BACKGROUND

Glycemic gap (GG), as a novel biomarker showing the acute glycemic change after the onset of acute illness, has been found to be associated with adverse outcomes in many diseases. This study aimed to explore the prognostic value of GG on long-term outcomes of spontaneous intracerebral hemorrhage (sICH).

METHODS

The current study included 528 patients from a multi-center, prospective, consecutive, observational cohort study. Poor clinical outcome was defined as the modified Rankin Scale ≥ 3. GG was calculated using admission blood glucose minus hemoglobin A1c-derived average blood glucose. Logistic regression analyses were performed to determine the association between GG and poor clinical outcomes at 30-day, 90-day and 1-year.

RESULTS

GG was significantly associated with poor clinical outcomes at 30-day, 90-day, and 1-year (P < 0.05 for all models), where patients with higher GG were more likely to have poor clinical outcome. Restricted cubic splines revealed a positive association between GG and poor clinical outcome. In addition, patients with higher GG were more likely to have a higher 1-year mortality rate. The addition of GG to the intracerebral hemorrhage score improved the discrimination and calibration properties for the prediction of poor clinical outcome.

CONCLUSIONS

GG was independently associated with poor outcomes and may be a valuable prognostic factor in patients with sICH.

Quantitative Analysis of Stress-Induced Hyperglycemia and Intracranial Blood Volumes for Predicting Mortality After Intracerebral Hemorrhage

Stress-induced hyperglycemia (SIH) is a neuroendocrine response to acute illness. Although SIH has an adverse association with intracerebral hemorrhage (ICH), quantitative measures and determinants of SIH are not well delineated. In the present study, we objectively evaluated SIH using glycemic gap (GG) and identified its radiological and clinical determinants, with a 5-year retrospective review of charts of ICH patients. We calculated GG using the regression equation (GG = AG -28.7 × HbA1c + 46.7) and evaluated whether GG is an independent predictor of mortality using a multivariate regression model. Radiological volumes of different intracranial compartments were determined using image segmentation software. We correlated GG with different clinical and radiological parameters using Pearson correlation coefficient (PCC), Spearman's rank correlation (SRC), and Wilcoxon rank sum test. Then, we calculated the value of GG associated with mortality. Out of 328 patients, 238 (73%) survived hospitalization and 90 (27%) expired. GG was found to be an independent predictor of mortality (r=0.008, p=0.04). Additionally, GG was positively correlated with intraparenchymal hemorrhage (IPH) volume (PCC=0.185, p<0.01) and intraventricular hemorrhage (IVH) volume (PCC=0.233, p<0.01) and negatively correlated with cerebrospinal fluid (CSF) volume (PCC=-0.151, p<0.01) and brain tissue volume (PCC=-0.099, p=0.08). GG was positively correlated with patients' ICH score (SRC=0.377, p<0.01), Glasgow Coma Scale (GCS) (PCC=-0.356, p<0.01), hydrocephalus (p<0.01), and IVH in the third ventricle (p<0.01). The univariate logistic regression model identified 30.0 mg/dl as the value of GG (AUC=0.655, p<0.01) that predicted mortality with 52.2% sensitivity and 75.2% specificity and defined SIH. In conclusion, GG independently predicts mortality in ICH patients and positively correlates with IPH and IVH volumes. However, causality between the two is not established and would require specifically designed studies.

Effects and mechanisms of CTRP3 overexpression in secondary brain injury following intracerebral hemorrhage in rats

C1q/TNF-related protein-3 (CTRP3) is a novel adipokine that serves an important role in oxidative stress, anti-apoptosis, anti-inflammation and immune regulation. The aim of the present study was to investigate the protective role of CTRP3 against intracerebral hemorrhage (ICH)-induced brain injury. A model of autologous arterial blood-induced ICH was constructed in rats. Intracerebral infusion of a lentivirus carrying the CTRP3 gene was used to induce CTRP3 overexpression in the brain. The effects and mechanisms of CTRP3 overexpression on brain injury were investigated by detecting brain edema, blood-brain barrier (BBB) integrity, neurological function and inflammatory-associated factors 3 days after ICH. The present results demonstrated that CTRP3 overexpression ameliorated ICH-induced neurological dysfunction, decreased brain edema, maintained BBB integrity and attenuated inflammation. The protective effect of CTRP3 overexpression was associated with increased activation of silent information regulator 1 (SIRT1). In conclusion, the present study demonstrated that CTRP3 overexpression protected against ICH-induced brain injury in rats, potentially via activating the SIRT1 signaling pathway.

Association of intraoperative hyperglycemia and postoperative outcomes in patients undergoing non-cardiac surgery: a multicenter retrospective study

BACKGROUND

While pre and postoperative hyperglycemia is associated with increased risk of surgical site infection, myocardial infarction, stroke and risk of death, there are no multicenter data regarding the association of intraoperative blood glucose levels and outcomes for the non-cardiac surgical population.

METHODS

We conducted a retrospective cohort study from the Michigan Surgical Quality Collaborative, a network of 64 hospitals that prospectively collects validated data on surgical patients for the purpose of quality improvement. We included data for adult general, vascular, endocrine, hepatobiliary, and gastrointestinal operations between 2013 and 2015. We assessed the risk-adjusted, independent relationship between intraoperative hyperglycemia (glucose > 180) and the primary outcome of 30-day morbidity/mortality and secondary outcome of infectious complications using multivariable logistic regression modelling. Post hoc sensitivity analysis to assess the association between blood glucose values ≥250 mg/dL and outcomes was also performed.

RESULTS

Ninety-two thousand seven hundred fifty-one patients underwent surgery between 2013 and 2015 and 5014 (5.4%) had glucose testing intra-operatively. Of these patients, 1647 patients (32.9%) experienced the primary outcome, and 909 (18.1%) the secondary outcome. After controlling for patient comorbidities and surgical factors, peak intraoperative glucose > 180 mg/dL was not an independent predictor of 30-day mortality/morbidity (adjusted OR 1.05, 95%CI:0.86 to 1.28; p-value 0.623; model c-statistic of 0.720) or 30-day infectious complications (adjusted OR 0.93, 95%CI:0.74,1.16; p 0.502; model c-statistic of 0.709). Subgroup analysis for patients with or without diabetes yielded similar results. Sensitivity analysis demonstrated blood glucose of 250 mg/dL was a predictor of 30-day mortality/morbidity (adjusted OR: 1.59, 95% CI: 1.24, 2.05; p < 0.001).

CONCLUSIONS

Among more than 5000 patients across 64 hospitals who had glucose measurements during surgery, there was no difference in postoperative outcomes between patients who had intraoperative glucose > 180 mg/ dL compared to patients with glucose values ≤180 mg/ dL.

Association of pre- and post-stroke glycemic status with clinical outcome in spontaneous intracerebral hemorrhage

In this study, we aimed to disclose the association of pre- and post-stroke glycemic status with clinical outcome in patients with spontaneous intracerebral hemorrhage (sICH). It was a multicenter, prospective, observational cohort study, conducted in 13 hospitals in Beijing from January 2014 to September 2016. The association of admission random blood glucose (RBG), fasting blood glucose (FBG) and hemoglobin A1c (HbA1c) with clinical outcome at 90 days after sICH onset were analyzed comprehensively. Poor outcome was defined as death or modified Rankin Scale (mRS) score >2. The results showed that elevated RBG and FBG were associated with larger hematoma volume, lower GCS, higher NIHSS (P < 0.001), and poor outcome, but HbA1c was not (P > 0.05). In stratified analysis, the association of poor outcome with elevated FBG or RBG retained statistical significance just in patients without diabetes. Kaplan-Meier curve and Cox regression showed that patients with elevated FBG or RBG had significantly higher risk of death within 90 days (P < 0.05). So we conclude that poststroke hyperglycemia was associated with larger hematoma volume, severe neurological damage and poor clinical outcome, but HbA1c was not relevant to hematoma volume or clinical outcome in patients with sICH.