Systemic Glycemic Variation Predicts Mortality of Acute Ischemic Stroke After Mechanical Thrombectomy: A Prospective Study Using Continuous Glucose Monitoring

Glycaemic level and glycaemic variability in acute ischaemic stroke and functional outcome: An observational continuous glucose monitoring study

INTRODUCTION

Glycaemic variability has been associated with poor outcomes in critically ill patients. We aimed to study the association between glycaemic variability and functional outcome in patients with acute ischaemic stroke using continuous glucose monitoring to ensure all episodes of hyper- and hypoglycaemia were captured.

RESEARCH DESIGN AND METHODS

Participants with acute ischaemic stroke were enrolled and started blinded continuous glucose monitoring (Dexcom G6) between November 2020 and December 2022. Glucose data from the first 72 hours after admission were analysed. Patients were classified into 3 groups based on change in functional status (Modified Rankin Scale) between admission and discharge. These included (i) remained independent (RI); (ii) deteriorated to dependent (DD); and (iii) remained dependent (RD).

RESULTS

Data of 67 patients (mean±SD age 72.1 ± 14 years) were analysed; 19 participants had diabetes. The median (IQR) National Institutes of Health Stroke Scale (NIHSS) was 8 (3,14), and 34.3% received reperfusion therapy. The percentage of patients with RI, DD, and RD was 25.4, 55.2, 19.4%. Patients with DD had older age, higher rate of atrial fibrillation, systolic blood pressure, rate of in-hospital infection, NIHSS at admission and at 24 hours after reperfusion therapy compared to those RI. Continuous glucose monitoring was started at 38.4 (29.5,51) hours after stroke onset. Those with DD had higher mean glucose, %time above 180 mg/dL, and glucose standard deviation than the RI group at discharge. Multivariate analysis showed only an association between NIHSS at admission and deterioration in functional status.

CONCLUSIONS

In this pilot study, an association between glycaemic variability and functional deterioration after acute ischaemic stroke was not observed. Clinical Trial Registration numberNCT04521634.

Performance of Continuous Glucose Monitoring System Among Patients With Acute Ischaemic Stroke Treated With Mechanical Thrombectomy

AIMS

Glucose metabolism abnormalities are prevalent in acute ischaemic stroke (AIS) patients and are associated with poor prognosis. The continuous glucose monitoring (CGM) system can provide detailed information on glucose levels and glycaemic excursions. This study aimed to evaluate the feasibility and accuracy of CGM application in the acute phase of AIS patients.

METHODS

This single-centre, prospective, and observational study consecutively enrolled patients with AIS with anterior circulation large vessel occlusion (AC-LVO) and received mechanical thrombectomy (MT) within 24 h of symptom onset. A user-retrospectively calibrated iPro2 CGM system was implanted right before the MT procedure started and removed on the fifth day after MT or at discharge. Fingertip glucose was measured as a reference. Accuracy evaluation included the Bland-Altman plot (with a proportion of CGM values within 15/15, 20/20 and 30/30), the absolute relative difference (ARD) and error grid analysis (EGA). The safety and glucose profiles were also evaluated.

RESULTS

Of the 183 patients screened, 141 were included, with a median monitoring duration of 4.49 days. Compared to reference measurements, 3097 CGM readings were matched with a mean bias of -4.16 mg/dL. The proportions of sensor readings meeting the 15/15, 20/20 and 30/30 criteria were 64.55%, 76.07% and 87.21%, respectively. The overall mean and median ARD were 14.60% ± 14.62% and 9.77% (4.15, 20.00). EGA showed that 98.97%, 99.42% and 99.06% values fall within clinically accurate zones in Clarke, Parkes and continuous glucose EGA, respectively.

CONCLUSION

The CGM system was feasible, safe and accurate for in-hospital use among AIS patients who received MT.

Glycemic variability after mechanical thrombectomy for anterior circulation acute ischemic stroke

INTRODUCTION

Morbidity remains high among patients who undergo successful mechanical thrombectomy (MT) for anterior circulation large vessel occlusion (LVO). Stress hyperglycemia worsens the prognosis after acute ischemic stroke (AIS), but aggressively treating hyperglycemia does not improve the outcome. There is no consensus on how to best manage glycemia after AIS. Glycemic variability (GV) reflects glycemic fluctuations over time and could be the culprit. We aimed to elucidate how GV impacts outcome of AIS patients treated with MT.

PATIENTS AND METHODS

This was a single-center retrospective study. We consecutively included AIS patients who received MT for anterior circulation LVO. We recorded discrete blood glucose measurements within the first 24 hours post thrombectomy, from which we calculated two measures of GV: standard deviation (SD) and coefficient of variation. Univariate and multivariate analyses were conducted to identify predictors of poor functional outcome (modified Ranking scale score 3-6) and mortality at 3-month follow-up.

RESULTS

We included 657 patients. Patients with poor functional outcome (42.5%) and patients that died (14.8%) had significantly higher GV as measured by SD. In a multivariable model adjusted for confounders, higher SD was associated with mortality -adjusted odds ratio: 1.020 (95% CI 1.001-1.040)- but not with functional outcome -adjusted odds ratio for modified Ranking scale score 3-6: 1.007 (95% CI 0.990-1.025)-.

CONCLUSIONS

Our results suggest that higher GV after MT for anterior circulation AIS is an independent risk factor for 3-month mortality. Future trials should evaluate the benefit of reducing GV in this setting.

Insulin resistance is associated with an unfavorable outcome among non-diabetic patients with isolated moderate-to-severe traumatic brain injury – A propensity score-matched study

Background

Hyperglycemia is an independent risk factor for the poor prognosis in patients with traumatic brain injury (TBI), and stress-induced impaired insulin function is the major factor of hyperglycemia in non-diabetic patients with TBI. Several types of research suggested that insulin resistance (IR) is related to the poor prognosis of neurocritical ill patients; here we focused on the role of IR in non-diabetic patients after TBI.

Methods

We performed a prospective observational study with the approval of the Ethics Committee of our institute. IR was accessed via the update Homeostasis Model Assessment (HOMA2) of IR, a computer-calculated index by glucose and insulin level. HOMA2 ≥ 1.4 was considered as the threshold of IR according to the previous studies. The glycemic variability (GV) indices were calculated by fingertip blood glucose concentration at an interval of 2 h within 24 h to explore the relationship between IR and GV. The outcome was the 6-month neurological outcome evaluated with the Glasgow outcome scale.

Results

A total of 85 patients with isolated moderate-to-severe TBI (admission GCS ≤ 12) were finally included in our study, 34 (40%) were diagnosed with IR with HOMA2 ≥ 1.4. After propensity score matching (PSM), 22 patients in IR group were matched to 34 patients in non-IR group. Patients with IR suffered increased systemic glycemic variation after isolated moderate-to-severe TBI. IR was a significant factor for the poor prognosis after TBI (OR = 3.25, 95% CI 1.03–10.31, p = 0.041).

Conclusions

The IR estimated by HOMA2 was associated with greater GV and an unfavorable outcome after isolated moderate-to-severe TBI. Ameliorating impaired insulin sensitivity may be a potential therapeutic strategy for the management of TBI patients.