Frequency and temporal profile of poststroke hyperglycemia using continuous glucose monitoring

Management of Poststroke Hyperglycemia: Results of the TEXAIS Randomized Clinical Trial

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.

Overexpressing glyoxalase 1 attenuates acute hyperglycemia-exacerbated neurological deficits of ischemic stroke in mice

Stress-induced hyperglycemia (SIH) is associated with poor functional recovery and high mortality in patients with acute ischemic stroke (AIS). However, intensive controlling of blood glucose by using insulin was not beneficial in patients with AIS and acute hyperglycemia. This study investigated the therapeutic effects of the overexpression of glyoxalase I (GLO1), a detoxifying enzyme of glycotoxins, on acute hyperglycemia-aggravated ischemic brain injury.  In the present study, adeno-associated viral (AAV)-mediated GLO1 overexpression reduced infarct volume and edema level but did not improve neurofunctional recovery in the mice with middle cerebral artery occlusion (MCAO). AAV-GLO1 infection significantly enhanced neurofunctional recovery in the MCAO mice with acute hyperglycemia but not in the mice with normoglycemia. Methylglyoxal (MG)-modified proteins expression significantly increased in the ipsilateral cortex of the MCAO mice with acute hyperglycemia. AAV-GLO1 infection attenuated the induction of MG-modified proteins, ER stress formation, and caspase 3/7 activation in MG-treated Neuro-2A cells, and reductions in synaptic plasticity and microglial activation were mitigated in the injured cortex of the MCAO mice with acute hyperglycemia. Treatment with ketotifen, a potent GLO1 stimulator, after surgery, alleviated neurofunctional deficits and ischemic brain damage in the MCAO mice with acute hyperglycemia.  Altogether, our data substantiate that, in ischemic brain injury, GLO1 overexpression can alleviate pathologic alterations caused by acute hyperglycemia. Upregulation of GLO1 may be a therapeutic strategy for alleviating SIH-aggravated poor functional outcomes in patients with AIS.

Beyond hyperglycemia: glycaemic variability as a prognostic factor after acute ischemic stroke

INTRODUCTION

Glycaemic variability (GV) refers to variations in blood glucose levels, and may affect stroke outcomes. This study aims to assess the effect of GV on acute ischaemic stroke progression.

METHODS

We performed an exploratory analysis of the multicentre, prospective, observational GLIAS-II study. Capillary glucose levels were measured every 4 hours during the first 48 hours after stroke, and GV was defined as the standard deviation of the mean glucose values. The primary outcomes were mortality and death or dependency at 3 months. Secondary outcomes were in-hospital complications, stroke recurrence, and the impact of the route of insulin administration on GV.

RESULTS

A total of 213 patients were included. Higher GV values were observed in patients who died (n = 16; 7.8%; 30.9 mg/dL vs 23.3 mg/dL; p = 0.05). In a logistic regression analysis adjusted for age and comorbidity, both GV (OR = 1.03; 95% CI, 1.003-1.06; p = 0.03) and stroke severity (OR = 1.12; 95% CI, 1.04-1.2; p = 0.004) were independently associated with mortality at 3 months. No association was found between GV and the other outcomes. Patients receiving subcutaneous insulin showed higher GV than those treated with intravenous insulin (38.95 mg/dL vs 21.34 mg/dL; p < 0.001).

CONCLUSIONS

High GV values during the first 48 hours after ischaemic stroke were independently associated with mortality. Subcutaneous insulin may be associated with higher VG levels than intravenous administration.

Incidence of Stress-Induced Hyperglycemia in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

The aim of this study was to systematically evaluate the incidence of stress-induced hyperglycemia (SIH) in acute ischemic stroke (AIS). Studies that reported SIH incidence in AIS and examined risk factors for SIH and non-SIH patients were systematically searched in PubMed, Embase, Cochrane Library, and Web of Science from the inception of each database to December 2021. Article screening and data extraction were performed by two independent reviewers according to the inclusion and exclusion criteria. The quality of the included studies was assessed using the Newcastle–Ottawa Scale (NOS), and meta-analysis was performed using Stata. A total of 13 studies involving 4552 patients (977 in the SIH group and 3575 in the non-SIH group) were included. Meta-analysis showed that the incidence of SIH was 24% (95% CI: 21–27%) in the total population, 33% (14–52%) in North America, 25% (20–29%) in Europe, and 21% (12–29%) in Asia. Subgroup analysis by year of publication revealed that the pooled incidence of SIH was 27% (22–32%) in studies published before 2010 and 19% (14–24%) in those published after 2010. SIH is relatively common in AIS and poses a serious public health problem. Therefore, more emphasis should be placed on the prevention and control of SIH in AIS.

Continuous glucose monitoring in acute ischemic stroke patients treated with endovascular therapy: A pilot study to assess feasibility and accuracy

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.

Admission hyperglycemia, stroke subtypes, outcomes in acute ischemic stroke

AIMS

Whether admission hyperglycemia is differentially associated with early vascular outcomes in acute ischemic stroke (AIS) depending on stroke subtype has been incompletely delineated.

METHODS

In a multicenter, prospective stroke registry, patients with AIS were categorized based on admission glucose levels into normoglycemia, moderate hyperglycemia, and severe hyperglycemia (<140mg/dl, 140-179mg/dl, and ≥180mg/dl, respectively) groups. Multivariate analysis assessed the interaction between the hyperglycemia and ischemic stroke subtypes of large artery atherothrombosis (LAA), cardioembolism (CE), and small vessel occlusion (SVO) and early vascular outcomes (3-month stroke, all-cause mortality, and composite of stroke, MI, and all-cause mortality).

RESULTS

Among the 32,772 patients (age:69.0±12.6yrs, male:58.4%) meeting eligibility criteria, 61.9% were in the normoglycemia group, 19.5% were in the moderate hyperglycemia group, and 18.7% were in the severe hyperglycemia group. Substantial interactions between hyperglycemia groups and stroke subtypes were observed for 3-month stroke (P_interaction = 0.003) and composite of stroke, MI, and all-cause mortality (P_interaction = 0.001), with differential recurrence strongest among CE, intermediate among LAA, and least among SVO.

CONCLUSIONS

Hyperglycemia was differently associated with the risk of 3-month stroke by ischemic stroke subtype. The associations of hyperglycemia with 3-month stroke were greatest in CE subtype but not in SVO subtype. These results suggest that the effect of glucose-lowering treatment after AIS may differ according to stroke subtype.

A review of stress-induced hyperglycaemia in the context of acute ischaemic stroke: Definition, underlying mechanisms, and the status of insulin therapy

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.

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.

Persistent hyperglycemia is a useful glycemic pattern to predict stroke mortality: a systematic review and meta-analysis

BACKGROUND

Glycemic patterns have been reported to be prognostic factors for stroke; however, this remains to be further evaluated. This meta-analysis aimed to evaluate the usefulness of glycemic patterns such as persistent hyperglycemia (PH) including short duration and long duration PH (SPH; LPH), admission hyperglycemia (AH), short-duration hyperglycemia (SH), and persistent normoglycemia (PN) in predicting stroke prognosis using published results.

METHODS

Major scientific databases including but are not limited to PubMed, EMBASE, Web of Science, Ovid, CNKI (Chinese National Knowledge Infrastructure), and Clinicaltrials.gov were searched till 1st March 2021 for clinical trials on the correlation between glycemic patterns and stroke outcomes. The primary outcome was defined as short-term (1- or 3-month) post-stroke mortality, and the secondary outcome was post-stroke hemorrhage at 6 months.

RESULTS

Ten studies involving 3584 individuals were included in the final analysis. In subgroup analyses, PH patients with no history of diabetes had increased post-stroke mortality (odds ratio [OR]: 4.80, 95% CI: 3.06-7.54) than patients with no PH; and patients with glucose levels > 140 mg/dl had greater mortality (OR: 5.12, 95% CI: 3.21-8.18) than those with glucose levels < 140 mg/dl; compared with AH patients, PH patients had increased short-term mortality (OR: 0.31, 95% CI: 0.16-0.60). In the prediction of stroke mortality among patients without diabetes, SPH (OR: 0.28, 95%CI: 0.12-0.69) seemed to be more related to increased mortality than LPH (OR: 0.35, 95% CI: 0.14--0.90).

CONCLUSIONS

PH, especially SPH, could predict increased post-stroke mortality in non-diabetic patients. The rank of individual glycemic patterns in predicting stroke mortality in non-diabetic patients was SPH > LPH > AH > PN.

A comparison of the stress hyperglycemia ratio, glycemic gap, and glucose to assess the impact of stress-induced hyperglycemia on ischemic stroke outcome

BACKGROUND

The aim of this study is to compare metrics specific for stress-induced hyperglycemia (SIH) with glucose for predicting ischemic stroke outcome.

METHODS

This observational retrospective study (n = 300) included patients acutely hospitalized for ischemic stroke over a 3.8-year period. We assessed the association between acute ischemic stroke outcome with the stress hyperglycemia ratio (SHR, relative increase in glycemia) and glycemic gap (GG, absolute increase in glycemia) using admission values and 5-day maximum values, along with incidence of poor outcome above recognized clinical thresholds of glucose 10 mmol/L, SHR 1.14, and GG 2.5 mmol/L.

RESULTS

At admission, only SHR was associated with outcome after adjustment for clinical covariates (odds ratio [OR] = 2.88; 95% CI: 1.05-7.91; P = .041), while glucose or GG were not. Admission SHR ≥ 1.14 was also an indicator of poor outcome (39.1% vs 23.4%, P = .016), but not glucose ≥10 mmol/L or GG ≥ 2.5 mmol/L. All 5-day maximum glucose metrics were associated with outcome, as was any SHR ≥ 1.14 (40.9% vs 20.1%, P < .001) or GG ≥ 2.5 mmol/L (42.9% vs 23.4%, P = .011), but not glucose ≥10 mmol/L. Increased comorbidity was strongly associated with worse outcome (P < .001) in all models.

CONCLUSIONS

SHR provided the best prognostic insight at admission to assess the relationship between SIH and ischemic stroke outcome. Absolute glucose levels failed to account for natural interpatient variation in background glycemia and provided little prognostic insight. To assess the impact of SIH, future interventional studies need to be designed using designated markers of SIH such as SHR in preference to absolute glucose.

Glycemic variability of acute stroke patients and clinical outcomes: a continuous glucose monitoring study

Introduction:

Glycemic variability (GV) has been associated with worse prognosis in critically ill patients. We sought to evaluate the potential association between GV indices and clinical outcomes in acute stroke patients.

Methods:

Consecutive diabetic and nondiabetic, acute ischemic or hemorrhagic stroke patients underwent regular, standard-of-care finger-prick measurements and continuous glucose monitoring (CGM) for up to 96 h. Thirteen GV indices were obtained from CGM data. Clinical outcomes during hospitalization and follow-up period (90 days) were recorded. Hypoglycemic episodes disclosed by CGM but missed by finger-prick measurements were also documented.

Results:

A total of 62 acute stroke patients [48 ischemic and 14 hemorrhagic, median NIHSS score: 9 (IQR: 3–16) points, mean age: 65 ± 10 years, women: 47%, nondiabetic: 79%] were enrolled. GV expressed by higher mean absolute glucose (MAG) values was associated with a lower likelihood of neurological improvement during hospitalization before and after adjusting for potential confounders (OR: 0.135, 95% CI: 0.024–0.751, p = 0.022). There was no association of GV indices with 3-month clinical outcomes. During CGM recording, 32 hypoglycemic episodes were detected in 17 nondiabetic patients. None of these episodes were identified by the periodic blood glucose measurements and therefore they were not treated.

Conclusions:

Greater GV of acute stroke patients may be related to lower odds of neurological improvement during hospitalization. No association was disclosed between GV indices and 3-month clinical outcomes.

Relationship between fasting blood glucose and subsequent vascular events in Chinese patients with mild ischaemic stroke: a cohort study

Objective

To characterise the relationship between fasting blood glucose (FBG) and the incidence of subsequent vascular events (SVE) during the 6 months following a mild ischaemic stroke (MIS) in Chinese patients.

Methods

Data from patients with MIS were retrospectively analysed. The primary endpoint was an SVE during the 6-month follow-up period. The participants were allocated to three groups (tertiles), according to their FBG concentration.

Results

Of the 260 participants, 51 (19.6%) reported an SVE during the follow-up period. The incidence of SVE significantly differed among the tertiles of FBG. The odds ratio (OR) was 2.361 (95% confidence interval [CI]: 1.551–3.594) for FBG as a continuous variable and that for FBG categorised according to tertile was 13.30 (95% CI: 3.519–50.322) in the fully adjusted model. Curve fitting showed that the incidence of SVE gradually increased with increasing FBG, with the highest tertile showing the highest mean incidence (46.7%; 95% CI: 16.2%–79.9%). In addition, participants with or without diabetes mellitus, hypertension, headache, dizziness, mild cognitive impairment or anterior circulation artery lesion showed similar associations between FBG and the incidence of SVE.

Conclusion

FBG is an independent predictor of 6-month SVE risk in Chinese patients with MIS.

Verapamil as an Adjunct Therapy to Reduce tPA Toxicity in Hyperglycemic Stroke: Implication of TXNIP/NLRP3 Inflammasome

Thrombolytic therapy has remained quite challenging in hyperglycemic patients for its association with poor prognosis and increased hemorrhagic conversions. We recently showed that tissue plasminogen activator (tPA)-induced cerebrovascular damage is associated with thioredoxin-interacting protein (TXNIP) upregulation, which has an established role in the detrimental effects of hyperglycemia. In the present work, we investigated whether verapamil, an established TXNIP inhibitor, may provide protection against hyperglycemic stroke and tPA-induced blood-brain barrier (BBB) disruption. Acute hyperglycemia was induced by intraperitoneal administration of 20% glucose, 15 min prior to transient middle cerebral artery occlusion (tMCAO). Verapamil (0.15 mg/kg) or saline was intravenously infused with tPA at hyperglycemic reperfusion, 1 h post tMCAO. After 24 h of ischemia/reperfusion (I/R), mice were assessed for neurobehavioral deficits followed by sacrifice and evaluation of brain infarct volume, edema, and microbleeding. Alterations in TXNIP, inflammatory mediators, and BBB markers were further analyzed using immunoblotting or immunostaining techniques. As adjunctive therapy, verapamil significantly reduced tPA-induced BBB leakage, matrix metalloproteinase 9 (MMP-9) upregulation, and tight junction protein deregulation, which resulted in lesser hemorrhagic conversions. Importantly, verapamil strongly reversed tPA-induced TXNIP/NLRP3 (NOD-like receptor pyrin domain-containing-3) inflammasome activation and reduced infarct volume. This concurred with a remarkable decrease in high-mobility group box protein 1 (HMGB-1) and nuclear factor kappa B (NF-κB) stimulation, leading to less priming of NLRP3 inflammasome. This preclinical study supports verapamil as a safe adjuvant that may complement thrombolytic therapy by inhibiting TXNIP's detrimental role in hyperglycemic stroke.

Symptomatic intracranial hemorrhage in patients with admission hyperglycemia and diabetes after mechanical thrombectomy: A systematic review and meta-analysis

OBJECTIVES

Symptomatic intracranial hemorrhage (sICH) is a severe complication of revascularization therapy. We aimed to investigate the association of admission hyperglycemia and sICH after mechanical thrombectomy in patients with acute ischemic stroke.

METHODS

We systematically searched PubMed, EMBASE and Cochrane Library to identify studies that reported incidence of sICH in patients with admission hyperglycemia and normoglycemia, or with and without a history of diabetes, or glucose level in patients with sICH and non-sICH from inception to December 10, 2019. The estimate effects were pooled by random-effects model.

RESULTS

Twelve eligible studies were included with 4892 patients enrolled. The risk of sICH was significantly higher in admission hyperglycemia patients than that in normoglycemia (OR 2.93, 95% CI 1.34-6.42, p = 0.007; adjusted OR1.95, 95% CI 1.22-3.13; p = 0.006). The admission glucose level was significantly higher in sICH patients than that in non-sICH with a mean difference of 37.49 (95% CI 3.03-71.94, p = 0.03). The risk of sICH increased with elevating glucose level (adjusted OR 1.06, 95% CI 1.01-1.11; p = 0.02). The risk of sICH was not significantly increased in patients with a history of diabetes than that of those without (OR 1.74, 95% CI 1.00-3.03, p = 0.05; adjusted OR 2.26, 95% CI 0.97-5.28; p = 0.06).

CONCLUSIONS

In patients of acute ischemic stroke treated with mechanical thrombectomy, the risk of sICH was associated with admission hyperglycemia but possibly not with a history of diabetes.

Dynamic change of MMP-9 in diabetic stroke visualized by optical imaging and treated with CD28 superagonist

By utilizing NIRF imaging, diabetic stroke mice were visualized with a trend of higher levels of MMP-9 than wild-type mice. CD28 SA down-regulated the expression of MMP-9 and represents a potential treatment to diabetic stroke.

Glycemic variability: prognostic impact on acute ischemic stroke and the impact of corrective treatment for hyperglycemia. The GLIAS-III translational study

Introduction

Glycemic variability (GV) represents the amplitude of oscillations in glucose levels over time and is associated with higher mortality in critically ill patients. Our aim is to evaluate the impact of GV on acute ischemic stroke (IS) outcomes in humans and explore the impact of two different insulin administration routes on GV in an animal model.

Methods

This translational study consists of two studies conducted in parallel: The first study is an observational, multicenter, prospective clinical study in which 340 patients with acute IS will be subcutaneously implanted a sensor to continuously monitor blood glucose levels for 96 h. The second study is a basic experimental study using an animal model (rats) with permanent occlusion of the middle cerebral artery and induced hyperglycemia (through an intraperitoneal injection of nicotinamide and streptozotocin). The animal study will include the following 6 groups (10 animals per group): sham; hyperglycemia without IS; IS without hyperglycemia; IS and hyperglycemia without treatment; IS and hyperglycemia and intravenous insulin; and IS and hyperglycemia and subcutaneous insulin. The endpoint for the first study is mortality at 3 months, while the endpoints for the animal model study are GV, functional recovery and biomarkers.

Discussion

The GLIAS-III study will be the first translational approach analyzing the prognostic influence of GV, evaluated by the use of subcutaneous glucose monitors, in acute stroke.

Trial registrationhttps://www.clinicaltrials.gov (NCT04001049)

Beyond hyperglycemia: glycaemic variability as a prognostic factor after acute ischemic stroke

INTRODUCTION

Glycaemic variability (GV) refers to variations in blood glucose levels, and may affect stroke outcomes. This study aims to assess the effect of GV on acute ischaemic stroke progression.

METHODS

We performed an exploratory analysis of the multicentre, prospective, observational GLIAS-II study. Capillary glucose levels were measured every 4 hours during the first 48 hours after stroke, and GV was defined as the standard deviation of the mean glucose values. The primary outcomes were mortality and death or dependency at 3 months. Secondary outcomes were in-hospital complications, stroke recurrence, and the impact of the route of insulin administration on GV.

RESULTS

A total of 213 patients were included. Higher GV values were observed in patients who died (n = 16; 7.8%; 30.9 mg/dL vs 23.3 mg/dL; p = 0.05). In a logistic regression analysis adjusted for age and comorbidity, both GV (OR = 1.03; 95% CI, 1.003-1.06; p = 0.03) and stroke severity (OR = 1.12; 95% CI, 1.04-1.2; p = 0.004) were independently associated with mortality at 3 months. No association was found between GV and the other outcomes. Patients receiving subcutaneous insulin showed higher GV than those treated with intravenous insulin (38.95 mg/dL vs 21.34 mg/dL; p < 0.001).

CONCLUSIONS

High GV values during the first 48 hours after ischaemic stroke were independently associated with mortality. Subcutaneous insulin may be associated with higher VG levels than intravenous administration.

Tissue Plasminogen Activator Promotes TXNIP-NLRP3 Inflammasome Activation after Hyperglycemic Stroke in Mice

Hyperglycemia has been shown to counterbalance the beneficial effects of tissue plasminogen activator (tPA) and increase the risk of intracerebral hemorrhage in ischemic stroke. Thioredoxin interacting protein (TXNIP) mediates hyperglycemia-induced oxidative damage and inflammation in the brain and reduces cerebral glucose uptake/utilization. We have recently reported that TXNIP-induced NLRP3 (NOD-like receptor pyrin domain-containing-3) inflammasome activation contributes to neuronal damage after ischemic stroke. Here, we tested the hypothesis that tPA induces TXNIP-NLRP3 inflammasome activation after ischemic stroke, in hyperglycemic mice. Acute hyperglycemia was induced in mice by intraperitoneal (IP) administration of a 20% glucose solution. This was followed by transient middle cerebral artery occlusion (t-MCAO), with or without intravenous (IV) tPA administered at reperfusion. The IV-tPA exacerbated hyperglycemia-induced neurological deficits, ipsilateral edema and hemorrhagic transformation, and accentuated peroxisome proliferator activated receptor-γ (PPAR-γ) upregulation and TXNIP/NLRP3 inflammasome activation after ischemic stroke. Higher expression of TXNIP in hyperglycemic t-MCAO animals augmented glucose transporter 1 (GLUT-1) downregulation and increased vascular endothelial growth factor-A (VEGF-A) expression/matrix metallopeptidase 9 (MMP-9) signaling, all of which result in blood brain barrier (BBB) disruption and increased permeability to endogenous immunoglobulin G (IgG). It was also associated with a discernible buildup of nitrotyrosine and accumulation of dysfunctional tight junction proteins: zonula occludens-1 (ZO-1), occludin and claudin-5. Moreover, tPA administration triggered activation of high mobility group box protein 1 (HMGB-1), nuclear factor kappa B (NF-κB), and tumor necrosis factor-α (TNF-α) expression in the ischemic penumbra of hyperglycemic animals. All of these observations suggest a powerful role for TXNIP-NLRP3 inflammasome activation in the tPA-induced toxicity seen with hyperglycemic stroke.

Association of Baseline Hyperglycemia With Outcomes of Patients With and Without Diabetes With Acute Ischemic Stroke Treated With Intravenous Thrombolysis: A Propensity Score-Matched Analysis From the SITS-ISTR Registry

Available data from observational studies on the association of admission hyperglycemia (aHG) with outcomes of patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis (IVT) are contradictory, especially when stratified by diabetes mellitus (DM) history. We assessed the association of aHG (≥144 mg/dL) with outcomes stratified by DM history using propensity score-matched (PSM) data from the SITS-ISTR. The primary safety outcome was symptomatic intracranial hemorrhage (SICH); 3-month functional independence (FI) (modified Rankin Scale [mRS] scores 0-2) represented the primary efficacy outcome. Patients with and without aHG did not differ in baseline characteristics both in the non-DM (n = 12,318) and DM (n = 6,572) PSM subgroups. In the non-DM group, patients with aHG had lower 3-month FI rates (53.3% vs. 57.9%, P < 0.001), higher 3-month mortality rates (19.2% vs. 16.0%, P < 0.001), and similar symptomatic intracerebral hemorrhage (SICH) rates (1.7% vs. 1.8%, P = 0.563) compared with patients without aHG. Similarly, in the DM group, patients with aHG had lower rates of 3-month favorable functional outcome (mRS scores 0-1, 34.1% vs. 39.3%, P < 0.001) and FI (48.2% vs. 52.5%, P < 0.001), higher 3-month mortality rates (23.7% vs. 19.9%, P < 0.001), and similar SICH rates (2.2% vs. 2.7%, P = 0.224) compared with patients without aHG. In conclusion, aHG was associated with unfavorable 3-month clinical outcomes in patients with and without DM and AIS treated with IVT.

Influence of Hyperglycemia Associated with Enteral Nutrition on Mortality in Patients with Stroke

Objectives: To evaluate in patients admitted for stroke: (1) The frequency of hyperglycaemia associated with enteral nutrition (EN). (2) The risk of morbidity and mortality associated with the development of this type of hyperglycaemia.

METHODS

A longitudinal observational study was conducted in 115 non-diabetic patients admitted for stroke with EN. Age, functional capacity (Rankin scale), and blood plasma glucose (BPG) were recorded. Hyperglycaemia was considered as: a value higher than 126 mg/dL before the EN and/or a value higher than 150 mg/dL after a week of enteral nutrition. According to this, three groups were differentiated: HyperES: Those who had hyperglycemia before the beginning of the EN (33% patients); NoHyper: those who did not have hyperglycemia before or after (47.8% patients); and HyperEN: Those who did not have hyperglycemia before but suffered it after the beginning of the EN (19.1% patients).

RESULTS

The age was 72.72 (15.32) years. A higher rate of mortality was observed in the HyperEN group 45.50%, than HyperES 15.80% or NoHyper: 10.90%). A lower recovery of the oral feeding was observed in those patients of the HyperEN group 27.30%, than HyperES: 42.10% or NoHyper: 61.80%). In the multivariate analysis adjusting for age, sex, and Rankin scale the development of hyperglycemia in those who did not have it at the beginning (HyperEN) was an independent risk factor for non-recovery of the oral feeding (OR: 4.21 (1.20-14.79), p = 0.02); and mortality adjusted for age, sex and Rankin scale (OR: 6.83 (1.76-26.47), p < 0.01).

CONCLUSIONS

In non-diabetic patients admitted for stroke with EN, the development of hyperglycaemia in relation to enteral nutrition supposes an independent risk factor for mortality and for the non-recovery of the oral feeding.

Microvascular complications of diabetes worsen long-term functional outcomes after acute ischemic stroke

Objective

This study was performed to evaluate the potential predictors of poor outcomes associated with diabetes-specific microvascular pathologies and to analyze their influence on clinical outcomes by adjusting for other well-known prognostic factors in patients with acute ischemic stroke.

Methods

We analyzed 1389 consecutive adult patients with acute ischemic stroke and explored the relationship among clinical characteristics, laboratory measurements, imaging findings, and 6-month functional outcomes.

Results

The final study population comprised 216 patients with both acute ischemic stroke and diabetes mellitus who were followed up for 6 months. A multiple logistic regression analysis of poor outcomes revealed the following independent predictors: leukoaraiosis severity [odds ratio (OR), 7.38; 95% confidence interval (CI), 1.40–38.86, per 1-point increase), diabetic nephropathy (OR, 10.66; 95% CI, 1.10–103.43), and the admission National Institutes of Health stroke scale score (OR, 2.58; 95% CI, 1.36–4.92 per 1-point increase). In this model, admission hyperglycemia and intracerebral hemorrhagic transformation were not independent prognostic predictors.

Conclusion

Microvascular complications (such as nephropathy) caused by diabetes mellitus predict an unfavorable clinical outcome after acute ischemic stroke. Diabetic nephropathy may partly affect post-stroke prognosis by means of exacerbating leukoaraiosis.

Combined utility of white blood cell count and blood glucose for predicting in-hospital outcomes in acute ischemic stroke

Background

High white blood cell (WBC) count and high blood glucose level are risk factors for mortality and pneumonia after acute ischemic stroke (AIS). We investigated the combined effect of high WBC count and high blood glucose level on hospital admission and in-hospital mortality and pneumonia in acute AIS patients.

Methods

A total of 3124 AIS patients enrolled from December 2013 to May 2014 across 22 hospitals in Suzhou city were included in the present study. We divided patients into four groups according to their level of WBC count and blood glucose: NWNG (normal WBC count and normal glucose), NWHG (normal WBC count and higher glucose), HWNG (higher WBC count and normal glucose), and HWHG (higher WBC count and higher glucose). Cox proportional hazard model and logistic regression model were used to estimate the combined effect of WBC count and blood glucose on all-cause in-hospital mortality and pneumonia in AIS patients.

Results

HWHG was associated with a 2.22-fold increase in the risk of in-hospital mortality in comparison to NWNG (adjusted hazard ratio [HR] 2.22; 95% confidence interval [CI], 1.21–4.07; P trend = 0.003). The risk of pneumonia was significantly higher in patients with HWHG compared to those with NWNG (adjusted odds ratio [OR] 2.61; 95% CI, 1.66–4.10; P trend < 0.001). The C-statistic for the combined WBC count and blood glucose was higher than WBC count or blood glucose alone for prediction of in-hospital mortality and pneumonia (all p < 0.01).

Conclusions

High WBC count combined with high blood glucose level at admission was independently associated with in-hospital mortality and pneumonia in AIS patients. Moreover, the combination of WBC count and blood glucose level appeared to be a better predictor than WBC count or blood glucose alone.

Electronic supplementary material

The online version of this article (10.1186/s12974-019-1422-7) contains supplementary material, which is available to authorized users.

Neurovascular unit transport responses to ischemia and common coexisting conditions: smoking and diabetes

Transporters at the neurovascular unit (NVU) are vital for the regulation of normal brain physiology via ion, water, and nutrients movement. In ischemic stroke, the reduction of cerebral blood flow causes several complex pathophysiological changes in the brain, one of which includes alterations of the NVU transporters, which can exacerbate stroke outcome by increased brain edema (by altering ion, water, and glutamate transporters), altered energy metabolism (by altering glucose transporters), and enhanced drug toxicity (by altering efflux transporters). Smoking and diabetes are common risk factors as well as coexisting conditions in ischemic stroke that are also reported to change the expression and function of NVU transporters. Coexistence of these conditions could cause an additive effect in terms of the alterations of brain transporters that might lead to worsened ischemic stroke prognosis and recovery. In this review, we have discussed the effects of ischemic stroke, smoking, and diabetes on some essential NVU transporters and how the simultaneous presence of these conditions can affect the clinical outcome after an ischemic episode. Further scientific investigations are required to elucidate changes in NVU transport in cerebral ischemia, which can lead to better, personalized therapeutic interventions tailor-made for these comorbid conditions.

Clinical Implications of Serial Glucose Measurements in Acute Ischemic Stroke Patients Treated with Intravenous Thrombolysis

Serial glucose might more accurately reflect glycemic status in acute ischemic stroke (AIS) than presenting glucose. We sought to investigate the clinical implications of various parameters of serial glucose on the outcomes of patients with AIS treated with intravenous thrombolysis (IVT). This was a single-center, prospective, observational study of stroke patients treated with IVT. Blood glucose (BG) was serially measured at 6-time points during the first 24 h of IVT. The primary endpoint analyzed was a good outcome at 3 m. Among the 492 patients in the cohort (age, 70 ± 12 y; men, 57%), the overall BG level was 131 ± 33 mg/dl. At 3 m, 40.4% of the patients had a good outcome. Patients with good outcomes had significantly lower mean BG (121 vs 128 mg/dl) and higher coefficient of variance (CoV, 17% vs 14%) but no differences in the others. For patients with higher mBG (every 30 mg/dl), the likelihood of achieving a good outcome decreased (OR 0.82, 95% CI 0.67–1.02). For patients with higher CoV (every 10%), the likelihood of a good outcome increased (OR 1.38, 95% CI 1.12–1.71). The results showed that higher mBG and lower CoV were consistently associated with worse outcomes in IV-thrombolyzed stroke patients, suggesting that lowering BG might be potential therapeutic target.

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

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.

Inpatient Glycemic Management of Non-cardiac CVD: Focus on Stroke and PVD

PURPOSE OF REVIEW

Hyperglycemia occurs frequently in hospitalized patients with stroke and peripheral vascular disease (PVD). Guidelines for inpatient glycemic management are not well established for this patient population. We will review the clinical impact of hyperglycemia in this acute setting and review the evidence for glycemic control.

RECENT FINDINGS

Hyperglycemia in acute stroke is associated with poor short and long-term outcomes, and perioperative hyperglycemia in those undergoing revascularization for PVD is linked to increased post-surgical complications. Studies evaluating tight glucose control do not demonstrate improvement in clinical outcomes, although the risk for hypoglycemia increases substantially. Additional studies are needed to evaluate tight glucose goals relative to our current standard of care and the role of permissive hyperglycemia. Given the limited data to guide glycemic management in these patient populations, it is recommended that general guidelines for inpatient glycemic control be followed. Special considerations should be made to address factors that may impact glucose management, including neurological deficits and clinical changes that occur in the postoperative state.

In-hospital dynamics of glucose, blood pressure and temperature predict outcome in patients with acute ischaemic stroke

INTRODUCTION

We aimed to assess alterations in glucose, blood pressure and temperature in acute ischaemic stroke and investigate their association with early all-cause mortality and functional outcome.

PATIENTS AND METHODS

We studied all consecutive acute ischaemic stroke patients admitted in 2001-2010 to the Acute Stroke Unit, at Alexandra University Hospital, in Athens. Serial measurements were performed in the first seven days post-stroke and different parameters have been estimated: mean daily values, variability, subject-specific baseline levels and rate of change in serial measurements. Cox-proportional-hazards-model analysis and logistic-regression analysis were applied to investigate the association between these parameters and all-cause mortality and functional outcome after adjustment for known confounders of stroke outcome.

RESULTS

In 1271 patients (mean age 72.3 ± 11.2 years), after adjusting for confounders, baseline glucose levels (HR: 1.005, 95%CI: 1.001-1.01; p = 0.017), variability of systolic BP (SBP) as estimated by standard deviation (HR: 1.028, 95%CI: 1.01-1.048; p = 0.005), the baseline temperature (HR: 2.758, 95%CI: 2.067-3.68; p < 0.001) and the rate of temperature change (HR: 1.841, 95%CI: 1.616-2.908; p < 0.001) were independently associated with all-cause mortality within three months. Poor functional outcome was associated with subject-specific baseline values of temperature (OR: 1.743; 95%CI: 1.076-2.825; p = 0.024), the rate of SBP (OR: 1.159; 95% CI: 1.047-1.280; p = 0.004) and temperature change (OR: 1.402; 95% CI: 1.061-1.853; p = 0.018).

DISCUSSION

The main strength of our study is that we analysed simultaneously three parameters and we used four different variables for each parameter of interest.

CONCLUSION

Baseline glucose levels, variability of SBP and baseline temperature and its rate of change are independent predictors of all-cause mortality. Baseline values of temperature and the rate of changes in SBP and temperature are independent predictors of poor functional outcome.

Range of glucose as a glycemic variability and 3-month outcome in diabetic patients with acute ischemic stroke

Glycemic variability (GV) is reportedly a predictor for poor outcome in various clinical conditions. We aimed to assess whether GV during hospital admission is associated with poor outcomes in patients with acute ischemic stroke (AIS) and diabetes. We prospectively enrolled consecutive patients with AIS from the registry of 6 tertiary hospitals between January 2013 and December 2014. For the GV index, we used a glucose level range that was divided into 4 quartiles. Multivariable binary and ordinal logistic regression analyses were performed to determine the association between GV and the modified Rankin Scale score (3–6) at 3 months. We enrolled 1,504 patients with AIS and diabetes (mean age, 68.1 years; male, 57.2%), of which 35.1% had poor outcomes at 3 months. An increasing glucose range quartile was positively associated with initial neurologic severity and development of hypoglycemia during hospital admission. Multivariable analysis showed that the glucose level range quartile was associated with poor outcomes, even after adjusting for the number of glucose measurement and hypoglycemia (odds ratio [OR] Q2 vs. Q1: 1.50, 95% confidence interval [CI]: 1.02–2.18; OR Q3 vs. Q1: 2.01, 95% CI: 1.34–3.01; OR Q4 vs. Q1: 1.98, 95% CI: 1.22–3.23). These associations remained significant after dichotomization according to glycated hemoglobin levels at admission. An increasing glucose level range as a GV index during hospital admission was associated with poor functional outcomes at 3 months in patients with AIS and diabetes.

Pre-stroke glycemic control is associated with early neurologic deterioration in acute atrial fibrillation-related ischemic stroke

Background

It has been suggested that AF-related ischemic stroke (IS) that is accompanied by atherosclerotic burden have poorer outcomes. The aim of this study was to investigate the importance of pre-stroke glycemic control (PSGC) on the early neurologic deterioration (END) of patients with acute AF-related IS.

Methods

We retrospectively recruited 121 patients with AF-related IS who also had Diabetes mellitus (DM). The HbA1C level was measured in all subjects. END was defined as an increase in the National Institute of Health Stroke Scale (NIHSS) score of 4 NIHSS points within 7 days of symptom onset compared to the initial NIHSS score.

Results

In this study, 20.7% (25 patients) were classified as having a poor PSGC status with a HbA1C level above 8.0%. In the univariate analysis, a poor PSGC status (p < 0.01), smoking (p = 0.01), severe neurologic deficits at admission (p = 0.01), and a larger size of ischemic lesions on DWI (p < 0.01) were associated with the occurrence of END. In the multivariate model, a poor PSGC status (p = 0.02) and larger size of ischemic lesions on MRI (p < 0.01) were independent predictors of END in acute AF-related IS.

Conclusion

The HbA1c level upon admission was independently associated with significant prediction of END in acute AF-related IS.

Is management of hyperglycaemia in acute phase stroke still a dilemma?

INTRODUCTION

Close monitoring of blood glucose levels during the immediate post-acute stroke phase is of great clinical value, as there is evidence that the risk of neurological deterioration is associated with both hyper- and hypoglycaemia. The aim of this review paper is to summarise the evidence on post-stroke blood glucose management and its impact on clinical outcomes, during the early post-acute stage.

FINDINGS

Post-stroke hyperglycaemia has been associated with increased cerebral oedema, haemorrhagic transformation, lower likelihood of recanalisation and deteriorating neurological state. Thus, hyperglycaemia during an acute stroke may result in poorer clinical outcomes, infarct progression, poor functional recovery and increased mortality rates. Although hypoglycaemia may also lead to poorer outcomes via further brain injury, it can be readily reversed by glucose administration. In most patients, the goal of regular treatment is euglycaemia and for acute-stroke patients, a reasonable approach is to target control of glucose level at 100-150 mg/dL.

CONCLUSION

Both hypoglycaemia and hyperglycaemia may lead to further brain injury and clinical deterioration; that is the reason these conditions should be avoided after stroke. Yet, when correcting hyperglycaemia, great care should be taken not to switch the patient into hypoglycaemia, and subsequently aggressive insulin administration treatment should be avoided. Early identification and prompt management of hyperglycaemia, especially in acute ischaemic stroke, is recommended. Although the appropriate level of blood glucose during acute stroke is still debated, a reasonable approach is to keep the patient in a mildly hyperglycaemic state, rather than risking hypoglycaemia, using continuous glucose monitoring.

Glucose control in acute brain injury: does it matter?

PURPOSE OF REVIEW

Alterations of blood glucose levels are secondary insults with detrimental consequences for the injured brain. Here, we review various aspects of brain glucose metabolism and analyze the evidence on glycemic control during acute brain injury.

RECENT FINDINGS

An essential component in the overall management of acute brain injury, especially during the acute phase, is maintaining adequate and appropriate control of serum glucose. This is one of the few physiological parameters that is modifiable. Hypoglycemia should be rigorously avoided. However, intensive insulin therapy is associated with unacceptable rates of hypoglycemia and metabolic crisis, and does not necessarily provide benefit. Hyperglycemia is harmful to the injured brain as it compromises microcirculatory blood flow, increases blood-brain barrier permeability, and promotes inflammation. In addition, it triggers osmotic diuresis, hypovolemia, and immunosuppression.

SUMMARY

Glucose is the primary energy substrate for the brain. During injury, the brain increases its needs and is vulnerable to glucose deficit. In these situations, alternative fuel can be lactate, which has potential implications for future research. In this review, various pathophysiological aspects of glucose metabolism during acute brain injury, as well as the risks, causes, and consequences of glucose deficiency or excess, will be discussed.

Managing a Stroke Unit: An Example from Australia with an Emphasis on Nursing Roles

Stroke care units (SCUs), which are co-ordinated by dedicated multidisciplinary teams and geographically located in one area, are currently the most generaliseable form of effective treatment for stroke. Although the evidence for SCUs is compelling, to date there has been limited evidence regarding the contribution of the different clinical team members who assist in producing the better patient outcomes observed in SCUs. In particular, there has been limited exploration of the different nursing roles. The purpose of this special report is to describe how an SCU operates and highlight the contribution of the various nursing roles as part of the multidisciplinary stroke team. The article is based on one of the longest established stroke services in Melbourne, Australia. The characteristics and composition of the Royal Melbourne Hospital stroke service in providing clinical care and management will be highlighted as an example. Further, the nursing roles related to avoiding complications, education for patients and families and other staff in the unit, as well as participation in research and future career development opportunities are discussed.

Treatment of hyperglycaemia in patients with acute stroke

The proportion of diabetic patients who are hospitalised for stroke has been increasing in recent years, currently reaching almost a third of all cases of stroke. In addition, about half of patients with acute stroke present hyperglycaemia in the first hours of the stroke. Although hyperglycaemia in the acute phase of stroke is associated with a poor prognosis, its treatment is currently a topic of debate. There is no evidence that the adminstration of intravenous insulin to these patients offers benefits in terms of the evolution of the stroke. New studies in development, such as the SHINE study (Stroke Hyperglycemia Insulin Network Effort), may contribute to clarifying the role of intensive control of glycaemia during the acute phase of the stroke. Ultimately, patients who have presented with stroke should be screened for diabetes.

Fermented soybeans, Chungkookjang, prevent hippocampal cell death and β-cell apoptosis by decreasing pro-inflammatory cytokines in gerbils with transient artery occlusion

Since Chungkookjang, a short-term fermented soybean, is known to improve glucose metabolism and antioxidant activity, it may prevent the neurological symptoms and glucose disturbance induced by artery occlusion. We investigated the protective effects and mechanisms of traditional (TFC) and standardized Chungkookjang fermented with Bacillus licheniformis (BLFC) against ischemia/reperfusion damage in the hippocampal CA1 region and against hyperglycemia after transient cerebral ischemia in gerbils. Gerbils were subjected to either an occlusion of the bilateral common carotid arteries for 8 min to render them ischemic or a sham operation. Ischemic gerbils were fed either a 40% fat diet containing 10% of either cooked soybean (CSB), TFC, or BLFC for 28 days. Neuronal cell death and cytokine expression in the hippocampus, neurological deficit, serum cytokine levels, and glucose metabolism were measured. TFC and BLFC contained more isoflavonoid aglycones than CSB. Artery occlusion increased the expressions of IL-1β and TNF-α as well as cell death in the hippocampal CA1 region and induced severe neurological symptoms. CSB, TFC, and BLFC prevented the neuronal cell death and the symptoms such as dropped eyelid, bristling hair, reduced muscle tone and flexor reflex, and abnormal posture and walking patterns, and suppressed cytokine expressions. CSB was less effective than TFC and BLFC. Artery occlusion induced glucose intolerance due to decreased insulin secretion and β-cell mass. TFC and BLFC prevented the impairment of glucose metabolism by artery occlusion. Especially TFC and BLFC increased β-cell proliferation and suppressed the β-cell apoptosis by suppressing TNF-α and IL-1β which in turn decreased cleaved caspase-3 that caused apoptosis. In conclusion, TFC and BLFC may prevent and alleviate neuronal cell death in the hippocampal CA1 region and neurological symptoms and poststroke hyperglycemia in gerbils with artery occlusion. This might be associated with increased isoflavonoid aglycones.

Is diabetes an independent risk factor for in-hospital complications after a stroke? ？

BACKGROUND

Patients with diabetes mellitus (DM) are more likely to develop in-hospital complications (IHCs) than patients without DM. In addition, they have poorer outcomes after an ischemic stroke (IS). Our goal was to evaluate whether the increase in risk for the development of IHCs in patients with IS is due to DM per se, to poor metabolic control of the DM or to glucose levels on admission.

METHODS

An observational study that included 1137 consecutive IS patients admitted to a stroke unit. Demographic data, vascular risk factors, stroke severity, on-admission glycemia and IHC were compared between patients with and without DM. Multivariate logistic regression analyses were performed to identify factors associated with IHCs.

RESULTS

Of all included patients, 283 (24.8%) had a previous diagnosis of DM. These patients were older and had higher comorbidity, with no differences in stroke severity. They presented on-admission glycemia ≥155 mg/dL more often and suffered IHCs more frequently (24% versus 17.7%, P = 0.034). However, after adjusting for baseline differences, DM was not associated with the development of any IHC, whereas on-admission glycemia ≥155 mg/dL (odds ratio: 1.959; 95% CI 1.276-3.009; P = 0.002) and stroke severity (odds ratio: 1.141; 95% CI 1.109-1.173; P < 0.001) were the primary predictors of the development of IHCs.

CONCLUSIONS

Although IS patients with DM more often suffered IHCs, previous diagnosis of DM is not per se associated with the risk of IHCs. Stroke severity and on-admission glycemia ≥155 mg/dL were the most significant predictors for the development of IHCs.

The correlation between admission blood glucose and intravenous rt-PA-induced arterial recanalization in acute ischemic stroke: a multi-centre TCD study

BACKGROUND

The relationship between hyperglycemia and arterial recanalization following intravenous recombinant tissue-plasminogen activator treatment in acute ischemic stroke is not well understood.

AIM

We aimed to evaluate the effects of hyperglycemia in thrombolysed ischemic stroke patients on recanalization rate and clinical outcome.

METHODS

We studied 348 (231 subjects from the CLOTBUST databank and 117 subjects from the CLOTBUST trial phase II) with documented intracranial artery occlusion treated with intravenous recombinant tissue-plasminogen activator. Serum glucose was determined at baseline before intravenous recombinant tissue-plasminogen activator administration. Hyperglycemia was defined as a glucose level ≥140 mg/dl (7·7 mmol/l). Transcranial Doppler findings were interpreted using the thrombolysis in brain ischemia flow grading system as persistent arterial occlusion, re-occlusion or complete recanalization. Poor clinical outcome was defined by modified Rankin score > 2 at three-months.

RESULTS

At baseline, 138 patients (37·4%) were hyperglycemic and 210 patients (56·9%) normoglycemic. Baseline characteristics based on glucose ≥ 140 (7·7 mmol/l) or less 140: age (70·0 ± 12·4 vs. 67·3 ± 14·1, P = 0·065), baseline National Institutes of Health Stroke Scale (17·0 ± 5·5 vs. 15·8 ± 5·5, P = 0·054), time to recombinant tissue-plasminogen activator (141·4 ± 69·1 vs. 145·3 ± 48·4 mins, P = 0·56), and history of diabetes mellitus [60/138 (43·5%) vs. 22/210 (10·5%), P < 0·001]). Patients with hyperglycemia have a higher rate of persisting occlusion [72/138 (52·2%) vs. 66/210 (31·4%)] and less rate of complete recanalization [34/138 (24·6%) vs. 82/210 (39%), P < 0·001]. Median time to recanalization in patients with severe hyperglycemia (glucose ≥ 200) (11 mmol/l) and glucose <200 was 163 ± 79 and 131 ± 90 mins, respectively (P = 0·045). Sixteen patients (11·6%) in the hyperglycemic group and 12 (5·7%) in the normoglycemic group had symptomatic intracerebral hemorrhage (P = 0·049). Seventy-eight patients (69%) in the hyperglycemia group and 72 patients (41·6%) in the normoglycemic group had poor clinical outcome (three-month modified Rankin score > 2) (P ≤ 0·001). After adjusting for stroke risk factors, patients with hyperglycemia were more likely to have poor clinical outcome (three-month modified Rankin score > 2) (adjusted odds ratio = 2·22, 95% confidence interval: 1·2-4·11, P = 0·011) and low complete recanalization rate (adjusted odds ratio: 0·5, confidence interval: 0·3-0·92, P = 0·025) with trend of increase risk of symptomatic intracerebral hemorrhage (adjusted odds ratio: 2·07, confidence interval:0·8-5·1, P = 0·114). There was no association between baseline glucose as a continuous variable and poor clinical outcome, but there was with the complete recanalization's rate.

CONCLUSION

Hyperglycemia is associated with low rate of complete recanalization and poor clinical outcome in intravenous recombinant tissue-plasminogen activator-treated patients. Further studies are needed to evaluate whether lowering hyperglycemia is beneficial in the management of acute stroke patients.

Autonomic dysfunction in acute ischemic stroke: an underexplored therapeutic area?

Impaired autonomic function, characterized by a predominance of sympathetic activity, is common in patients with acute ischemic stroke. This review describes methods to measure autonomic dysfunction in stroke patients. It summarizes a potential relationship between ischemic stroke-associated autonomic dysfunction and factors that have been associated with worse outcome, including cardiac complications, blood pressure variability changes, hyperglycemia, immune depression, sleep disordered breathing, thrombotic effects, and malignant edema. Involvement of the insular cortex has been suspected to play an important role in causing sympathovagal imbalance, but its exact role and that of other brain regions remain unclear. Although sympathetic overactivity in patients with ischemic stroke appears to be a negative prognostic factor, it remains to be seen whether therapeutic strategies that reduce sympathetic activity or increase parasympathetic activity might improve outcome.

Combination approaches to attenuate hemorrhagic transformation after tPA thrombolytic therapy in patients with poststroke hyperglycemia/diabetes

To date, tissue type plasminogen activator (tPA)-based thrombolytic stroke therapy is the only FDA-approved treatment for achieving vascular reperfusion and clinical benefit, but this agent is given to only about 5% of stroke patients in the USA. This may be related, in part, to the elevated risk of symptomatic intracranial hemorrhage, and consequently limited therapeutic time window. Clinical investigations demonstrate that poststroke hyperglycemia is one of the most important risk factors that cause intracerebral hemorrhage and worsen neurological outcomes. There is a knowledge gap in understanding the underlying molecular mechanisms, and lack of effective therapeutics targeting the severe complication. This short review summarizes clinical observations and experimental investigations in preclinical stroke models of the field. The data strongly suggest that interactions of multiple pathogenic factors including hyperglycemia-mediated vascular oxidative stress and inflammation, ischemic insult, and tPA neurovascular toxicity in concert contribute to the BBB damage-intracerebral hemorrhagic transformation process. Development of combination approaches targeting the multiple pathological cascades may help to attenuate the hemorrhagic complication.

Continuous glucose monitoring after kidney transplantation in non-diabetic patients: early hyperglycaemia is frequent and may herald post-transplantation diabetes mellitus and graft failure

OBJECTIVES

New onset of diabetes after transplantation (NODAT) is a known complication of renal transplantation, but early glycaemic status after transplantation has not been described prospectively. This study aimed to assess blood glucose (BG) levels immediately following kidney transplantation in non-diabetic subjects and to explore their relationship to later graft outcomes and NODAT occurrence.

PATIENTS AND METHODS

Over a 9-month period, 43 consecutive non-diabetic patients who received a kidney transplant were prospectively investigated. During the first 4 days after transplantation, fasting BG was measured and the 24-h BG profile assessed by continuous glucose monitoring (CGM). Capillary BG was measured on hospital admittance and at least four times a day for CGM calibration thereafter. All adverse events were recorded, and fasting BG and HbA1c were assessed at 3, 6 and 12 months and at the last visit to our centre.

RESULTS

Immediately following renal transplantation, capillary BG was 12.2 ± 3.8 mmol/L. On day 1 (D1), fasting BG was 9.9 ± 4.3 mmol/L and decreased to 6.0 ± 1.5 mmol/L on D3. The CGM-reported mean 24-h BG (mmol/L) was 10.2±2.4 on D1, 7.7 ± 1.3 on D2 and 7.5 ± 1.1 on D3. From D1 to D4, 43% of patients spent>12h/day with BG levels>7.7 mmol/L. While morbidity during the 3 months following transplantation appeared unrelated to BG, the first post-transplantation capillary BG measurement and fasting BG on D1 tended to be higher in patients who developed diabetes 3 months later. Tacrolimus treatment was associated with a higher incidence of dysglycaemia at 3 and 6 months. After a mean follow-up of 72 months, NODAT was frequently seen (18.6%), and was associated with tacrolimus medication (P<0.01) and a higher rate of renal transplantation failure (RR: 3.6, P<0.02).

CONCLUSION

Hyperglycaemia appears to be a nearly constant characteristic immediately following transplantation in non-diabetic kidney recipients. Higher BG values could identify patients at risk for later post-transplant diabetes and graft failure.