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Admission hyperglycemia and outcome after intravenous thrombolysis: is there a difference among the stroke-subtypes?

ABSTRACT: The prognostic influence of hyperglycemia in acute stroke has been well established. While in cortical stroke there is a strong association between hyperglycemia and poor outcome, this relation is less clear in lacunar stroke. It has been suggested that this discrepancy is present among patients treated with intravenous tissue plasminogen activator (tPA), but confirmation is needed.In two prospectively collected cohorts of patient treated with intravenous tPA for acute ischemic stroke, we investigated the effect of hyperglycemia (serum glucose level >8 mmol/L) on functional outcome in lacunar and non-lacunar stroke. Poor functional outcome was defined as modified Rankin Scale score ? 3 at 3 months.A total of 1012 patients was included of which 162 patients (16%) had lacunar stroke. The prevalence of hyperglycemia did not differ between stroke subtypes (22% vs 21%, p = 0.85). In multivariate analysis hyperglycemia was associated with poor functional outcome in non-lacunar stroke (OR 2.1, 95% CI 1.39-3.28, p = 0.001). In patients with lacunar stroke, we did not find an association (OR 1.8, 95% CI 0.62-4.08, p = 0.43).This study confirms a difference in prognostic influence of hyperglycemia between non-lacunar and lacunar ischemic stroke.

SUBMITTER: Miedema I

PROVIDER: S-EPMC4946238 | biostudies-literature | 2016 Jul

REPOSITORIES: biostudies-literature

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Admission hyperglycemia and outcome after intravenous thrombolysis: is there a difference among the stroke-subtypes?

Miedema Irene I Luijckx Gert-Jan GJ Brouns Raf R De Keyser Jacques J Uyttenboogaart Maarten M

BMC neurology 20160715

<h4>Background</h4>The prognostic influence of hyperglycemia in acute stroke has been well established. While in cortical stroke there is a strong association between hyperglycemia and poor outcome, this relation is less clear in lacunar stroke. It has been suggested that this discrepancy is present among patients treated with intravenous tissue plasminogen activator (tPA), but confirmation is needed.<h4>Methods</h4>In two prospectively collected cohorts of patient treated with intravenous tPA f ...[more]

PMID: 27422152

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Project description:BackgroundStress hyperglycemia ratio (SHR), calculated as glucose/glycated hemoglobin, has recently been developed for assessing stress hyperglycemia and could provide prognostic information for various diseases. However, calculating SHR using random blood glucose (RBG) drawn on admission or fasting blood glucose (FBG) could lead to different results. This study intends to evaluate the association between SHR and functional outcomes in patients with acute ischemic stroke (AIS) with recombinant tissue plasminogen activator (r-tPA) intravenous thrombolysis.MethodsData from 230 patients with AIS following thrombolytic therapy with r-tPA in the Third Affiliated Hospital of Wenzhou Medical University from April 2016 to April 2019 were retrospectively reviewed. SHR1 was defined as [RBG (mmol/L)]/[HbA1c (%)] and SHR2 was defined as [FBG (mmol/L)]/[HbA1c (%)]. The outcomes included early neurological improvement (ENI), poor function defined as a modified Rankin Scale score (mRS) of 3-6, and all-cause death in 3 months. Multivariable logistic regression was performed to estimate the association between SHR and adverse outcomes.ResultsAfter adjustment for possible confounders, though patients with AIS with higher SHR1 tend to have a higher risk of poor outcome and death and unlikely to develop ENI, these did not reach the statistical significance. In contrast, SHR2 was independently associated with poor functional outcome (per 0.1-point increases: odds ratios (OR) = 1.383 95% CI [1.147-1.668]). Further adjusted for body mass index (BMI), triglyceride-glucose index (TyG), and diabetes slightly strengthen the association between SHR (both 1 and 2) and adverse outcomes. In subgroup analysis, elevated SHR1 is associated with poor functional outcomes (per 0.1-point increases: OR = 1.246 95% CI [1.041-1.492]) in non-diabetic individuals and the association between SHR2 and the poor outcomes was attenuated in non-cardioembolic AIS.ConclusionSHR is expected to replace random or fasting glucose concentration as a novel generation of prognostic indicator and a potential therapeutic target.

Project description:Background and purposeWe aim to investigate whether the higher admission fibrin degradation products (FDPs) levels are associated with parenchymal hematomas (PHs) and unfavorable outcome after intravenous thrombolysis (IVT).MethodsConsecutive patients with acute ischemic stroke treated with IVT were studied. The FDP level was obtained on admission. PH was evaluated 24 h after treatment. The unfavorable outcome was defined as a 90-day modified Rankin Scale >2. The multivariable linear stepwise regression was used to assess independent factors associated with the log-transformed FDP (lgFDP). The receiver operating characteristics (ROCs) curve analysis was used to determine the predictive value of the FDP level for PH and unfavorable outcome. The logistic regression was used to identify independent predictors for PH and unfavorable outcome. The mediation analyses were performed to investigate associations among the FDP level, PH, and outcome.ResultsA total of 181 patients were included in the final analyses [median age, 73 (63-79) years; 102 (56.4%) males; and the median baseline National Institutes of Health Stroke Scale (NIHSS) score, 8 (5-15)]. The lgFDP was independently associated with age (B = 0.011, 95% CI 0.006-0.015, p < 0.001) and the baseline NIHSS score (B = 0.016, 95% CI 0.008-0.025, p < 0.001). The FDP was positively associated with PH [odds ratio (OR) 1.034, 95% CI 1.000-1.069; p = 0.047]. According to the ROC analysis, the best discriminating factor for unfavorable outcome was the FDP ≥3.085 μg/ml. The FDP ≥3.085 μg/ml was an independent predictor of unfavorable outcome (OR 7.086, 95% CI 2.818-17.822; p < 0.001). Mediation analysis revealed that the association of the FDP ≥3.085 μg/ml with unfavorable outcome was not mediated by PH (p = 0.161).ConclusionThe admission FDP levels can predict PH and unfavorable outcome in patients with acute ischemic stroke after IVT. PH does not mediate the effect of the FDP level on the outcome.

Project description:Introduction:Alterations in haemoglobin levels are frequent in stroke patients. The prognostic meaning of anaemia and polyglobulia on outcomes in patients treated with intravenous thrombolysis is ambiguous. Patients and methods:In this prospective multicentre, intravenous thrombolysis register-based study, we compared haemoglobin levels on hospital admission with three-month poor outcome (modified Rankin Scale 3-6), mortality and symptomatic intracranial haemorrhage (European Cooperative Acute Stroke Study II-criteria (ECASS-II-criteria)). Haemoglobin level was used as continuous and categorical variable distinguishing anaemia (female: <12 g/dl; male: <13 g/dl) and polyglobulia (female: >15.5 g/dl; male: >17 g/dl). Anaemia was subdivided into mild and moderate/severe (female/male: <11 g/dl). Normal haemoglobin level (female: 12.0-15.5 g/dl, male: 13.0-17.0 g/dl) served as reference group. Unadjusted and adjusted odds ratios with 95% confidence intervals were calculated with logistic regression models. Results:Among 6866 intravenous thrombolysis-treated stroke patients, 5448 (79.3%) had normal haemoglobin level, 1232 (17.9%) anaemia - of those 903 (13.2%) had mild and 329 (4.8%) moderate/severe anaemia - and 186 (2.7%) polyglobulia. Anaemia was associated with poor outcome (ORadjusted 1.25 (1.05-1.48)) and mortality (ORadjusted 1.58 (1.27-1.95)). In anaemia subgroups, both mild and moderate/severe anaemia independently predicted poor outcome (ORadjusted 1.29 (1.07-1.55) and 1.48 (1.09-2.02)) and mortality (ORadjusted 1.45 (1.15-1.84) and ORadjusted 2.00 (1.46-2.75)). Each haemoglobin level decrease by 1?g/dl independently increased the risk of poor outcome (ORadjusted 1.07 (1.02-1.11)) and mortality (ORadjusted 1.08 (1.02-1.15)). Anaemia was not associated with occurrence of symptomatic intracranial haemorrhage. Polyglobulia did not change any outcome. Discussion:The more severe the anaemia, the higher the probability of poor outcome and death. Severe anaemia might be a target for interventions in hyperacute stroke. Conclusion:Anaemia on admission, but not polyglobulia, is a strong and independent predictor of poor outcome and mortality in intravenous thrombolysis-treated stroke patients.

Project description:Background and purposeWe performed a meta-analysis to assess whether leukoaraiosis on brain computed tomographic scans of acute ischemic stroke patients treated with intravenous thrombolysis is associated with an increased risk of symptomatic intracerebral hemorrhage (sICH) or poor functional outcome at 3 to 6 months after stroke, or both.MethodsWe searched PubMed and pooled relevant data in meta-analyses using random effects models. Using odds ratios (OR), we quantified the strength of association between the presence and severity of leukoaraiosis and post-thrombolysis sICH or 3- to 6-month modified Rankin Score >2.ResultsEleven eligible studies (n=7194) were pooled in meta-analysis. The risk of sICH was higher in patients with leukoaraiosis (OR, 1.55; 95% confidence interval [CI], 1.17-2.06; P=0.002) and severe leukoaraiosis (OR, 2.53; 95% CI, 1.92-3.34; P<0.0001) compared with patients without leukoaraiosis. Leukoaraiosis was an independent predictor of sICH in 6 included studies (n=4976; adjusted OR, 1.75; 95% CI, 1.35-2.27; P<0.0001). OR for leukoaraiosis and poor 3- to 6-month outcome was 2.02 (95% CI, 1.54-2.65; P<0.0001), with significant statistical heterogeneity (I(2), 75.7%; P=0.002). In adjusted analyses, leukoaraiosis was an independent predictor of poor outcome (n=3688; adjusted OR, 1.61; 95% CI, 1.44-1.79; P<0.0001). In post hoc analyses, including only leukoaraiosis patients in randomized controlled trials (IST-3 [third International Stroke Trial], NINDS [National Institute of Neurological Disorders and Stroke], ECASS-1-2 [European Cooperative Acute Stroke Study]; n=2234), tissue-type plasminogen activator versus control was associated with higher sICH risk (OR, 5.50; 95% CI, 2.49-12.13), but lower poor outcome risk (OR, 0.75; 95% CI, 0.60-0.95).ConclusionsLeukoaraiosis might increase post-intravenous thrombolysis sICH risk and poor outcome poststroke. Despite increased sICH risk, intravenous tissue-type plasminogen activator treatment has net clinical benefit in patients with leukoaraiosis. Given the risk of bias/confounding, these results should be considered hypothesis-generating and do not justify withholding intravenous thrombolysis.

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Admission hyperglycemia and outcome after intravenous thrombolysis: is there a difference among the stroke-subtypes?

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Admission hyperglycemia and outcome after intravenous thrombolysis: is there a difference among the stroke-subtypes?

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