Dynamic Hyperglycemic Patterns Predict Adverse Outcomes in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy

Abstract

Background: Admission hyperglycemia impairs outcome in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT). Since hyperglycemia in AIS represents a dynamic condition, we tested whether the dynamic patterns of hyperglycemia, defined as blood glucose levels > 140 mg/dl, affect outcomes in these patients. Methods: We retrospectively analyzed data of 200 consecutive patients with prospective follow-up. Based on blood glucose level, patients were distinguished into 4 groups: (1) persistent normoglycemia; (2) hyperglycemia at baseline only; (3) hyperglycemia at 24-h only; and (4) persistent (at baseline plus at 24-h following MT) hyperglycemia. Results: AIS patients with persistent hyperglycemia have a significantly increased risk of poor functional outcome (OR 6.89, 95% CI 1.98–23.94, p = 0.002, for three-month poor outcome; OR 11.15, 95% CI 2.99–41.52, p = 0.001, for no major neurological improvement), mortality (OR 5.37, 95% CI 1.61–17.96, p = 0.006, for in-hospital mortality; OR 4.43, 95% CI 1.40–13.97, p = 0.01, for three-month mortality), and hemorrhagic transformation (OR 6.89, 95% CI 2.35–20.21, p = 0.001, for intracranial hemorrhage; OR 5.42, 95% CI 1.54–19.15, p = 0.009, for symptomatic intracranial hemorrhage) after endovascular treatment. These detrimental effects were partially confirmed after also excluding diabetic patients. The AUC-ROC showed a very good performance for predicting three-month poor outcome (0.76) in-hospital mortality (0.79) and three-month mortality (0.79). Conclusions: Our study suggests that it is useful to perform the prolonged monitoring of glucose levels lasting 24-h after MT.

Stress Hyperglycemia in Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion Undergoing Mechanical Thrombectomy

“…This is true not only for AIS patients receiving alteplase but also for those subjects with LVO undergoing MT. Indeed, we previously reported that poor functional outcome, mortality, and hemorrhagic transformation after endovascular treatment were significantly associated with the presence of persistent hyperglycemia—that is, hyperglycemia at baseline plus at 24 h ( 18 ). Although our study provided new insights into the role of impaired glucose metabolism as a predictor of outcome in AIS patients undergoing MT, we were not able to discern between the detrimental effects due to the presence of underlying diabetes and those associated with stress hyperglycemia.…”

“…Hyperglycemia at admission has been associated with a decreased likelihood of good outcomes in patients with AIS undergoing MT ( 14 – 17 ). However, we recently demonstrated that persistent hyperglycemia—that is, hyperglycemia at admission and at 24 h post-admission—was a better predictor of poor outcome than baseline hyperglycemia in AIS subjects affected by LVO and treated with MT ( 18 ). Persistent hyperglycemia might impair outcomes as a marker of either diabetes mellitus or activation of the hypothalamic–pituitary–adrenal axis, that is, stress hyperglycemia.…”

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

“…The negative correlation observed in the present study might be due to the difference in the definition of hyperglycemia (i.e., 126 mg/dl, not 140 mg/dl). Among the included studies, some included populations with the same disease severity [ 9 , 10 ], and some studies included patients with slightly higher NIHSS scores and PH [ 8 , 11 , 12 , 14 , 20 , 21 ], but the outcome was mostly worse in patients with PH. Most of the studies removed the effect of disease severity in the final multivariable analysis [ 8 , 11 , 12 , 20 , 21 ]; therefore, the effect of disease severity on disease prognosis was not decisive or significant.…”

“…A higher blood glucose level at admission predicts worse short-term stroke outcomes, such as increased mortality and hemorrhagic transformation (HT) in patients with ischemic stroke [ 4 – 7 ]. Persistent hyperglycemia (PH), defined as a hyperglycemic state with blood glucose levels > 140 or 150 mg/dl measured at admission and at a random time point within a duration (≥ 24 h, i.e., 48–72 h [ 8 ]) since admission [ 9 , 10 ], can predict poor functional outcomes and increased HTs in patients with stroke with or without DM [ 9 , 10 ]. In addition, PH can be divided into two subgroups: short duration PH (SPH) and long-duration PH (LPH); SPH is defined as a high glucose status at the time of admission and at a random time after admission, with the random time after admission being within 24 h after admission, and LPH is defined as a high glucose status at the time of admission and at a random time after admission, with the random time after admission being greater than 24 h after admission.…”

“…However, other studies found no significant difference in this prediction between persistent hyperglycemic and normoglycemic states in patients with stroke [ 8 , 11 ]. Hyperglycemia of long duration (more than 1 d after admission) can better predict worse stroke outcomes than a single-point hyperglycemia after stroke onset (SH, defined as hyperglycemia only at 24 h after stroke onset) [ 9 , 10 ]) or at admission (AH, which was defined as hyperglycemia at admission) [ 8 , 10 , 12 – 14 ]. Apart from the studies mentioned above, few studies have investigated the efficacy of PH, AH, and SH in predicting post-stroke outcomes, and the superiority of PH over SH and AH.…”