Stress hyperglycemia as a modifiable predictor of futile recanalization in patients undergoing mechanical thrombectomy for acute ischemic stroke

Abstract

IntroductionMechanical thrombectomy (MT) is the first line treatment in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Approximately half of patients treated with MT does not have a favorable outcome 3 months after stroke. The aim of this study was to identify predictors of futile recanalization (FR) in patients with LVO treated with MT.MethodsA retrospective analysis of consecutive patients with acute ischemic stroke due to anterior circulation LVO who underwent MT. Patients with a TICI score of 2b or 3 were included. We distinguished two groups, FR and meaningful recanalization (MR), according to patients' disability three months after stroke (FR: mRS score > 2; MR: mRS score < 2).ResultsWe enrolled 238 patients (FR, n = 129, 54.2%; MR, n = 109, 45.8%). Age (OR 1.05, 95% CI 1.01–1.09, p = 0.012), female sex (OR 2.43, 95% CI 1.12–5.30, p = 0.025), stress hyperglycemia, as measured by the GAR index, (OR 1.17, 95% CI 1.06–1.29, p = 0.002), NIHSS at admission (OR 1.15, 95% CI 1.07–1.25, p = 0.001) and time from symptoms onset to MT (OR 1.01, 95% CI 1.00–1.01, p = 0.020) were independent predictors of FR. The AUC for the model combining age, female sex, GAR index, NIHSS at admission and time from symptoms onset to MT was 0.81 (95% CI 0.76–0.87; p < 0.001). The optimal GAR index cut-off score to predict FR was 17.9.DiscussionFR is common after MT. We recognized older age, female sex and baseline NIHSS as non-modifiable predictors of FR. On the other hand, time from symptoms onset to MT and stress hyperglycemia were modifiable pre- and post-MT factors, respectively. Any effort should be encouraged to reduce the impact of these modifiable predictors.

Prognostic Determinants of Anterior Large Vessel Occlusion in Acute Stroke in Elderly Patients

“…The association between stress hyperglycemia and futile recanalization has already been reported by Merlino et al [25]. Since GAR is a strong predictor of poor prognosis, they suggest that, in future studies, the management of stress hyperglycemia should not be based on absolute glucose levels but on GAR levels.…”

“…Since GAR is a strong predictor of poor prognosis, they suggest that, in future studies, the management of stress hyperglycemia should not be based on absolute glucose levels but on GAR levels. Furthermore, they suggest paying special attention to patients who have undergone MT for anterior circulation LVO with a GAR index of 17.9 or higher [ 25 ]. However, in our study, there were no statistically significant differences in stress hyperglycemia, HbA1c, or the GAR index.…”

Stress hyperglycemia increases short-term mortality in acute ischemic stroke patients after mechanical thrombectomy

“…Hyperglycemia in AIS patients treated with MT aggravates oxidative stress and endothelial cell damage, causing reperfusion injury to brain tissue, thus leading to a poor patient prognosis [ 37 , 38 ]. Giovanni Merlino et al reported that stress hyperglycemia is a modifiable predictor of futile recanalization in patients with large vessel occlusion treated with MT [ 39 ]. Hyperglycemia may promote futile recanalization by through lactate production and intracellular acidosis, disrupting the blood–brain barrier and affecting cerebrovascular autoregulation to cause reperfusion injury and hemorrhagic transformation [ 40 , 41 ].…”

Triglyceride-glucose index predicts death in patients with stroke younger than 65

“…Previous studies have shown the association between TGI levels and the outcomes of patients undergoing thrombolysis ( 24 , 53 ), while there were no studies on the effect of TGI on the outcomes in patients who underwent MT. According to Merlino’s study, stress hyperglycemia is strictly and independently associated with futile recanalization in patients undergoing MT ( 61 ). Thus, further study focus on the predictive value of TGI on the outcome of patients treated with MT is promising.…”