Higher admission fasting plasma glucose levels are associated with a poorer short-term neurologic outcome in acute ischemic stroke patients with good collateral circulation

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Abstract

Aims

In this retrospective study, we sought to delineate the collateral circulation status of acute ischemic stroke patients by CT perfusion and evaluate 90-day modified Rankin Scale (mRS) scores of patients with good or poor collaterals and its correlation with admission fasting plasma glucose (FPG).

Methods

We enrolled acute ischemic stroke patients who presented to our hospital 4.5 h within an onset of the first episode between January 2009 and December 2015. Neurological assessment was performed using the 90-day mRS scores (0–2 for a favorable and 3–6 for an unfavorable neurologic outcome). Relative filling time delay (rFTD) was evaluated by CT perfusion scan. The primary outcomes were 90-day mRS scores stratified by good (rFTD ≤ 4 s) versus poor collateral circulation (rFTD > 4 s).

Results

Totally 270 patients were included, and 139 (51.5%) patients achieved a favorable neurologic outcome. One hundred eighty-five (68.5%) patients had good collateral circulation. Significantly greater portions of patients with good collateral circulation (60.5%, 112/185) achieved a favorable neurologic outcome compared to those with poor collateral circulation (31.8%, 27/85) (P < 0.05). Patients with good collateral circulation achieving a favorable neurologic outcome had significantly lower baseline FPG (6.6 ± 1.96) than those with good collateral circulation achieving an unfavorable neurologic outcome (8.12 ± 4.02; P = 0.002). Spearman correlation analysis showed that rFTD significantly correlated with 90-day mRS scores (adjusted r = 0.258; P < 0.001) and admission FPG (r = 0.286; P < 0.001).

Conclusion

Higher admission FPG levels are associated with significantly higher rates of unfavorable neurologic outcome of acute ischemic stroke patients with good collateral circulation. FPG and rFTD may serve as useful predictors of short-term patient outcome and could be used for risk stratification in clinical decision making.

Keywords

Ischemic stroke Admission fasting plasma glucose Collaterals Modified Rankin Scale Large artery occlusion Relative filling time delay 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Human and Animal Rights disclosure

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Melbourne Health Human Research Ethics Committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

Patient consent was not required because of the retrospective nature of the study.

Supplementary material

592_2018_1139_MOESM1_ESM.tif (300 kb)
Supplementary Figure 1 ROC curve of baseline FPG for 90-day mortality in diabetic patients with good collateral circulation. (TIFF 299 kb)
592_2018_1139_MOESM2_ESM.docx (27 kb)
Supplementary material 2 (DOCX 26 kb)

References

  1. 1.
    Gao X et al (2012) Admission clinical characteristics and early clinical outcomes among acute ischemic stroke patients. J Biomed Res 26(3):152–158CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Jeng JS et al (2008) Predictors of survival and functional outcome in acute stroke patients admitted to the stroke intensive care unit. J Neurol Sci 270(1–2):60–66CrossRefPubMedGoogle Scholar
  3. 3.
    Kwak HS et al (2013) Predictors of functional outcome after emergency carotid artery stenting and intra-arterial thrombolysis for treatment of acute stroke associated with obstruction of the proximal internal carotid artery and tandem downstream occlusion. AJNR Am J Neuroradiol 34(4):841–846CrossRefPubMedGoogle Scholar
  4. 4.
    Scott JF et al (1999) Prevalence of admission hyperglycaemia across clinical subtypes of acute stroke. Lancet 353(9150):376–377CrossRefPubMedGoogle Scholar
  5. 5.
    Bruno A, Williams LS, Kent TA (2004) How important is hyperglycemia during acute brain infarction? Neurologist 10(4):195–200CrossRefPubMedGoogle Scholar
  6. 6.
    Weir CJ et al (1997) Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study. BMJ 314(7090):1303–1306CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Williams LS et al (2002) Effects of admission hyperglycemia on mortality and costs in acute ischemic stroke. Neurology 59(1):67–71CrossRefPubMedGoogle Scholar
  8. 8.
    Stead LG et al (2009) Hyperglycemia as an independent predictor of worse outcome in non-diabetic patients presenting with acute ischemic stroke. Neurocrit Care 10(2):181–186CrossRefPubMedGoogle Scholar
  9. 9.
    Osei E et al (2017) Admission glucose and effect of intra-arterial treatment in patients with acute ischemic stroke. Stroke 48(5):1299–1305CrossRefPubMedGoogle Scholar
  10. 10.
    Gray CS et al (2007) Glucose-potassium-insulin infusions in the management of post-stroke hyperglycaemia: the UK Glucose Insulin in Stroke Trial (GIST-UK). Lancet Neurol 6(5):397–406CrossRefPubMedGoogle Scholar
  11. 11.
    Bruno A et al (2008) Treatment of hyperglycemia in ischemic stroke (THIS): a randomized pilot trial. Stroke 39(2):384–389CrossRefPubMedGoogle Scholar
  12. 12.
    Winship IR (2015) Cerebral collaterals and collateral therapeutics for acute ischemic stroke. Microcirculation 22(3):228–236CrossRefPubMedGoogle Scholar
  13. 13.
    Hatano S (1976) Experience from a multicentre stroke register: a preliminary report. Bull World Health Organ 54(5):541–553PubMedPubMedCentralGoogle Scholar
  14. 14.
    Cox NH, Lorains JW (1986) The prognostic value of blood glucose and glycosylated haemoglobin estimation in patients with stroke. Postgrad Med J 62(723):7–10CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Uyttenboogaart M et al (2005) Optimizing cutoff scores for the Barthel index and the modified Rankin scale for defining outcome in acute stroke trials. Stroke 36(9):1984–1987CrossRefPubMedGoogle Scholar
  16. 16.
    Uyttenboogaart M et al (2007) Moderate hyperglycaemia is associated with favourable outcome in acute lacunar stroke. Brain 130(Pt 6):1626–1630CrossRefPubMedGoogle Scholar
  17. 17.
    Cao W et al (2014) Relative filling time delay based on CT perfusion source imaging: a simple method to predict outcome in acute ischemic stroke. AJNR Am J Neuroradiol 35(9):1683–1687CrossRefPubMedGoogle Scholar
  18. 18.
    Dankbaar JW et al (2017) Internal carotid artery stenosis and collateral recruitment in stroke patients. Clin Neuroradiol.  https://doi.org/10.1007/s00062-017-0568-x PubMedGoogle Scholar
  19. 19.
    van Seeters T et al (2015) The prognostic value of CT angiography and CT perfusion in acute ischemic stroke. Cerebrovasc Dis 40(5–6):258–269CrossRefPubMedGoogle Scholar
  20. 20.
    Capes SE et al (2001) Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 32(10):2426–2432CrossRefPubMedGoogle Scholar
  21. 21.
    Rosso C et al (2012) Intensive versus subcutaneous insulin in patients with hyperacute stroke: results from the randomized INSULINFARCT trial. Stroke 43(9):2343–2349CrossRefPubMedGoogle Scholar
  22. 22.
    Kruyt ND et al (2010) Hyperglycemia in acute ischemic stroke: pathophysiology and clinical management. Nat Rev Neurol 6(3):145–155CrossRefPubMedGoogle Scholar
  23. 23.
    Bruno A et al (2002) Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial. Neurology 59(5):669–674CrossRefPubMedGoogle Scholar
  24. 24.
    Pulsinelli WA et al (1983) Increased damage after ischemic stroke in patients with hyperglycemia with or without established diabetes mellitus. Am J Med 74(4):540–544CrossRefPubMedGoogle Scholar
  25. 25.
    Ahmed N et al (2010) Association of admission blood glucose and outcome in patients treated with intravenous thrombolysis: results from the Safe Implementation of Treatments in Stroke International Stroke Thrombolysis Register (SITS-ISTR). Arch Neurol 67(9):1123–1130CrossRefPubMedGoogle Scholar
  26. 26.
    Kim JJ et al (2004) Regional angiographic grading system for collateral flow: correlation with cerebral infarction in patients with middle cerebral artery occlusion. Stroke 35(6):1340–1344CrossRefPubMedGoogle Scholar
  27. 27.
    Prado R et al (1988) Hyperglycemia increases infarct size in collaterally perfused but not end-arterial vascular territories. J Cereb Blood Flow Metab 8(2):186–192CrossRefPubMedGoogle Scholar
  28. 28.
    Mitchell EA et al (2012) Hyperglycaemia monitoring and management in stroke care: policy vs. practice. Diabet Med 29(9):1108–1114CrossRefPubMedGoogle Scholar
  29. 29.
    Bravata DM et al (2003) Hyperglycaemia in patients with acute ischaemic stroke: how often do we screen for undiagnosed diabetes? QJM 96(7):491–497CrossRefPubMedGoogle Scholar
  30. 30.
    Gray CS et al (2004) Prevalence and prediction of unrecognised diabetes mellitus and impaired glucose tolerance following acute stroke. Age Ageing 33(1):71–77CrossRefPubMedGoogle Scholar
  31. 31.
    Masrur S et al (2015) Association of acute and chronic hyperglycemia with acute ischemic stroke outcomes post-thrombolysis: findings from get with the guidelines-stroke. J Am Heart Assoc 4(10):e002193PubMedPubMedCentralGoogle Scholar
  32. 32.
    Ntaios G et al (2011) Persistent hyperglycemia at 24–48 h in acute hyperglycemic stroke patients is not associated with a worse functional outcome. Cerebrovasc Dis 32(6):561–566CrossRefPubMedGoogle Scholar
  33. 33.
    Luitse MJ et al (2017) Chronic hyperglycemia is related to poor functional outcome after acute ischemic stroke. Int J Stroke 12(2):180–186CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Italia S.r.l., part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of NeurologyShanghai Jiao Tong University Affiliated Sixth People’s HospitalShanghaiChina
  2. 2.Melbourne Brain Centre at the Royal Melbourne HospitalUniversity of MelbourneParkvilleAustralia
  3. 3.Department of Neurology, Huashan HospitalFudan UniversityShanghaiChina

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