The new results suggest that intensive glucose control should be limited to patients with good collaterals, researchers say.
Higher serum levels of glucose are associated with poorer outcomes among patients undergoing mechanical thrombectomy for acute ischemic stroke, but this relationship is seen only among patients with good collaterals to start with, according to new analysis of a pooled data set.
“Hyperglycemia is an important predictor of poor outcome in patients with acute ischemic stroke (AIS), especially when treated with intravenous tPA (tissue-type plasminogen activator),” write Joon-Tae Kim, MD, PhD (Chonnam National University Hospital, Gwangju, Korea), and colleagues in their paper published online September 20, 2018, ahead of print in Stroke. “The reported effects of hyperglycemia on the biological events in AIS are diverse and include impaired recanalization, decreased reperfusion, increased reperfusion injury, and increased rates of hemorrhagic transformation.”
They point out, however, that the heterogeneity of hyperglycemia’s effects might mean that intensive glucose control may not be advantageous in all clinical situations related to AIS. “Given that collateral status (CS) has been demonstrated to be a predictor of the size of the core infarct and outcomes, it might also modify the biological impact of hyperglycemia on outcomes in AIS,” the researchers speculate.
To find out, Kim et al analyzed angiographic data on collaterals and functional outcome collected for 309 patients included in the Triple-S database. This database comprises individual patient data pooled from three prospective studies: SWIFT, SWIFT PRIME, and STAR.
All patients had acute ischemic stroke with moderate to severe neurological deficits, angiographically confirmed large vessel occlusion, and were treatable by endovascular thrombectomy within 8 hours of onset. Patients’ mean age was 67 ± 12 years, and their mean serum glucose level was 131 ± 55 mg/dL.
Targeting Tight Glucose Control
Overall, glucose level at presentation was not associated with pretreatment collateral status. Patients with a good outcome at 90 days (defined as an mRS 0-2) did, however, have lower serum glucose levels at presentation (124 vs 140 mg/dL; P = 0.01).
The association between glucose levels and outcome was influenced by collateral grade (P for interaction= 0.03). Specifically, the association was present among patients with good collaterals (grade 3-4) but not those with poor collaterals (grade 0-2). Among patients with good collaterals, higher serum glucose levels at presentation reduced the likelihood of a 90-day good outcome with an odds ratio of 0.81 (95% CI 0.69-0.95) per 10 mg/dL increase.
“These findings suggest that patients with good pretreatment collaterals might be potential targets for meticulous glucose control and future investigations about the effect of glucose management in AIS,” conclude the authors.
Kim J-T, Liebeskind DS, Jahan R, et al. Impact of hyperglycemia according to the collateral status on outcomes in mechanical thrombectomy. Stroke 2018;Epub ahead of print.
Kim reports no relevant conflicts of interest.