Prediction of adverse outcomes by blood glucose level after endovascular therapy for acute ischemic stroke

Clinical article

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Object

The authors evaluated the prognostic significance of blood glucose level at admission (BGA) and change in blood glucose at 48 hours from the baseline value (CG48) in nondiabetic and diabetic patients before and after endovascular therapy for acute ischemic stroke (AIS).

Methods

The BGA and CG48 data were analyzed in 614 patients with AIS who received endovascular therapy at 7 US centers between 2006 and 2009. Data reviewed included demographics, stroke risk factors, diabetic status, National Institutes of Health Stroke Scale (NIHSS) score at presentation, recanalization grade, intracranial hemorrhage (ICH) rate, and 90-day outcomes (mortality rate and modified Rankin Scale score of 3–6 [defined as poor outcome]). Variables with p values < 0.2 in univariate analysis were included in a binary logistic regression model for independent predictors of 90-day outcomes.

Results

The mean patient age was 67.3 years, the median NIHSS score was 16, and 27% of patients had diabetes. In nondiabetic patients, BGA ≥ 116 mg/dl (≥ 6.4 mmol/L) and failure of glucose level to drop > 30 mg/dl (> 1.7 mmol/L) from the admission value were both significant predictors of 90-day poor outcome and death (p < 0.001). In patients with diabetes, BGA ≥ 116 mg/dl (≥ 6.4 mmol/L) was an independent predictor of poor outcome (p = 0.001). The CG48 was not a predictor of outcome in diabetic patients. A simplified 6-point scale including BGA, Thrombolysis in Myocardial Infarction (TIMI) Grade 2–3 Reperfusion, Age, presentation NIHSS score, CG48, and symptomatic ICH (BRANCH) corresponded with poor outcomes at 90 days; the area under the curve value was > 0.79.

Conclusions

Failure of blood glucose values to decrease in the first 48 hours after AIS intervention correlated with poor 90-day outcomes in nondiabetic patients. The BRANCH scale shows promise as a simple prognostication tool after endovascular therapy for AIS, and it merits prospective validation.

Abbreviations used in this paper: AC = anterior circulation; AIS = acute ischemic stroke; AUC = area under the curve; BAN = BGA, Age, NIHSS; BGA = blood glucose at admission; BRANCH = BGA, Reperfusion, Age, NIHSS score, CG48, and intracranial Hemorrhage; CARDINAL = Complement and ReDuction of INfarct size after Angioplasty or Lytics; CG48 = change in blood glucose at 48 hours from the baseline value; ICH = intracranial hemorrhage; MCA = middle cerebral artery; MERCI = Mechanical Embolus Removal in Cerebral Ischemia; MI = myocardial infarction; mRS = modified Rankin Scale; NIHSS = National Institutes of Health Stroke Scale; PC = posterior circulation; ROC = receiver operating characteristic; sICH = symptomatic ICH; TIMI = Thrombolysis in MI; UCLA = University of California Los Angeles; WUS = wakeup stroke.

Article Information

Address correspondence to: Elad I. Levy, M.D., University at Buffalo Neurosurgery, 3 Gates Circle, Buffalo, New York 14209. email: elevy@ubns.com.

Please include this information when citing this paper: published online February 25, 2011; DOI: 10.3171/2011.1.JNS10884.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Histograms of 90-day outcome measured using the mRS and the stratification of good outcome (mRS Score 0–2; green shading) and death (mRS Score 6; red shading) in the identified categories.

  • View in gallery

    Histograms of 90-day outcomes classified as mRS Score 0–2 (good outcome), mRS Score 3–5, and mRS Score 6 (death) show stratification of poor and good outcomes among each of the BGA categories (upper panel) and individual CG48 categories in each BGA category (lower panel) in the total group.

  • View in gallery

    Histograms of 90-day outcomes classified as mRS Score 0–2 (good outcome), mRS Score 3–5, and mRS Score 6 (death) show stratification of poor and good outcomes among each of the BGA categories (upper panel) and individual CG48 categories in each BGA category (lower panel) in nondiabetic patients.

  • View in gallery

    Histograms of 90-day outcomes classified as mRS Score 0–2 (good outcome), mRS Score 3–5, and mRS Score 6 (death) show stratification of death and good outcomes among each of the BGA categories (upper panel) and individual CG48 categories in each BGA category (lower panel) in diabetic patients.

  • View in gallery

    Histograms showing the results of calibration and internal validation by Hosmer-Lemeshow (HL) statistics of the final (upper) and admission (lower) scores. The expected rate of poor outcomes, as calibrated from the scores, and the observed rates of poor outcome in our patient population are plotted against each category of the score in the x axis. Notice that patients with an admission or a final score of ≥ 4 have a dismal 90-day prognosis, and the scores are able to predict the expected outcomes very closely.

  • View in gallery

    Upper: The percentage of patients with different final scores in each admission score category. From our calibration, we know that patients with a final score of ≥ 4 have a dismal 90-day outcome (red shading). Notice that only 3%–11% of patients with an admission score of 0–2 have a final score of ≥ 4, and thus have a poor outcome. In patients with an admission score of 3–4, the chance of having a final score of ≥ 4 and therefore a poor outcome is 35%–55%. In patients with an admission score of 3–4, it is very important to achieve TIMI Grade 2–3 reperfusion (subtracts 1 from the admission score) and avoid an sICH (to avoid getting 2 points on the final score) to avoid a poor outcome. Patients with an admission score of 5–6 always have a final score of ≥ 4, and therefore have a poor 90-day outcome, despite revascularization. Lower: The derivation of prognostication zones for risk-benefit analysis before endovascular therapy, based on the logic derived from the values in the upper panel. Patients with an admission score of 0–2 always have a good outcome after endovascular therapy. In patients with a score of 3–4, it is important to achieve TIMI Grade 2–3 reperfusion and avoid an sICH to achieve a final score of < 4. Patients with an admission score of 5–6 have questionable benefit, despite endovascular therapy, because they always have a final score of ≥ 4.

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