Effects of admission hyperglycemia on stroke outcome in reperfused tissue plasminogen activator--treated patients.
OBJECTIVE
We sought to investigate the impact of hyperglycemia before reperfusion on long-term outcome in patients treated with intravenous tissue plasminogen activator (tPA).


METHODS
Of 268 consecutive patients with a nonlacunar middle cerebral artery (MCA) stroke evaluated at <3 hours after onset, 73 (27.2%) received intravenous tPA. Serum glucose was determined at baseline before tPA administration. Hyperglycemia was defined as a glucose level >140 mg/dL. National Institutes of Health Stroke Scale (NIHSS) scores were obtained at baseline and 24 hours. Transcranial Doppler monitoring of recanalization and reocclusion was conducted during the first 24 hours. Total infarct volume was measured on CT at day 5 to 7. Modified Rankin Scale was used to assess outcome at 3 months.


RESULTS
Median NIHSS score was 17. At baseline, 31 patients (42.5%) were hyperglycemic and 42 (57.5%) normoglycemic. Early reperfusion (<6 hours) occurred in 43 patients (58.9%). Admission blood glucose correlated negatively with the degree of neurological improvement at 24 hours in reperfused (r=-0.43; P=0.019) but not in nonreperfused (r=-0.20; P=0.21) tPA-treated patients. Increased age (P=0.014), history of diabetes mellitus (P=0.043), admission glucose >140 mg/dL (P=0.002), and early reocclusion (P=0.004) were factors associated with poor outcome among reperfused patients. A logistic regression modeling revealed that only admission glucose value >140 mg/dL (odds ratio, 8.4; 95% CI, 1.76 to 40.02; P=0.005) emerged as an independent predictor of poor outcome despite tPA-induced recanalization. In patients with 6-hour persistent MCA occlusion, baseline NIHSS score >15 points (P=0.011) and proximal MCA occlusion (P=0.039) were variables associated with poor outcome on univariate analysis. In a logistic regression model, only NIHSS score >15 points (odds ratio, 11.9; 95% CI, 1.48 to 97.1; P=0.032) remained as an independent predictor of poor outcome and functional dependence at 3 months in nonreperfused tPA-treated patients.


CONCLUSIONS
Hyperglycemia before reperfusion may in part counterbalance the beneficial effect of early restoration of blood flow, which translates into a worse outcome in hyperglycemic patients despite tPA-induced recanalization.
Alvarez-Sabín
José
J
Cerebrovascular Unit, Department of Neurology, Hospital Vall d'Hebrón, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain. alsa@hg.vhebron.es
Molina
Carlos A
CA
Montaner
Joan
J
Arenillas
Juan F
JF
Huertas
Rafael
R
Ribo
Marc
M
Codina
Agusti
A
Quintana
Manuel
M
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001786:Blood Glucose / Q000032:analysis; D002543:Cerebral Hemorrhage / Q000453:epidemiology / Q000209:etiology; D015897:Comorbidity; D003920:Diabetes Mellitus / Q000453:epidemiology; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006801:Humans; D006943:Hyperglycemia / Q000150:complications*; D006949:Hyperlipidemias / Q000453:epidemiology; D006973:Hypertension / Q000453:epidemiology; D020244:Infarction, Middle Cerebral Artery / Q000097:blood / Q000150:complications* / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000473:pathology; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D018384:Oxidative Stress; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000627:therapeutic use; D012008:Recurrence; D015424:Reperfusion; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D017585:Ultrasonography, Doppler, Transcranial
D001786:Blood Glucose; D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator