HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

Correspondence to:

ARTICLES: Th. Karapanayiotides, B. Piechowski-Jozwiak, G. van Melle, J. Bogousslavsky, and G. Devuyst Stroke patterns, etiology, and prognosis in patients with diabetes mellitus Neurology 2004; 62: 1558-1562 [Abstract] [Full text] [PDF]

Correspondence: Submit a response to this article

Correspondence published:

Stroke patterns, etiology, and prognosis in patients with diabetes mellitus

Derya Uluduz, MD, Birsen Ince MD, Melda Bozluolcay MD, Istanbul, Turkey   (5 October 2004)

Stroke patterns, etiology, and prognosis in patients with diabetes mellitus

Antonino Tuttolomondo, Antonio Pinto, Domenico Di Raimondo, Paola Fernandez, and Giuseppe Licata   (5 October 2004)

Reply to Dr. Uluduz and Tuttulomondo

Theodoros Karapanayiotides   (5 October 2004)

Stroke patterns, etiology, and prognosis in patients with diabetes mellitus 5 October 2004
Derya Uluduz, MD, MD Alkent 2000, Camlica Sitesi Tugba Sokak, No 10 Villa Hadimkoy, Istanbul, Turkey, Birsen Ince MD, Melda Bozluolcay MD, Istanbul, Turkey Send Correspondence to journal: Re: Stroke patterns, etiology, and prognosis in patients with diabetes mellitus deryaulu{at}yahoo.com Derya Uluduz, MD, et al.	We read the article by Karapanayiotides et al [1] with interest. Although the relationship between diabetes and stroke has been reported, the effect of diabetes as the cause of stroke is unclear. Hypertension is common in patients with diabetes and the combination of hyperglycemia and hypertension can increase the diabetic complications including stroke. [2] In our stroke center, we evaluated 414 patients (204 male, 210 female, age range; 62.3±11.5) admitted consecutively between January 2002-2004. The ischemic stroke etiology deduced from our data is presented in the Table. Unlike the article by Karapanayiotides et al, we found no etiological differences between diabetic and nondiabetic patients. Kiers et al [3] analyzed stroke topography in diabetics, and the patients were classified according to their glucose levels, type and site of stroke. They also found no differences between the groups. The stroke production mechanism secondary to diabetes may be due to cerebrovascular atherosclerosis, cardio-embolism, or rheologic abnormalities. [4] Similar etiologies can be seen in diabetic and nondiabetic patients. Schulz et al proposed that there was a discrimination concerning the association of the risk factors and stroke subtypes in the hospitalized and nonhospitalized patients. [5] Contrary to the hospital based studies, there was only a weak and inconsistent association between small-vessel disease and hypertension and no association with diabetes. Our study is hospital based and shows no etiological difference between the diabetic and nondiabetic individuals. The effect of diabetes on the etiology of ischemic stroke is still unclear. Table Table References 1. Karapanayiotides Th, Piechowski-Jozwiak B, Melle G, et al. Stroke patterns, etiology, and prognosis in patients with diabetes mellitus. Neurology 2004;62:1558-1562. 2. Goldstein LB, Adams R, Becher K, et al. Primary prevention of ischemic stroke. Circulation 2001:103;160. 3. Kiers L, Davis SM, Larkins R, et al. Stroke topography and outcome in relation to hyperglycaemia and diabetes. J Neurol Neurosurg Psychiatry. 1992;55:263-70. 4. Biller J, Love BB. Diabetes and stroke. Med Clin North Am 1993;77: 95-111. 5. Schulz UG, Rothwell PM: Differences in vascular risk factors between etiological subtypes of ischemic stroke : importance of population based studies. Stroke 2003;34: 2050-2059.
Stroke patterns, etiology, and prognosis in patients with diabetes mellitus 5 October 2004
Antonino Tuttolomondo, Internal Medicine Department Via Abruzzi n.67, 90144 Palermo, Italy, Antonio Pinto, Domenico Di Raimondo, Paola Fernandez, and Giuseppe Licata Send Correspondence to journal: Re: Stroke patterns, etiology, and prognosis in patients with diabetes mellitus pinto{at}neomedia.it Antonino Tuttolomondo, et al.	We read the article by Karapanayiotides et al [1] with interest. The authors reviewed clinical features, etiologic patterns, topography and outcome of stroke in diabetic patients. In this study, clinical subtypes of ischemic stroke were rated according to the their own topographic criteria but perhaps TOAST Classification [2] would have offered a more precise selection of patients with lacunar strokes. Karapanayiotides et al evaluated outcome indicators including five-grade activities of the daily-living scale and six clinical features encoded in the LSR that offered a crude approximation of the NIH Stroke Scale. We believe that applying the Rankin Score to evaluate disability grade and to assess acute neurological deficit by the Scandinavian Stroke Scale could determine a better profile of patients with ischemic stroke by analyzing differences in disability and acute neurological deficit grades between diabetic and nondiabetic subjects. Due to the high prevalence of hypertension in diabetic subjects (almost 60%), and to the confirmed role of high blood pressure in lacunar strokes pathogenesis, [3] the absence of an interaction between diabetes and hypertension in patients with lacunar strokes is not easily conceived. Our case-control study [4] compared diabetic (102 patients) and nondiabetic controls (204 patients) matched by age and sex with acute ischemic stroke and evaluated the relationship between diabetes and stroke subtype. In our study, diabetes results associated with lacunar ischemic stroke subtype, with a history of hypertension and with a higher Scandinavian Stroke Scale (SSS) score at admission.The association of diabetes with lacunar subtype remains significant also after adjustment for hypertension. This suggests peculiar anathomopathological findings of the diabetic cerebral infarction as showed by Aronson et al [5] that reported higher, autoptically detected incidence of lacunar infarcts in diabetic subjects who died after an ischemic stroke. The higher SSS score of our diabetic patients converges with the higher frequency of lacunar stroke subtype among diabetics, because lacunar stroke could lead to a lower neurological deficit grade at admission due to brain infarct size. References 1. Karapanayiotides Th, Piechowski-Jozwiak B, Vam Melle G, Bogousslavsky J, Devuyst G. Stroke Patterns, etiology and prognosis in patients with diabetes mellitus. Neurology 2004;62:1558-1562. 2. Adams HP, Bendixen BH, Kappelle J, Biller J, Love B, Gordon MD, Marsh EE, and the TOAST Investigators. Classification of subtype of acute ischemic stroke. Stroke 1993;24:35-41. 3. Boiten J, Lodder J. Lacunar infarcts : Pathogenesis and validity of the clinical syndromes. Stroke 1991;22: 1374-1378. 4. Pinto A,Tuttolomondo A, Licata G. Diabete ed ictus Italian Heart Journal Suppl 2002;3:471-477. 5.Peress NS, Kane WC. Central nervous system findings in a tenth decade autopsy population. Prog. Brain Res 1973; 40:473-83.
Reply to Dr. Uluduz and Tuttulomondo 5 October 2004
Theodoros Karapanayiotides, CHUV 90-92 Agias Paraskevis Str, 111 44 Athens, Greece Send Correspondence to journal: Re: Reply to Dr. Uluduz and Tuttulomondo theoneu{at}otenet.gr Theodoros Karapanayiotides	We thank Drs Uluduz and Tuttolomondo for their interest in our study. We would like to clarify the following points. First, the TOAST classification pertains to etiology and not to topography of stroke. The classification used in the Lausanne Stroke Registry (LSR) is identical to the TOAST classification. In this regard, all patients with “small vessel disease” (SVD) represented “lacunes”. In our cohort, SVD and subcortical infarctions were more frequent in diabetics. Had we limited our analyses only to “classical” lacunes we should have missed the important association with the broader spectrum of subcortical infarction. Second, Scandinavian stroke and Rankin scales were developed much later than the LSR. Third, the fact that hypertension and diabetes are strongly and independently associated with SVD does not obligatorily imply an interaction between them. The lack of interaction between hypertension and diabetes has also been documented in patients entering the NASCET. [1] Fourth, a higher relative frequency of “lacunes” may be a reasonable explanation for a less severe neurologic deficit on admission in diabetic stroke sufferers. [2] However, it would be interesting to see if this difference in stroke severity was translated into a better functional outcome. The differences in risk factor profile and stroke subtypes between hospitalized and nonhospitalized patients probably do not apply to our population because LSR is essentially a community-based registry. Data from the State of Vaud (Lausanne urban and rural area) indicate that >90% of all stroke patients are admitted to our institution, which is the only public hospital in the area of Lausanne and has the only department of neurology in the entire county. Furthermore, in contrast with the UK where only about half of stroke patients are hospitalized [3], in Lausanne, general practitioners always refer patients with stroke. The hospital-based study mentioned [4] by Uluduz et al included only 176 stroke patients and was not powered enough to detect differences between diabetics and nondiabetics. In the study by Schulz et al [3], SVD was associated only with female sex and not with “traditional” risk factors such as age and hypertension. This was a CT-based study which may have underestimated the burden of “lacunar” infarcts relative to MRI. An MRI population-based study [5] showed that except from the “classical” risk factors for SVD, (i.e. increased age and blood pressure), history of diabetes at entrance into the study was associated with SVD-related stroke. These results are in accordance with our study. References 1. Inzitari D, Eliasziw M, Sharpe BL, Fox AJ, Barnett HJ. Risk factors and outcome of patients with carotid artery stenosis presenting with lacunar stroke. Neurology 2000;54:660-666. 2. Licata G, Tuttolomondo A, Sinagra D, Pinto A. Diabetes mellitus and stroke. Ital Heart J Suppl. 2002;3:471-477. 3. Schulz UGR, Rothwell PM. Differences in vascular risk factors between etiological subtypes of ischemic stroke : importance of population-based studies. Stroke 2003;34:2050-2059. 4. Kiers L, Davis SM, Hopper J, et al. Stroke topography and outcome in relation to hyperglycemia and diabetes. J Neurol Neurosurg Psychiatry 1992;55:263-270. 5. Longstretch WT, Bernick C, Manolio TA, et al. Lacunar infarcts defined by magnetic resonance imaging of 3600 elderly people. Arch Neurol 1998;55:1217-1225.