Acute blood glucose level and outcome from ischemic stroke
Abstract
Objective: To study the relation between acute blood glucose level and outcome from ischemic stroke.
Background: Hyperglycemia may augment acute ischemic brain injury and increase the risk of hemorrhagic transformation of the infarct.
Methods: The authors analyzed the relation between admission blood glucose level (within 24 hours from ischemic stroke onset) and clinical outcome in 1,259 patients enrolled in the Trial of ORG 10172 in Acute Stroke Treatment (TOAST)—a placebo-controlled, randomized, double-blind trial to test the efficacy of a low-molecular weight heparinoid in acute ischemic stroke. Very favorable outcome was defined as a Glasgow Outcome Scale score of 1 and a modified Barthel index of 19 or 20. Neurologic improvement at 3 months was defined as a decrease by ≥4 points on the NIH Stroke Scale compared with baseline or a final score of 0. Hemorrhagic transformation of infarct was assessed within 10 days after onset of stroke with repeat cerebral CT. Stroke subtype as lacunar or nonlacunar (atherothromboembolic, cardioembolic, and other or undetermined etiology) was classified by one investigator after completion of stroke evaluation according to study protocol. Results: In all strokes combined (p = 0.03) and in nonlacunar strokes (p = 0.02), higher admission blood glucose levels were associated with worse outcome at 3 months according to multivariate logistic regression analysis adjusted for stroke severity, diabetes mellitus, and other vascular risks. In lacunar strokes, the relationship between acute blood glucose level and outcome was related to treatment. In the placebo group, higher admission blood glucose levels were associated with better outcome at 3 months. However, in the active drug group, as the glucose level increased from 50 to 150 mg/dL, the probability of a very favorable outcome decreased sharply and remained relatively unchanged as the glucose level increased further (p = 0.002, for overall effect of glucose on outcome). Acute blood glucose level was not associated with symptomatic hemorrhagic transformation of infarcts or with neurologic improvement at 3 months. Conclusions: During acute ischemic stroke hyperglycemia may worsen the clinical outcome in nonlacunar stroke, but not in lacunar stroke, and is not associated with an increased risk of hemorrhagic transformation of the infarct.
Get full access to this article
View all available purchase options and get full access to this article.
References
1.
Venables G, Miller SA, Gibson G, Hardy J, Strong A. The effects of hyperglycaemia on changes during reperfusion following focal cerebral ischaemia in the cat. J Neurol Neurosurg Psychiatry 1985;48:663–669.
2.
de Courten – Myers GM, Kleinholz M, Holm P, et al. Hemorrhagic infarct conversion in experimental stroke. Ann Emerg Med 1992;21:120–126.
3.
de Courten – Myers GM, Kleinholz M, Wagner KR, Myers RE. Fatal strokes in hyperglycemic cats. Stroke 1989;20:1707–1715.
4.
Chew W, Kucharczyk J, Moseley M, Derugin N, Norman D. Hyperglycemia augments ischemic brain injury : in vivo MR imaging/spectroscopic study with nicardipine in cats with occluded middle cerebral arteries. AJNR Am J Neuroradiol 1991;12:603–609.
5.
Prado R, Ginsberg MD, Dietrich WD, Watson BD, Busto R. Hyperglycemia increases infarct size in collaterally perfused but not end-arterial vascular territories. J Cereb Blood Flow Metab 1988;8:186–192.
6.
Woo E, Chan Y, Yu Y, Huang C. Admission glucose level in relation to mortality and morbidity outcome in 252 stroke patients. Stroke 1988;19:185–191.
7.
Topić E, Pavliček I, Brinar V, Koršić M. Glycosylated haemoglobin in clarification of the origin of hyperglycaemia in acute cerebrovascular accident. Diabet Med 1989;6:12–15.
8.
Woo J, Lam CW, Kay R, Wong AH, Teoh R, Nicholls G. The influence of hyperglycemia and diabetes mellitus on immediate and 3-month morbidity and mortality after acute stroke. Arch Neurol 1990;47:1174–1177.
9.
Kiers L, Davis S, Larkins R, et al. Stroke topography and outcome in relation to hyperglycaemia and diabetes. J Neurol Neurosurg Psychiatry 1992;55:263–270.
10.
Murros K, Fogelholm R, Kettunen S, Vuorela A-L, Valve J. Blood glucose, glycosylated haemoglobin, and outcome of ischemic brain infarction. J Neurol Sci 1992;111:59–64.
11.
Toni D, Sacchetti ML, Argentino C, et al. Does hyperglycaemia play a role on the outcome of acute ischaemic stroke patients? J Neurol 1992;239:382–386.
12.
Moulin T, Tatu L, Crépin–Leblond T, Chavot D, Bergès S, Rumbach L. The Besançon Stroke Registry : an acute stroke registry of 2,500 consecutive patients. Eur Neurol 1997;38:10–20.
13.
Weir CJ, Murray GD, Dyker AG, Lees KR. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow-up study. BMJ 1997;314:1303–1306.
14.
Helgason CM. Blood glucose and stroke. Stroke 1988;19:1049–1053.
15.
Voll C, Auer R. The effect of postischemic blood glucose levels on ischemic brain damage in the rat. Ann Neurol 1988;24:638–646.
16.
Kawai N, Keep RF, Betz AL. Hyperglycemia and the vascular effects of cerebral ischemia. Stroke 1997;28:149–154.
17.
Widmer H, Abiko H, Faden AI, James TL, Weinstein PR. Effects of hyperglycemia on the time course of change in energy metabolism and pH during global cerebral ischemia and reperfusion in rats : correlation of 1H and 31P NMR spectroscopy with fatty acid and excitatory amino acid levels. J Cereb Blood Flow Metab 1992;12:456–468.
18.
Dietrich WD, Alonso O, Busto R. Moderate hyperglycemia worsens acute blood–brain barrier injury after forebrain ischemia in rats. Stroke 1993;24:111–116.
19.
Folbergrová J, Memezawa H, Smith M-L, Siesjö BK. Focal and perifocal changes in tissue energy state during middle cerebral artery occlusion in normo- and hyperglycemic rats. J Cereb Blood Flow Metab 1992;12:25–33.
20.
Dávalos A, Cendra E, Teruel J, Martinez M, Genís D. Deteriorating ischemic stroke : risk factors and prognosis. Neurology 1990;40:1865–1869.
21.
Publications committee for the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) investigators.Low molecular weight heparinoid, ORG 10172 (Danaparoid), and outcome after acute ischemic stroke : a randomized controlled trial. JAMA 1998;279:1265–1272.
22.
Adams HP Jr, Bendixen BH, Kapelle LJ, et al. Classification of subtype of acute ischemic stroke : definitions for use in a multicenter clinical trial. Stroke 1993;24:35–41.
23.
Ginsberg MD, Prado R, Dietrich WD, Busto R, Watson BD. Hyperglycemia reduces the extent of cerebral infarction in rats. Stroke 1987;18:570–574.
24.
Nedergaard M, Diemer N. Focal ischemia of the rat brain, with special reference to the influence of plasma glucose concentration. Acta Neuropathol 1987;73:131–137.
25.
Nedergaard M, Gjedde A, Diemer NH. Hyperglycemia protects against neuronal injury around experimental brain infarcts. Neurol Res 1987;9:241–244.
26.
Zasslow MA, Pearl RG, Shuer LM, Steinberg GK, Lieberson RE, Larson CP Jr. Hyperglycemia decreases acute neuronal ischemic changes after middle cerebral artery occlusion in cats. Stroke 1989;20:519–523.
27.
Kraft SA, Larson CP Jr, Shuer LM, Steinberg GK, Benson GV, Pearl RG. Effect of hyperglycemia on neuronal changes in a rabbit model of focal cerebral ischemia. Stroke 1990;21:447–450.
28.
Combs DJ, Dempsey RJ, Kumar S, Donaldson D. Focal cerebral infarction in cats in the presence of hyperglycemia and increased insulin. Metab Brain Dis 1990;5:169–178.
29.
Osuga S, Hogan MJ. In vivo uptake of [3H]nimodipine in focal cerebral ischemia : modulation by hyperglycemia. J Cereb Blood Flow Metab 1997;17:1057–1065.
30.
Giroud M, Chirpaz L, Beuriat P, et al. Hyperglycemia in acute stroke. A factor of bad prognosis. Presse Med 1987;16:1079–1082.
31.
de Falco F, Visconti O, Fucci G, Caruso G. Correlation between hyperglycemia and cerebral infarct size in patients with stroke. A clinical and x-ray computed tomography study in 104 patients. Schweiz Arch Neurol Psychiatr 1993;144:233–239.
32.
Oppenheimer SM, Hoffbrand BI, Oswald GA, Yudkin JS. Diabetes mellitus and early mortality from stroke. BMJ 1985;291:1014–1015.
33.
Emara M, Saadah A, Tohfa Y, Guindi R, Gupta R, Senthilselvan A. The hematocrit value in diabetic patients with ischaemic stroke. Diabetes Res 1989;12:189–192.
34.
Lefkovits J, Davis S, Rossiter S, et al. Acute stroke outcome : effects of stroke type and risk factors. Aust NZ J Med 1992;22:30–35.
35.
Mitchell AJ. Clinical implications of poststroke hypothalamo-pituitary adrenal axis dysfunction : a critical literature review. J Stroke Cerebrovasc Dis 1997;6:377–388.
36.
O’Neill P, Davies I, Fullerton K, Bennett D. Stress hormone and blood glucose response following acute stroke in the elderly. Stroke 1991;22:842–847.
37.
Feibel JH, Hardy PM, Campbell RG, Goldstein MN, Joynt RJ. Prognostic value of the stress response following stroke. JAMA 1977;238:1374–1377.
38.
Cazzato G, Zorzon M, Mase G, Iona L. Hyperglycemia at ischemic stroke onset as prognostic factor. Ital J Neurol Sci 1991;12:283–288.
39.
Broderick JP, Hagen T, Brott T, Tomsick T. Hyperglycemia and hemorrhagic transformation of cerebral infarcts. Stroke 1995;26:484–487.
Information & Authors
Information
Published In
Copyright
© 1999.
Publication History
Received: August 10, 1998
Accepted: October 3, 1998
Published online: January 1, 1999
Published in print: January 1, 1999
Authors
Metrics & Citations
Metrics
Citation information is sourced from Crossref Cited-by service.
Citations
Download Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Select your manager software from the list below and click Download.
Cited By
- Fluid Management During Craniotomy, Cottrell & Patel's Neuroanesthesia, (167-181), (2025).https://doi.org/10.1016/B978-0-323-93273-8.00009-2
- High glycated albumin is associated with early neurological deterioration in patients with acute ischemic stroke, BMC Neurology, 24, 1, (2024).https://doi.org/10.1186/s12883-024-03747-4
- Non-fasting Glucose Level at Admission Associated with Outcomes in Cerebral Venous Thrombosis, Journal of Stroke Medicine, 7, 1, (59-65), (2024).https://doi.org/10.1177/25166085241231676
- Improved hypertensive stroke classification based on multi-scale feature fusion of head axial CT angiogram and multimodal learning, Physica Medica, 121, (103359), (2024).https://doi.org/10.1016/j.ejmp.2024.103359
- Admission hyperglycemia effect on symptomatic intracranial hemorrhage in tenecteplase versus alteplase before large vessel occlusion stroke thrombectomy, Journal of Neurology, 271, 12, (7605-7612), (2024).https://doi.org/10.1007/s00415-024-12704-7
- Protective Role of Chronic Exercise Training in Modulating the Impact of Hyperglycemia on Vascular Sensitivity to Ischemia-Reperfusion, Nutrients, 15, 1, (212), (2023).https://doi.org/10.3390/nu15010212
- The Prognostic Significance of Early Glycemic Profile in Acute Ischemic Stroke Depends on Stroke Subtype, Journal of Clinical Medicine, 12, 5, (1794), (2023).https://doi.org/10.3390/jcm12051794
- A review of stress-induced hyperglycaemia in the context of acute ischaemic stroke: Definition, underlying mechanisms, and the status of insulin therapy, Frontiers in Neurology, 14, (2023).https://doi.org/10.3389/fneur.2023.1149671
- Blood glucose level affects prognosis of patients who received intravenous thrombolysis after acute ischemic stroke? A meta-analysis, Frontiers in Endocrinology, 14, (2023).https://doi.org/10.3389/fendo.2023.1120779
- The Management of Acute Ischaemic Stroke – A Review and South African Perspective, Wits Journal of Clinical Medicine, 5, 3, (2023).https://doi.org/10.18772/26180197.2023.v5n3a6
- See more
Loading...
View Options
Login options
Check if you have access through your login credentials or your institution to get full access on this article.
Personal login Institutional LoginPurchase Options
The neurology.org payment platform is currently offline. Our technical team is working as quickly as possible to restore service.
If you need immediate support or to place an order, please call or email customer service:
- 1-800-638-3030 for U.S. customers - 8:30 - 7 pm ET (M-F)
- 1-301-223-2300 for customers outside the U.S. - 8:30 - 7 pm ET (M-F)
- [email protected]
We appreciate your patience during this time and apologize for any inconvenience.