Faculty of Medicine
Library of the School of Health Sciences

2023-12-27

2023

Palaiodimou Lina

Γεώργιος Τσιβγούλης, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ, Επιβλέπων
Βαΐα Λαμπαδιάρη, Καθηγήτρια, Ιατρική Σχολή, ΕΚΠΑ
Κωνσταντίνος Βουμβουράκης, Ομότιμος Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Σωτήριος Γιαννόπουλος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Γεώργιος Παρασκευάς, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Αναστάσιος Μπονάκης, Αναπληρωτής Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Ιωάννης Τζάρτος, Αναπληρωτής Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ

Γλυκαιμική μεταβλητότητα στην οξεία φάση των αγγειακών εγκεφαλικών επεισοδίων

Greek

Glycemic variability in the acute phase of stroke

Background
Hyperglycemia after acute stroke is a common phenomenon, reported in up to one third of acute stroke patients, affecting both diabetic and non-diabetic patients as well. Admission hyperglycemia has been associated with a pathophysiological sequalae that may lead to poor outcomes in stroke patients, including higher mortality and unfavorable functional recovery post-stroke. In ischemic stroke patients receiving reperfusion therapies, increased glucose values at admission have also been related with lower recanalization rates and higher likelihood of symptomatic intracranial hemorrhage. Therefore, appropriate glucose management in the acute setting was expected to lead to better functional results of the stroke patients. Yet, the results of the randomized-controlled clinical trials in the field did not demonstrate any significant difference in efficacy outcomes among acute stroke patients administered intensive treatment with continuous intravenous insulin compared to the standard of care. On the other hand, the patients receiving intensive treatment showed significantly more hypoglycemic episodes. Investigating other hypoglycemic treatment options that take hypoglycemic risk and glycemic variability into account was thought to be of significant value. Glycemic variability is considered the third component of dysglycemia (along with hyperglycemia and hypoglycemia) but its association with post-stroke outcomes remains only partially elucidated.
Methods
A systematic review of the literature and a narrative presentation of studies describing glycemic management in the acute phase of stroke, as well as studies investigating the association between glycemic variability and clinical outcomes post stroke, were conducted.
In addition, a prospective follow-up study of 138 patients with acute stroke who were implanted with a continuous glucose monitoring device for up to 96 hours was performed. Thirteen indices of glycemic variability were calculated from the continuous glucose recording data. Clinical outcomes during hospitalization and the follow-up period (90 days) were recorded. Hypoglycaemic episodes revealed by continuous glucose recording device but not detected by finger prick measurements were also recorded.
Results
According to the systematic review, glucose management should be started in the first hours after the onset of stroke, preferably within the first 12 hours. Regarding the glucose values that necessitate intervention and the target range to be achieved, it is preferable to adhere to the limits suggested by international recommendations, as tighter glycaemic control was not associated with better outcome but was accompanied by higher rates of hypoglycaemic events. It is also recommended that the duration of treatment should be longer than 48 hours, as the presence of persistent hyperglycaemia and its association with worse outcome is well documented. In addition, a longer duration of hypoglycaemic treatment up to 72 hours is suggested in organised stroke units, whereas the time frame of 120 hours seems to be arduous for nurses without being associated with better clinical outcome. A new potential therapeutic target is glycemic variability, which is calculated from sequential glucose measurements. Higher quality data can be obtained by implementing continuous glucose monitoring in stroke patients. To date, there are limited studies that have evaluated the association between glycaemic variability and clinical outcome after stroke.
The continuous glucose monitoring device was successfully implanted in a total of 138 patients with acute stroke (mean age 64±10 years, 61% male, median NIHSS score at admission: 9, IQR: 3-14) after a median duration of 29 hours (IQR: 22-35) from the onset of stroke. Thirty-six (26%) patients were diabetic. The median duration of recording was 78 hours (IQR: 66-92) and provided a total of 115,846 glucose measurements for analysis. None of the indices of glycemic variability were associated with clinical outcomes post-stroke when the complete cohort was analyzed. However, in the subgroup of ischemic stroke patients receiving acute reperfusion therapies, mean glucose, as measured by continuous glucose monitoring, was independently associated with excellent functional outcome at 90 days. Asymptomatic hypoglycaemic episodes were detected in 46 patients (33%) during continuous glucose monitoring; none of these were detected by finger prick measurements. The incidence of hypoglycaemic episodes was higher in non-diabetic patients (34%) than in diabetic subjects (11%, p=0.004).
Conclusions
Glycemic variability was calculated during continuous glucose recording in patients with acute stroke and 13 different indices were calculated. No index of glycemic variability was associated with clinical outcome at 3 months, suggesting a shorter-term effect of glycemic variability on early neurological status post stroke. Continuous glucose recording identified several hypoglycaemic episodes in non-diabetic patients with acute stroke that had been underdiagnosed by periodic finger-prick blood glucose measurements, highlighting that glycaemic management in the context of acute stroke should be further optimised. Furthermore, according to subgroup analyses, it was shown that mean glucose in the first 96 h, as measured by continuous glucose recording, was independently associated with favorable functional outcome at 3 months among acute ischemic stroke patients receiving acute recanalization therapies.

Health Sciences

Glycemic variability, Stroke, Continuous glucose monitoring, Post-stroke hyperglycemia, Hypoglycemic episodes

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Yes

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https://pergamos.lib.uoa.gr/uoa/dl/object/3374871