Filipov Alexandra, Ebert Anne D, Neumaier-Probst Eva, Alonso Angelika
Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg,Germany.
Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg,Germany.
J Stroke Cerebrovasc Dis. 2018 May;27(5):1343-1349. doi: 10.1016/j.jstrokecerebrovasdis.2017.12.027. Epub 2018 Feb 1.
Intravenous thrombolysis with recombinant tissue plasminogen activator is still not approved by the European Medicines Agency for patients with diabetes mellitus and previous stroke. We assessed functional benefit and potential risk of thrombolysis in patients with diabetes and previous stroke and the influence of age, preexisting diabetic damage, as well as acute and chronic hyperglycemia on outcome, symptomatic intracranial hemorrhage, and in-hospital mortality.
We analyzed 527 consecutive patients treated with thrombolysis for acute stroke. Poor outcome was defined as deterioration of prestroke modified Rankin Scale (mRS) to 3 or greater at discharge. Symptomatic intracranial hemorrhage was defined according to the Safe Implementation of Thrombolysis in Stroke-Monitoring Study criteria.
Of the patients, 35.9% were diabetic and 33.2% had previous stroke. Of these patients, 14.4% were diabetics with previous stroke (index group). The rate of patients with poor functional outcome at discharge, symptomatic intracranial hemorrhage, or mortality did not differ between the index group and patients with either diabetes or previous stroke in 2 × 2 comparisons. Diabetics with first-ever stroke showed significantly more symptomatic intracranial hemorrhage (9.7%, P < .001) than the other groups, poorer functional recovery (P = .036), and the highest rate of mortality (12.4%, P < .001). Significant predictors for poor outcome were age (P < .001) and HbA1c (P = .013), for symptomatic intracranial hemorrhage HbA1c (P = .006) and for mortality acute hyperglycemia (P = .001) and age (P = .004).
Diabetics with previous stroke should not be withheld from intravenous thrombolysis. The risk of complications derives primarily from poor long-term metabolic control rather than from acute hyperglycemia or from previous stroke.
欧洲药品管理局仍未批准重组组织型纤溶酶原激活剂用于患有糖尿病和既往有卒中史的患者进行静脉溶栓治疗。我们评估了糖尿病合并既往有卒中史患者溶栓治疗的功能获益和潜在风险，以及年龄、已存在的糖尿病损害，以及急性和慢性高血糖对预后、症状性颅内出血和住院死亡率的影响。
我们分析了527例连续接受急性卒中溶栓治疗的患者。预后不良定义为出院时卒中前改良Rankin量表（mRS）恶化至3级或更高。症状性颅内出血根据卒中溶栓安全实施监测研究标准进行定义。
患者中，35.9%患有糖尿病，33.2%既往有卒中史。在这些患者中，14.4%为糖尿病合并既往有卒中史（指数组）。在2×2比较中，指数组与糖尿病患者或既往有卒中史患者在出院时功能预后不良、症状性颅内出血或死亡率方面无差异。首次发生卒中的糖尿病患者症状性颅内出血显著多于其他组（9.7%，P<0.001），功能恢复较差（P=0.036），死亡率最高（12.4%，P<0.001）。预后不良的显著预测因素为年龄（P<0.001）和糖化血红蛋白（HbA1c）（P=0.013），症状性颅内出血的预测因素为HbA1c（P=0.006），死亡率的预测因素为急性高血糖（P=0.001）和年龄（P=0.004）。
既往有卒中史的糖尿病患者不应被排除在静脉溶栓治疗之外。并发症风险主要源于长期代谢控制不佳，而非急性高血糖或既往卒中史。
