From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.).
Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (D.S.L., J.L.S.), University of California Los Angeles.
Stroke. 2018 Nov;49(11):2706-2714. doi: 10.1161/STROKEAHA.118.022167.
Background and Purpose- Understanding the influence of hyperglycemia on outcomes in terms of the pretreatment collateral status might contribute to the achievement of case-specific glucose management in acute ischemic stroke. We sought to investigate whether the glucose level can influence the pretreatment collateral status and functional outcomes of endovascular thrombectomy in acute ischemic stroke and whether the impact of hyperglycemia on outcomes can be modified by the pretreatment collateral status. Methods- We analyzed the Triple-S database, which includes individual patient data pooled from 3 prospective Solitaire stent retriever studies (SWIFT [Solitaire With the Intention for Thrombectomy], SWIFT PRIME [SWIFT as Primary Endovascular Treatment], and STAR [Solitaire Flow Restoration Thrombectomy for Acute Revascularization]). Patients were eligible if they had acute ischemic stroke with moderate to severe neurological deficits, harbored angiographically confirmed large vessel occlusion, and were treatable by endovascular thrombectomy within 8 hours of onset. Pretreatment catheter angiograms were scored for collateral grades by a core imaging laboratory. The main outcome was 3-month good outcome (modified Rankin Scale score of 0-2). Results- Angiographic data on collaterals were available in 309 patients (age, 67±12 years; glucose, 131±55 mg/dL). Overall, the glucose level at presentation was not associated with pretreatment collateral status but was significantly lower in patients with a good outcome at 90 days (124 versus 140 mg/dL). Collateral grades modified the effect of glucose on good outcomes at 90 days ( P=0.03). Among patients with poor collaterals (collateral grades, 0-2), higher glucose levels did not alter the outcome, whereas among patients with good collaterals (3-4), higher glucose levels reduced the likelihood of a good outcome at 90 days (per 10 mg/dL increase: odds ratio, 0.81; 95% CI, 0.69-0.95). Conclusions- Our study revealed that higher glucose levels reduce the likelihood of a good outcome among patients with good collaterals, but their effects on the outcome are less significant for patients with poor collaterals. The results suggest that good collaterals at presentation may be targets for more intensive glucose control and future studies relating to glucose management.
背景与目的-了解高血糖对预处理侧支状态的影响，可能有助于实现急性缺血性脑卒中的个体化血糖管理。我们试图探讨血糖水平是否会影响急性缺血性脑卒中血管内血栓切除术的预处理侧支状态和功能结局，以及高血糖对结局的影响是否可以通过预处理侧支状态来修正。方法-我们分析了 Triple-S 数据库，该数据库包含了来自 3 项前瞻性 Solitaire 支架取栓研究（SWIFT[Solitaire 取栓术意向]、SWIFT PRIME[SWIFT 作为主要血管内治疗]和 STAR[Solitaire 血流恢复取栓术用于急性再通]）的个体患者数据。如果患者有中度至重度神经功能缺损的急性缺血性脑卒中、存在血管造影证实的大血管闭塞，并且可以在发病后 8 小时内进行血管内血栓切除术，则患者符合入组条件。预处理导管血管造影由核心影像实验室对侧支分级进行评分。主要结局为 3 个月时的良好结局（改良 Rankin 量表评分为 0-2）。结果-309 例患者（年龄 67±12 岁；血糖 131±55mg/dL）的血管造影侧支数据可用。总体而言，入院时的血糖水平与预处理侧支状态无关，但 90 天时预后良好的患者血糖水平显著较低（124 与 140mg/dL）。侧支分级改变了血糖对 90 天时良好结局的影响（P=0.03）。在侧支较差（侧支分级 0-2）的患者中，血糖水平升高并未改变结局，而在侧支较好（侧支分级 3-4）的患者中，血糖水平升高降低了 90 天时良好结局的可能性（每增加 10mg/dL：比值比 0.81；95%置信区间 0.69-0.95）。结论-我们的研究表明，在侧支较好的患者中，较高的血糖水平降低了良好结局的可能性，但对于侧支较差的患者，血糖水平对结局的影响较小。结果提示，发病时的良好侧支可能是更强化血糖控制的目标，未来与血糖管理相关的研究值得关注。
