Published Online
on August 14, 2008

A more recent version of this article appeared on October 1, 2008

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Submitted on January 8, 2008
Revised on February 29, 2008
Accepted on March 6, 2008

Dynamic of Hyperglycemia as a Predictor of Stroke Outcome in the ECASS-II Trial

Mei Yong PhD, MSc, MPH^* and Markku Kaste MD, PhD, FAHA, FESC

From the Department of Statistics in Medicine (M.Y.), Heinrich Heine University Hospital, Duesseldorf, Germany; and the Department of Neurology (M.K.), Helsinki University Central Hospital, Helsinki, Finland.

^* To whom correspondence should be addressed. E-mail: yong{at}uni-duesseldorf.de.

Background and Purpose—Baseline hyperglycemia has been considered an independent predictor of stroke outcome. The present study analyzes the dynamics of serum glucose levels within the first 24 hours and its impact on stroke outcome.

Methods—We studied 748 patients with acute ischemic hemispheric stroke in the second European Cooperative Acute Stroke Study (ECASS-II). The patients had 2 serum glucose measurements, at baseline and at 24 hours. Four dynamic patterns were defined as baseline hyperglycemia present only at baseline, 24-hour hyperglycemia present only at 24 hours, persistent hyperglycemia, ie, hyperglycemia at baseline and at 24 hours, and persistent normoglycemia, ie, normoglycemia at baseline and at 24 hours. The end points were 7-day neurological improvement on National Institutes of Health Stroke Scale, 30-day favorable functional outcome (Barthel Index 95 or 100), 90-day negligible dependence (modified Rankin Scale 0 to 2), all-cause mortality within 90 days, and hemorrhagic transformation on CT within the first 7 days.

Results—In nondiabetic patients, persistent hyperglycemia was inversely associated with neurological improvement (OR=0.31; 95% CI=0.16 to 0.60), 30-day favorable functional outcome (OR=0.27; 95% CI=0.12 to 0.62), and 90-day negligible dependence (OR=0.36; 95% CI=0.17 to 0.73); it was associated with an increased risk of mortality within 90 days (OR=7.61; 95% CI=3.23 to 17.90) and for parenchymal hemorrhage (OR=6.64; 95% CI=2.63 to 16.78), whereas it was inversely associated with hemorrhagic infarction (OR=0.30; 95% CI=0.13 to 0.71). Delayed hyperglycemia at 24 hours was associated with the risks of death (OR=5.99; 95% CI=2.51 to 14.2) and parenchymal hemorrhage (OR=5.69; 95% CI-2.05 to 15.8) and inversely associated with no and negligible dependency (OR=0.40; 95% CI=0.20 to 0.78). Hyperglycemia at baseline only was not associated with any parameter of worse outcome. In patients with diabetes, the dynamic patterns of hyperglycemia did not suggest an association with stroke outcome.

Conclusions—Persistent hyperglycemia was associated with all bad outcome end points studied. In addition to a single glucose measurement, the pattern of change should be considered in the prediction of stroke outcome.

Key words: hyperglycemia • ischemic stroke • outcome • prediction • recombinant tissue plasminogen activator • serum glucose

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