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      Effect of Hyperglycemia at Presentation on Outcomes in Acute Large Artery Occlusion Patients Treated With Solitaire Stent Thrombectomy

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          Abstract

          Background: Sporadic data showed hyperglycemia at presentation is associated with poor outcomes in patients with acute ischemic stroke (AIS) under mechanical thrombectomy (MT) treatment.

          Objective: This study aims to evaluate the relationship of admission hyperglycemia and outcomes in patients treated with solitaire stent thrombectomy.

          Methods: This multicenter prospective study registered patients with AIS due to anterior circulation large vessel occlusion (LVO) suitable for MT with Solitaire stent retriever. We analyzed the influence of admission hyperglycemia (≥7.8 mmol/L) and serum glucose on functional independence which is defined as modified Rankin Scale score (mRS) of 0–2, symptomatic intracranial hemorrhage (sICH) and several outcomes of interest using univariable and multiple logistic regression analysis.

          Results: This study involved 17 stroke centers across China and consecutively recruited 149 patients. Patients with hyperglycemia at presentation less frequently exhibited a functional independence at 3 months than patients without hyperglycemia (22.2 vs. 66.4%; odds ratio 0.75, 95% confidence interval 0.61–0.92; P = 0.005). Higher glucose levels were correlated with worse outcome (per 1 mmol/L increase in glucose: odds ratio for mRS score 0–2 at 3 months 0.17, 95% confidence interval 0.06–0.45; P < 0.001) at 3 months and sICH (per 1 mmol/L increase in glucose: odds ratio for sICH was 8.2, 95% confidence interval 1.13–29.57; P < 0.001) after thrombectomy.

          Conclusions: Higher admission serum glucose and hyperglycemia were independently correlated with lower functional independence at 3 months in patients treated with Solitaire stent thrombectomy of anterior circulation LVO. Higher admission serum glucose was also associated with sICH after thrombectomy.

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          Most cited references23

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          Glucose and NADPH oxidase drive neuronal superoxide formation in stroke.

          Hyperglycemia has been recognized for decades to be an exacerbating factor in ischemic stroke, but the mechanism of this effect remains unresolved. Here, we evaluated superoxide production by neuronal nicotinamide adenine dinucleotide phosphate (NADPH) oxidase as a possible link between glucose metabolism and neuronal death in ischemia-reperfusion. Superoxide production was measured by the ethidium method in cultured neurons treated with oxygen-glucose deprivation and in mice treated with forebrain ischemia-reperfusion. The role of NADPH oxidase was examined using genetic disruption of its p47(phox) subunit and with the pharmacological inhibitor apocynin. In neuron cultures, postischemic superoxide production and cell death were completely prevented by removing glucose from the medium, by inactivating NADPH oxidase, or by inhibiting the hexose monophosphate shunt that generates NADPH from glucose. In murine stroke, neuronal superoxide production and death were decreased by the glucose antimetabolite 2-deoxyglucose and increased by high blood glucose concentrations. Inactivating NADPH oxidase with either apocynin or deletion of the p47(phox) subunit blocked neuronal superoxide production and negated the deleterious effects of hyperglycemia. These findings identify glucose as the requisite electron donor for reperfusion-induced neuronal superoxide production and establish a previously unrecognized mechanism by which hyperglycemia can exacerbate ischemic brain injury.
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            Symptomatic intracranial hemorrhage after stroke thrombolysis: the SEDAN score.

            A study was undertaken to develop a score for assessing risk for symptomatic intracranial hemorrhage (sICH) in ischemic stroke patients treated with intravenous (IV) thrombolysis. The derivation cohort comprised 974 ischemic stroke patients treated (1995-2008) with IV thrombolysis at the Helsinki University Central Hospital. The predictive value of parameters associated with sICH (European Cooperative Acute Stroke Study II) was evaluated, and we developed our score according to the magnitude of logistic regression coefficients. We calculated absolute risks and likelihood ratios of sICH per increasing score points. The score was validated in 828 patients from 3 Swiss cohorts (Lausanne, Basel, and Geneva). Performance of the score was tested with area under a receiver operating characteristic curve (AUC-ROC). Our SEDAN score (0 to 6 points) comprises baseline blood Sugar (glucose; 8.1-12.0 mmol/l [145-216 mg/dl] = 1; >12.0 mmol/l [>216 mg/dl] = 2), Early infarct signs (yes = 1) and (hyper)Dense cerebral artery sign (yes = 1) on admission computed tomography scan, Age (>75 years = 1), and NIH Stroke Scale on admission (≥10 = 1). Absolute risk for sICH in the derivation cohort was: 1.4%, 2.9%, 8.5%, 12.2%, 21.7%, and 33.3% for 0, 1, 2, 3, 4, and 5 score points, respectively. In the validation cohort, absolute risks were similar (1.0%, 3.5%, 5.1%, 9.2%, 16.9%, and 27.8%, respectively). AUC-ROC was 0.77 (0.71-0.83; p < 0.001). Our SEDAN score reliably assessed risk for sICH in IV thrombolysis-treated patients with anterior- and posterior circulation ischemic stroke, and it can support clinical decision making in high-risk patients. External validation of the score supports its generalization. Copyright © 2012 American Neurological Association.
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              Predicting outcome of IV thrombolysis-treated ischemic stroke patients: the DRAGON score.

              To develop a functional outcome prediction score, based on immediate pretreatment parameters, in ischemic stroke patients receiving IV alteplase. The derivation cohort consists of 1,319 ischemic stroke patients treated with IV alteplase at the Helsinki University Central Hospital, Helsinki, Finland. We evaluated the predictive value of parameters associated with the 3-month outcome and developed the score according to the magnitude of logistic regression coefficients. We assessed accuracy of the model with bootstrapping. External validation was performed in a cohort of 330 patients treated at the University Hospital Basel, Basel, Switzerland. We assessed the score performance with area under the receiver operating characteristic curve (AUC-ROC). The DRAGON score (0-10 points) consists of (hyper)Dense cerebral artery sign/early infarct signs on admission CT scan (both = 2, either = 1, none = 0), prestroke modified Rankin Scale (mRS) score >1 (yes = 1), Age (≥ 80 years = 2, 65-79 years = 1, 8 mmol/L [>144 mg/dL] = 1), Onset-to-treatment time (>90 minutes = 1), and baseline National Institutes of Health Stroke Scale score (>15 = 3, 10-15 = 2, 5-9 = 1, 0-4 = 0). AUC-ROC was 0.84 (0.80-0.87) in the derivation cohort and 0.80 (0.74-0.86) in the validation cohort. Proportions of patients with good outcome (mRS score 0-2) were 96%, 88%, 74%, and 0% for 0-1, 2, 3, and 8-10 points, respectively. Proportions of patients with miserable outcome (mRS score 5-6) were 0%, 2%, 5%, 70%, and 100% for 0-1, 2, 3, 8, and 9-10 points, respectively. External validation showed similar results. The DRAGON score is valid at our site and was reliable externally. It can support clinical decision-making, especially when invasive add-on strategies are considered. The score was not studied in patients with basilar artery occlusion. Further external validation is warranted.
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                Author and article information

                Contributors
                Journal
                Front Neurol
                Front Neurol
                Front. Neurol.
                Frontiers in Neurology
                Frontiers Media S.A.
                1664-2295
                19 February 2019
                2019
                : 10
                : 71
                Affiliations
                [1] 1Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University , Beijing, China
                [2] 2Department of Neurology, Beijing Tiantan Hospital, Capital Medical University , Beijing, China
                Author notes

                Edited by: Linxin Li, University of Oxford, United Kingdom

                Reviewed by: Bruce Campbell, The University of Melbourne, Australia; Michele Romoli, University of Perugia, Italy

                *Correspondence: Zhongrong Miao doctorzhongrongm@ 123456126.com

                This article was submitted to Stroke, a section of the journal Frontiers in Neurology

                Article
                10.3389/fneur.2019.00071
                6390827
                30837929
                9eb0c13d-a479-43fc-a344-362969d7316b
                Copyright © 2019 Huo, Liu, Gao, Ma, Mo, Liao, Wang, Sun, Song, Jia, Liu, Wang, Pan, Wang, Liu, Zhao, Wang, Miao and the EAST Study Group.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 07 September 2018
                : 18 January 2019
                Page count
                Figures: 0, Tables: 4, Equations: 0, References: 29, Pages: 8, Words: 5645
                Categories
                Neurology
                Original Research

                Neurology
                mechanical thrombectomy,hyperglycemia,acute ischemic stroke,stent retriever,outcomes
                Neurology
                mechanical thrombectomy, hyperglycemia, acute ischemic stroke, stent retriever, outcomes

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