Effect of hyperglycemia on stroke outcome is not homogeneous to all patients treated with mechanical thrombectomy.

OBJECTIVES: Admission hyperglycemia is a penumbra-modifying factor that is associated with poor functional outcome in acute ischemic stroke (AIS) patients treated with intravenous rt-PA and/or mechanical thrombectomy (MT). Insulin therapy has failed to demonstrate a clinical benefit and the question of the patient selection remains under debate. We assessed the relationship between admission glycemia (AG) and functional outcome in AIS patients treated by MT according to both penumbra characteristics and reperfusion status. PATIENTS AND METHODS: We performed a retrospective analysis of a multi-center registry of consecutive AIS (NIHSS ≥ 10) due to middle cerebral artery occlusion treated by MT (± tissue Plasminogen Activator (tPA)). To evaluate the association between AG and the 3-month functional outcome (modified Rankin Scale (mRS) ≤2), univariable and multivariable analyses were used. Subgroup analyses were performed according to both clinical-ASPECTS Mismatch (CAM2) and the complete recanalization (CR) status defined by a mTICI scale (modified Thrombolysis in Cerebral Infarction) 2b/3. RESULTS: 216 AIS patients were included (Median Age: 68.43[58.12-77.95], median NIHSS: 18[15-21]). 104/216 (48.15%) patients had mRS≤2 at 3 months. AG was an independent predictor of functional outcome (/1 g/L OR: 0.10[0.03-0.37]) after adjusting for potential cofounders. Among subgroups formed by combining CAM2 and CR, AG was found to be predictor of functional outcome only in CAM2+/CR+ and specifically when recanalization was early. CONCLUSION: This study highlights the fact that the relationship between AG and prognosis is not homogeneous for all patients and indicates that AG has a deleterious effect on the ischemic penumbra, thus explaining its statistical association with functional outcome. Stroke neuroprotection by targeting hyperglycemia should be considered in acute stroke patients with mismatch and early complete recanalization. More prospective randomized trials are needed to generalize the conclusions.

SURF (stroke with underlying risk of atrial fibrillation): Proposals for a definition.

OBJECTIVES: Diagnosis of occult atrial fibrillation (AF) in stroke patients remains challenging. Several scores predictive of occult AF in stroke patients have been proposed, all based on the positive predictive value of clinical, biological, and radiological parameters, but they failed to modify the management of AF detection after stroke. The aim of this study was to identify a group of Stroke patients with Underlying Risk of Atrial Fibrillation (SURF) excluding stroke patients with low risk of AF. PATIENTS AND METHODS: We enrolled consecutive AF-naive stroke patients without indication of long-term anticoagulation. AF was adjudicated after prolonged Holter ECG and 2 years of follow-up. The negative predictive value (NPV) was determined for each relevant parameter in the acute phase. Firstly, clinico-radiological parameters with NPV > 95% defined the initial exclusion criteria of SURF. Secondly, the ultimate exclusion criterion of SURF was defined by a composite criterion constructed using the beta-coefficient of independent predictive parameters of AF determined by logistic regression. RESULTS: Among 773 AF-naïve patients without indication of anticoagulation, 111(14.4%) AFs were found. Initial SURF exclusion criteria, determined by NPV ≥ 95%, are: symptomatic atherosclerotic stenosis ≥50%, symptomatic arterial dissection or lacunar stroke. The SURF definition was completed by a composite exclusion criterion [Age*10+BNP< = 700] (NPV: 96.8%[92.6-98.9]). In the SURF group, 93/195(47.7%) AFs were diagnosed. CONCLUSIONS: In the SURF group, nearly half of the stroke patients had AF. The criteria used to define such a group are easily obtained in all stroke units, in the acute phase. SURF is a new concept proposal, which aims to improve the effectiveness of AF diagnosis after stroke.