Ann Rehabil Med.  2015 Dec;39(6):1011-1017. 10.5535/arm.2015.39.6.1011.

The Prediction of Clinical Outcome Using HbA1c in Acute Ischemic Stroke of the Deep Branch of Middle Cerebral Artery

• Shin SB
• Kim TU
• Hyun JK
• Kim JY

• KMID: 2165629
• DOI: http://doi.org/10.5535/arm.2015.39.6.1011

Abstract

OBJECTIVE
To elucidate the association between glycemic control status and clinical outcomes in patients with acute ischemic stroke limited to the deep branch of the middle cerebral artery (MCA).
METHODS
We evaluated 65 subjects with first-ever ischemic stroke of the deep branches of the MCA, which was confirmed by magnetic resonance angiography. All subjects had blood hemoglobin A1c (HbA1c) measured at admission. They were classified into two groups according to the level of HbA1c (low <7.0% or high > or =7.0%). Neurological impairment and functional status were evaluated using the National Institutes of Health Stroke Scale (NIHSS), Functional Independence Measure (FIM), Korean version of Modified Barthel Index (K-MBI), Korean version of Mini-Mental State Examination (MMSE-K), and the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) at admission and discharge. Body mass index, serum glucose, homocysteine and cholesterol levels were also measured at admission.
RESULTS
The two groups did not show any difference in the NIHSS, FIM, K-MBI, MMSE-K, and LOTCA scores at any time point. Body mass index and levels of blood homocysteine and cholesterol were not different between the two groups. The serum blood glucose level at admission was negatively correlated with all outcome measures.
CONCLUSION
We found that HbA1c cannot be used for predication of clinical outcome in patients with ischemic stroke of the deep branch of the middle cerebral artery.

Keyword

Hemoglobin A1c; Stroke; Diabetes mellitus; Middle cerebral artery; Prognosis

MeSH Terms

Blood Glucose
Body Mass Index
Cholesterol
Diabetes Mellitus
Homocysteine
Humans
Magnetic Resonance Angiography
Middle Cerebral Artery*
National Institutes of Health (U.S.)
Occupational Therapy
Outcome Assessment (Health Care)
Prognosis
Stroke*
Blood Glucose
Cholesterol
Homocysteine

Figure

• 

  Fig. 1 (A) Korean version of Modified Barthel Index (K-MBI) at admission and discharge. Significant improvements were detected between admission and discharge in both groups (p<0.01). No differences were shown between groups. (B) Functional Independence Measure (FIM) at admission and discharge. Significant improvements were detected between admission and discharge in both groups (p<0.01). No differences were shown between groups.

Reference

1. Wolfe CD. The impact of stroke. Br Med Bull. 2000; 56:275–286. PMID: 11092079.

2. Adams HP Jr, Davis PH, Leira EC, Chang KC, Bendixen BH, Clarke WR, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: a report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. 1999; 53:126–131. PMID: 10408548.

3. Frankel MR, Morgenstern LB, Kwiatkowski T, Lu M, Tilley BC, Broderick JP, et al. Predicting prognosis after stroke: a placebo group analysis from the National Institute of Neurological Disorders and Stroke rt-PA Stroke Trial. Neurology. 2000; 55:952–959. PMID: 11061250.

4. Muir KW, Weir CJ, Murray GD, Povey C, Lees KR. Comparison of neurological scales and scoring systems for acute stroke prognosis. Stroke. 1996; 27:1817–1820. PMID: 8841337.

5. Andersen KK, Andersen ZJ, Olsen TS. Predictors of early and late case-fatality in a nationwide Danish study of 26,818 patients with first-ever ischemic stroke. Stroke. 2011; 42:2806–2812. PMID: 21817152.

6. Knoflach M, Matosevic B, Rucker M, Furtner M, Mair A, Wille G, et al. Functional recovery after ischemic stroke: a matter of age: data from the Austrian Stroke Unit Registry. Neurology. 2012; 78:279–285. PMID: 22238419.

7. Petty GW, Brown RD Jr, Whisnant JP, Sicks JD, O'Fallon WM, Wiebers DO. Ischemic stroke subtypes : a population-based study of functional outcome, survival, and recurrence. Stroke. 2000; 31:1062–1068. PMID: 10797166.

8. Nedeltchev K, der Maur TA, Georgiadis D, Arnold M, Caso V, Mattle HP, et al. Ischaemic stroke in young adults: predictors of outcome and recurrence. J Neurol Neurosurg Psychiatry. 2005; 76:191–195. PMID: 15654030.

9. Sumer MM, Ozdemir I, Tascilar N. Predictors of outcome after acute ischemic stroke. Acta Neurol Scand. 2003; 107:276–280. PMID: 12675701.

10. Saposnik G, Raptis S, Kapral MK, Liu Y, Tu JV, Mamdani M, et al. The iScore predicts poor functional outcomes early after hospitalization for an acute ischemic stroke. Stroke. 2011; 42:3421–3428. PMID: 21960583.

11. Shindo A, Tomimoto H. Diabetes and ischemic stroke. Brain Nerve. 2014; 66:107–119. PMID: 24523309.

12. Cantu-Brito C, Mimenza-Alvarado A, Sanchez-Hernandez JJ. Diabetes mellitus and aging as a risk factor for cerebral vascular disease: epidemiology, pathophysiology and prevention. Rev Invest Clin. 2010; 62:333–342. PMID: 21222313.

13. Mankovsky BN, Ziegler D. Stroke in patients with diabetes mellitus. Diabetes Metab Res Rev. 2004; 20:268–287. PMID: 15250030.

14. Luitse MJ, Biessels GJ, Rutten GE, Kappelle LJ. Diabetes, hyperglycaemia, and acute ischaemic stroke. Lancet Neurol. 2012; 11:261–271. PMID: 22341034.

15. Kruyt ND, Biessels GJ, Devries JH, Roos YB. Hyperglycemia in acute ischemic stroke: pathophysiology and clinical management. Nat Rev Neurol. 2010; 6:145–155. PMID: 20157308.

16. Kamouchi M, Matsuki T, Hata J, Kuwashiro T, Ago T, Sambongi Y, et al. Prestroke glycemic control is associated with the functional outcome in acute ischemic stroke: the Fukuoka Stroke Registry. Stroke. 2011; 42:2788–2794. PMID: 21817134.

17. Saudek CD, Derr RL, Kalyani RR. Assessing glycemia in diabetes using self-monitoring blood glucose and hemoglobin A1c. JAMA. 2006; 295:1688–1697. PMID: 16609091.

18. American Diabetes Association. Standards of medical care in diabetes, 2014. Diabetes Care. 2014; 37(Suppl 1):S14–S80. PMID: 24357209.

19. Rohlfing CL, Wiedmeyer HM, Little RR, England JD, Tennill A, Goldstein DE. Defining the relationship between plasma glucose and HbA(1c): analysis of glucose profiles and HbA(1c) in the Diabetes Control and Complications Trial. Diabetes Care. 2002; 25:275–278. PMID: 11815495.

20. Zoungas S, Chalmers J, Ninomiya T, Li Q, Cooper ME, Colagiuri S, et al. Association of HbA1c levels with vascular complications and death in patients with type 2 diabetes: evidence of glycaemic thresholds. Diabetologia. 2012; 55:636–643. PMID: 22186981.

21. Caplan LR, Van Gijn J. Stroke syndromes. 3rd ed. New York: Cambridge University press;2012. p. 344–358.

22. Caplan LR. Diabetes and brain ischemia. Diabetes. 1996; 45(Suppl 3):S95–S97. PMID: 8674904.

23. Ghika J, Bogousslavsky J, Regli F. Infarcts in the territory of lenticulostriate branches from the middle cerebral artery. Etiological factors and clinical features in 65 cases. Schweiz Arch Neurol Psychiatr. 1991; 142:5–18.

24. Hjalmarsson C, Manhem K, Bokemark L, Andersson B. The role of prestrike glycemic control on severity and outcome of acute ischemic stroke. Stroke Res Treat. 2014; 2014:694569. PMID: 25295219.

25. Wu S, Wang C, Jia Q, Liu G, Hoff K, Wang X, et al. HbA1c is associated with increased all-cause mortality in the first year after acute ischemic stroke. Neurol Res. 2014; 36:444–452. PMID: 24649851.

26. Lei C, Wu B, Liu M, Chen Y. Association between hemoglobin A₁C levels and clinical outcome in ischemic stroke patients with or without diabetes. J Clin Neurosci. 2015; 22:498–503. PMID: 25595961.

27. Baird TA, Parsons MW, Phan T, Butcher KS, Desmond PM, Tress BM, et al. Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome. Stroke. 2003; 34:2208–2214. PMID: 12893952.

28. Garg R, Chaudhuri A, Munschauer F, Dandona P. Hyperglycemia, insulin, and acute ischemic stroke: a mechanistic justification for a trial of insulin infusion therapy. Stroke. 2006; 37:267–273. PMID: 16306459.

29. Williams LS, Rotich J, Qi R, Fineberg N, Espay A, Bruno A, et al. Effects of admission hyperglycemia on mortality and costs in acute ischemic stroke. Neurology. 2002; 59:67–71. PMID: 12105309.

30. Weil ZM. Ischemia-induced hyperglycemia: consequences, neuroendocrine regulation, and a role for RAGE. Horm Behav. 2012; 62:280–285. PMID: 22521211.

31. Chmielewska B, Hasiec T, Belniak-Legiec E. Value of glucose, glycosylated hemoglobin and fructosamine in blood of patients with ischemic cerebral infarction without diabetes during the early stage of the disease. Ann Univ Mariae Curie Sklodowska Med. 1996; 51:61–68. PMID: 9467249.

32. Allport LE, Butcher KS, Baird TA, MacGregor L, Desmond PM, Tress BM, et al. Insular cortical ischemia is independently associated with acute stress hyperglycemia. Stroke. 2004; 35:1886–1891. PMID: 15192241.

33. Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke. 2001; 32:2426–2432. PMID: 11588337.

34. Ogbera AO, Oshinaike OO, Dada O, Brodie-Mends A, Ekpebegh C. Glucose and lipid assessment in patients with acute stroke. Int Arch Med. 2014; 7:45. PMID: 25379056.

35. Murros K, Fogelholm R, Kettunen S, Vuorela AL, Valve J. Blood glucose, glycosylated haemoglobin, and outcome of ischemic brain infarction. J Neurol Sci. 1992; 111:59–64. PMID: 1402998.