Waimei Tai, MD

Rocco A, Heuschmann PU, Schellinger PD, Köhrmann M, Diedler J, Sykora M. Glycosylated Hemoglobin A1 Predicts Risk for Symptomatic Hemorrhage After Thrombolysis for Acute Stroke. Stroke. 2013

Rocco, et al. published an interesting article recently looking at the relationship between glycosylated hemoglobin A1c and the risk of bleeding after an acute ischemic stroke. This was a registry study at a single, large stroke center of acute ischemic stroke patients treated with iv-tpa. Patients were evaluated for symptomatic intracranial hemorrhage (sICH) and other clinical factors including HgbA1c. Without surprise, higher NIHSS, history of diabetes, entry serum glucose and higher HgbA1c were associated with a higher sICH rate. In fact, the c-statistic for HgbAc was 0.8 to predict sICH which is quite high for a clinical parameter.

In addition, after multivariate anaylsis, age, NIHSS and HgbA1c were independent predictors of dependent status (mRS 3-5). Similarly age, history of diabetes sICH, and HgbA1c predicted risk of death at 90 days.

Previous studies have suggested that diabetes and hyperglycemia at stroke presentation increases sICH and subsequent poor outcomes for ischemic stroke patients. This has been the premise for such randomized controlled trials such as SHINE (Stroke Hyperglycemia Insulin Network Effort Trial, NCT01369069) which is evaluating strict glycemic control with intravenous insulin versus more traditional subcutaneous insulin regimens in the first 72 hours after ischemic stroke.

This study bolsters current clinical knowledge about the relationship between diabetes and outcomes from acute ischemic stroke. HgbA1c, a quantifiable measure, is a better independent predictor for sICH and functional status after stroke, than merely the history of diabetes alone.

I don’t think this would really change current clinical practice. We already routinely check HgbA1c as a marker for diabetes in our acute ischemic stroke patients. We also routinely get repeat imaging 1-2 days after acute iv thrombolysis treatment and monitor patients carefully to evaluate for sICH. This may perhaps persuade me to be more cautious or delay in starting antithrombotic therapy if poorly controlled diabetic patients had any hint of micro hemorrhages on imaging. How do you see this affecting your clinical practice?