International Stroke Conference
Kevin S. Attenhofer, MD
Diabetes is not just a matter of the sugar! Like stroke, diabetes is a vascular disease. This morning, Drs. Wuwei Feng, Karen C. Johnston, Kunjan Dave, and Adviye Ergul presented an intriguing series of lectures looking into some of the subtleties of pathophysiology and management of diabetes in the acute stroke patient. This is a particularly important topic here in the United States, where 1 in 4 patients carry this diagnosis — an independent risk factor for stroke that is modifiable!
In mouse models, diabetes leads to a proliferation of immature and “leaky” microvasculature. When stroke is induced, a phenomenon of “vasoregression” is seen in the diabetic mouse. That is, there is a loss of vasculature that persists even when the non-diabetic control mouse undergoes a later reparative angiogenesis. In these mouse models, diabetic mice had greater incidence of hemorrhagic transformation and worse outcomes.
These findings closely mirror the physician experience with stroke patients. The NINDS trial noted a 6.4% incidence of symptomatic ICH; however, if you examine a subpopulation of hyperglycemia patients in NINDS, then the incidence of sICH increases to 10–11%.
NINDS is not alone. Multiple studies over the years have reinforced an association between hyperglycemia and worse outcomes in acute ischemic stroke, but causation remains unclear. If you dive deeper into this data, you find a consistent theme: Hyperglycemia is associated with worse outcomes in large vessel disease and large vessel occlusion, but not in lacunar strokes. Despite decades of literature supporting this association, there remains a terrible paucity of definitive evidence guiding acute management of hyperglycemia in the acute stroke patient.
To this point, Dr. Johnston spent her time talking about the ongoing SHINE trial, which is a multi-center, randomized trial evaluating targeted glucose therapy in the acute phase of stroke. They have enrolled almost 1100 out of 1400 patients with a mean glucose of 187 at randomization. They seek to compare the outcomes and risk of ICH in acute stroke patients stratified by degree of glycemic control. Over 60% of the patients currently enrolled have been treated with IV tPA, which will ensure that the results are well-powered to inform the discussion.