Premorbid frailty, stress hyperglycemia ratio, and functional outcome in patients with acute ischemic stroke

 So, you described something, but NOTHING HERE helps you get recovered! Damn it all, stroke research should help survivors recover! Doesn't anyone in stroke actually have two neurons to rub together for a spark of intelligence?

Premorbid frailty, stress hyperglycemia ratio, and functional outcome in patients with acute ischemic stroke

Marialuisa Zedde¹Simona Lattanzi²Andrea Pilotto^3,4,5,6Daniel Janitschke⁷Jakob Stögbauer^7*Fatma Merzou⁷Rosario Pascarella⁸Alessandro Padovani^3,4,5,6,9Andrea Morotti^3,5Piergiorgio Lochner⁷

• ¹Neurology Unit, Stroke Unit, Azienda Unita Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
• ²Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
• ³Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
• ⁴Laboratory of Digital Neurology and Biosensors, University of Brescia, Brescia, Italy
• ⁵Neurobiorepository and Laboratory of Advanced Biological Markers, University of Brescia and Azienda Socio Sanitaria Territoriale Spedali Civili Hospital, Brescia, Italy
• ⁶Neurology Unit, Department of Continuity of Care and Frailty, Azienda Socio Sanitaria Territoriale Spedali Civili Brescia Hospital, Brescia, Italy
• ⁷Department of Neurology, University of the Saarland, Homburg, Saar, Germany
• ⁸Neuroradiology Unit, Azienda Unita Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
• ⁹Brain Health Center, University of Brescia, Brescia, Italy

Background: Frailty, defined as multidimensional prognostic index (MPI), has been recently identified as strong predictor of disability and mortality in the elderly with acute ischemic stroke (AIS). The stress hyperglycemia ratio (SHR) is a recently introduced biomarker significantly associated with poor outcome in AIS.

Objectives: This study aimed to investigate in what extent frailty, measured by MPI, and SHR affects the 3-months outcome of patients > 65 years-old with AIS.

Methods: Consecutive patients with AIS >65 years-old who underwent intravenous thrombolysis (IVT) from 2015 to 2019 were enrolled in a German and an Italian Stroke Unit. The SHR was calculated by dividing the fasting plasma glucose at admission with glycated hemoglobin. Demographics and clinical premorbid data, stroke-related variables, including baseline and post-treatment NIHSS score were included in a logistic regression model. The 3-months functional outcome was evaluated by using modified Rankin scale (mRS); good outcome was defined as mRS 0–2, poor as mRS ≥ 3.

Results: One hundred and fifty-five AIS patients were enrolled in the study. Median MPI was 0.19 [0.13–0.31]; 118 (76.1%) patients were classified as “robust” and 37 (23.9%) as “frail.” In regression analysis, age, NIHSS, and MPI demonstrated as the most significant predictor of 3-months good outcome in the whole cohort. In robust patients, SHR values were significantly associated with the outcome.

Conclusions: MPI is associated with the 3-months outcome in our cohort, in particular with good outcome. Conversely, SHR seems to be associated with a 3-months poor outcome in “robust” patients but not in frail patients.

Introduction

Recent studies demonstrated that premorbid frailty assessed with different measures including the multidimensional frailty index (MPI) is a major determinant of the short and long-term response to acute reperfusion treatment in elderly patients with cerebrovascular events (1, 2). Stress hyperglycemia ratio (SHR) is a different parameter, proposed as a marker of increased risk of short-term mortality and poor functional outcome after ischemic stroke (3, 4).

Some studies have observed that SHR is associated with greater activation of the hypothalamic pituitary axis with an increase of pro-inflammatory cytokines. Another role of SHR is the possible induction of prothrombotic shift and enhance of platelet-endothelial adhesion. Altogether, this can increase induction of endothelial apoptosis, greater inflammation and oxidative stress.

However, the relation between SHR and stroke severity has been demonstrated in young patients and in this category, frailty is not contemplated (5).

In older patients the severity of stroke could be predicted by both frailty and SHR and the independent role of each to another in this issue has not been documented until now. In addition, the majority of studies are about Asian populations and this issue limits the extensions of the findings without further larger studies in other countries (6–8).

In a recent meta-analysis (9), higher SHR significantly increased the occurrence of poor outcomes, mortality, neurological deficit, haemorrhagic transformation, and infectious complications independent of the presence of diabetes and the type of reperfusion treatment. MPI and SHR might represent independent predictors of outcome in stroke but their performance has never been assessed in the same cohort to the best of our knowledge.

Therefore, in the present study, we investigated the role of both indexes, MPI and SHR, as predictors of poor outcome in AIS patients treated with intravenous thrombolysis (IVT).

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