Journal of Neurology (2018) 265:1426–1431
Impaired fasting glucose is associated with unfavorable outcome
in ischemic stroke patients treated with intravenous alteplase
· S. Fonville
· A. A. M. Zandbergen
· P. J. Koudstaal
· D. W. J. Dippel
· H. M. den Hertog
Received: 11 December 2017 / Revised: 7 April 2018 / Accepted: 10 April 2018 / Published online: 17 April 2018
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
Objectives Hyperglycemia on admission and diabetes mellitus type II are associated with unfavorable outcome in stroke
patients. We studied whether impaired fasting glucose (IFG) is associated with unfavorable outcome in ischemic stroke
patients treated with intravenous alteplase as well and if IFG is a stronger prognostic factor than hyperglycemiaon admission.
Methods We studied 220 consecutive patients with ischemic stroke treated with intravenous alteplase. In all nondiabetic
patients, fasting glucose was determined on day 2–5. IFG was deﬁned as fasting glucose level of ≥ 5.6 mmol/L, hyperglycemia
on admission as glucose levels ≥ 7.9 mmol/L. The primary eﬀect measure was the adjusted common odds ratio (acOR) for a
shift in the direction of worse outcome on the modiﬁed Rankin Scale at 3 months, estimated with ordinal logistic regression,
and adjusted for common prognostic factors.
Results The fasting glucose levels were available in 194 and admission glucose levels in 215 patients. Sixty-three (32.5%) had
IFG, 58 (27%) hyperglycemia on admission and 32 (14.6%) pre-existent diabetes. Patients with IFG showed a shift towards
worse functional outcome compared with patients with normal fasting glucose levels (acOR 2.77; 95% CI 1.54–4.97), which
was stronger than hyperglycemia on admission (acOR 1.75; 95% CI 0.91–3.4).
Conclusions IFG is associated with unfavorable outcome after treatment with intravenous alteplase for acute ischemic stroke.
IFG predicts unfavorable outcome better than hyperglycemia on admission.
Keywords Glucose · Thrombolysis · Hyperglycemia · Stroke · Outcome
Hyperglycemia on admission is associated with unfavorable
outcome in patients receiving intravenous alteplase. Patients
with hyperglycemia are more likely to have poor functional
outcome, increased infarction volume and/or symptomatic
Diabetes mellitus type 2 is also associated with unfavora-
ble outcome [7–9] and less recanalization after treatment
with intravenous alteplase . Impaired fasting glucose
(IFG) is highly prevalent in patients with stroke without
known diabetes prior to the event. IFG is associated with an
increased risk of recurrent stroke and other cardiovascular
Since IFG is a more reliable screening tool for diabe-
tes mellitus than random glucose levels, it could also be a
stronger predictor of outcome than random glucose levels.
 Few data are available on the association of IFG and
outcome in ischemic stroke patients who received intrave-
nous alteplase. One study showed that increased fasting
glucose levels on the day after treatment with intravenous
alteplase was associated with unfavorable outcome, but
admission glucose levels and diabetes were not .
The possible underlying mechanisms of the association
between hyperglycemia and poor outcome after intravenous
alteplase in stroke patients are reduction of the ﬁbrinolytic
activity of alteplase, impairment of cerebrovascular reactiv-
ity in the microvasculature and altered blood-barrier perme-
These associations of increased glucose with poor out-
come could be of importance of determining the prog-
nosis and possible treatment options in patients treated
* E. Osei
Medical Spectrum Twente, Enschede, The Netherlands
University Medical Center Utrecht, Utrecht, The Netherlands
Erasmus Medical Center, Rotterdam, The Netherlands