|Year : 2018 | Volume
| Issue : 1 | Page : 7-11
Stroke in patients with and without diabetes mellitus
Avin Subhash, Chinta Raj Kumar, Neelam Kumari Singh, Suresh Krishnamurthy, MV Nagabushana, YJ Visweswara Reddy
Department of General Medicine, PESIMSR, Kuppam, Andhra Pradesh, India
|Date of Web Publication||8-Jan-2019|
Y J Visweswara Reddy
Professor and Head, Department of General Medicine, PESIMSR, Kuppam, Chittoor - 517 425, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: Diabetes mellitus (DM) is a well-recognized risk factor for stroke. Stroke in diabetic patients is different from stroke in non-diabetics from several perspectives. This study was carried out with the aim to identify and compare distinctive patterns between diabetic and non-diabetic stroke cases.
Methods: It is a hospital based cross-sectional study, carried out at PESIMSR Hospital, Kuppam, Andhra Pradesh, in which 80 consecutive patients with stroke (40 patients with and 40 without DM) were studied. Clinical features, risk factors, stroke patterns and outcome were studied.
Results: The mean age (years) in stroke patients 57.5 ± 12.7 and 61.3 ± 12.9 (p=NS) stroke in patients with and without DM respectively. Males outnumbered females in both the groups (p=NS). Stroke patients with DM known to have hypertension were 75% and that of non-DM group was 42.5%. Diabetic stroke patients with history of coronary artery disease formed 32.5% and that of non-diabetic group was 27.5%. The mean high density lipoprotein (HDL) cholesterol (mg/dL) was lower in the diabetic group (38.8 ± 12.6) compared to that in the non-diabetic group (50.1 ± 6.9). The mean triglycerides (TG) (mg/dL) was significantly higher in the diabetic (216.9 ± 67.6) than in the non- diabetic group (150.05 ± 60.58). Both diabetic and non-diabetic patients had greater incidence of ischemic stroke (about 75%) than hemorrhagic stroke. In the present study, 37.5% of stroke patients with diabetes had a poor outcome compared to 22.5% of stroke patients without diabetes.
Conclusions: DM is an independent risk factor for stroke. Stroke in patients with DM differs from that of stroke in persons without DM with respect to age, gender, stroke severity, prevalence of risk factors and outcome. Hypertension, HDL level and TG were significantly associated with DM. Diabetics stroke patients were having significantly higher levels of mean TG level, lower mean HDL level.
Keywords: Diabetes mellitus, high-density lipoprotein cholesterol, hypertension, stroke
|How to cite this article:|
Subhash A, Kumar CR, Singh NK, Krishnamurthy S, Nagabushana M V, Visweswara Reddy Y J. Stroke in patients with and without diabetes mellitus. J Clin Sci Res 2018;7:7-11
|How to cite this URL:|
Subhash A, Kumar CR, Singh NK, Krishnamurthy S, Nagabushana M V, Visweswara Reddy Y J. Stroke in patients with and without diabetes mellitus. J Clin Sci Res [serial online] 2018 [cited 2019 May 21];7:7-11. Available from: http://www.jcsr.co.in/text.asp?2018/7/1/7/249630
| Introduction|| |
Diabetes mellitus (DM) is a risk factor for both excess incidence and mortality from stroke. The first edition of Diabetes in America documented the strong association of DM with risk of stroke, especially strokes due to vascular disease and infarction.DM is associated with doubling of the risk of stroke and with poor long-term outcome after ischaemic stroke. Hyperglycaemia predicts higher mortality and morbidity after acute stroke, independent of other adverse prognostic factors, such as older age, type and severity of stroke and non-reversibility of neurologic deficit. The effect of hyperglycaemia on mortality is large.,,
In stroke patients, diabetes provokes anaerobic metabolism, lactic acidosis and free radical production, and hyperglycaemia may exert direct membrane lipid peroxidation and cell lysis in metabolically challenged tissues. Moderately and severely increased blood glucose has been found to further worsen the metabolic state and mitochondrial function in the area of ischaemic penumbra. Insulin resistance is a known risk factor for the onset of stroke acting through a number of intermediate vascular disease risk factors (i.e., thrombophilia, endothelial dysfunction and inflammation).
DM is a frequent condition in stroke patients. Epidemiological studies have suggested that the overall relative risk of stroke is 1.5–3 times greater in patients with DM than in healthy controls.,, The prevalence varied greatly according to the subtype of stroke considered. In patients suffering from spontaneous intracerebral haemorrhage, the prevalence of DM is lower than in those with ischaemic stroke. In the latter group, the prevalence is about 25%.,,,, The present study was conceived to study the clinical presentation patterns and outcome in patients with and without DM with stroke.
| Material and Methods|| |
This hospital-based, cross-sectional study was conducted on 80 consecutive patients with stroke admitted to Peoples Education Society Institute of Medical Sciences and Research (PESIMSR), Kuppam, Andhra Pradesh, during the period July 2012 to July 2014 as per the National Institute of Health Stroke Scoring (NIHSS) protocol.
Central nervous system infarction was defined as 'brain, spinal cord or retinal cell death due to ischaemia based on: (i) pathological, imaging or other objective evidence of cerebral, spinal cord or retinal focal ischaemic injury in a defined vascular distribution or (ii) clinical evidence of cerebral, spinal cord or retinal focal ischaemic injury based on symptoms persisting at least 24 h or until death and other aetiologies excluded'. Haemorrhagic stroke was defined as 'rapidly developing clinical signs of neurologic dysfunction due to a focal collection of the blood within the brain parenchyma or ventricular system which is not due to trauma'.
DM was confirmed on the basis of history, history of receiving oral hypoglycaemic drugs or insulin, previous medical records suggestive of diabetes or previous reports of blood sugar or glycosylated haemoglobin (HbA1C) confirming the diagnosis of diabetes according to the World Health Organization criteria. Persons not known to have DM admitted with high blood sugar levels underwent repeat blood sugar (48 h after admission) and HbA1C estimation.
Patients with neurologic deficits due to neuro-glycopaenic neurodefictis, stroke mimickers, trauma, tumours, infections, demyelination and post-seizure phenomenon were excluded. Patients receiving diabetogenic drugs, those with all uncommon strokes caused by hypercoagulable disorders, venous sinus thrombosis, vasculitis, etc., and those on dextrose-containing intravenous fluids at admission were also excluded.
At admission, detailed history regarding temporal profile of stroke and risk factors such as hypertension, DM, smoking, alcohol intake and previous strokes were recorded. Detailed neurological and other system examinations were done and recorded. Severity of stroke was assessed as per the NIHSS at admission and at the end of 1 week (on the day of discharge); appropriate laboratory testing and imaging were also done and treated as per the standard protocol in intensive care unit and general wards by a single observer and classified as patients with/without DM.
The data were entered into Microsoft Excel 2007 and further analysed using statistical package SPSS version 20. The descriptive data were analysed as follows: categorical data were reported as percentages and the continuous data were reported using mean and standard deviation. For inferential statistics, Chi-square test and 't-test' were carried out. A P < 0.05 was considered as statistically significant.
| Results|| |
Hypertension, high-density lipoprotein (HDL) levels and triglyceride (TG) levels were significantly associated with DM. Stroke patients with DM had significantly higher levels of mean TG level and lower mean HDL level [Table 1]. The association of hypertension and DM in stroke patients was statistically significant [Table 1].
The odds ratio of getting stroke in DM was 4 times more in the presence of hypertension. The mean random blood glucose level was lower in strokes/patients with DM compared to patients without DM.
The mean age in diabetic stroke patients was 57.5 ± 12.7 years and in non-diabetic stroke patients was 61.3 ± 12.9 years. Males outnumbered females in both the groups.
The number of stroke patients with DM with history of hypertension was 75% and that of non-diabetic group was 42.5%. Diabetic stroke patients with a history of coronary artery disease (CAD) were 32.5% and that of non-diabetic group were 27.5%. The mean HDL cholesterol was lower in the diabetic group (38.8 ± 12.6 mg/dL) compared to that in the non-diabetic group (50.1 ± 6.9 mg/dL). The mean TG was significantly higher in the person with diabetes (216.9 ± 67.6 mg/dL) than in the non-diabetic group (150.1 ± 60.6 mg/dL). Both diabetic and non-diabetic patients had greater incidence of ischaemic stroke than haemorrhagic stroke. In the present study, 37.5% of stroke patients with DM had a poor outcome compared to 22.5% of stroke patients without DM [Table 2].
|Table 2: Logistic regression analysis relating to stroke among diabetes mellitus patients with hypertension, coronary artery disease, smoking and alcoholism|
Click here to view
Of 40 diabetic patients with stroke, diabetic neuropathy (10%) was the most common diabetic complication found. Other diabetic complications were retinopathy (7.5%) and nephropathy (7.5%). Combination of retinopathy and nephropathy was found in 5%. Combination of retinopathy, nephropathy and neuropathy was found in 2.5% and diabetic ketoacidosis was found in 2.5%. People with diabetes without complications formed 60% of the group.
Poor stroke outcome was higher in people with diabetes. However, it was not statistically significant.
In the present study, 37.5% of stroke patients with diabetes had a poor outcome compared to 22.5% of stroke patients without diabetes.
| Discussion|| |
In the present study, the mean age in diabetic stroke patients was 57.5 ± 12.7 years and in non-diabetic stroke patients was 61.3 ± 12.9 years. Maximum patients were in the age group of 60–69 years (40%) in diabetic stroke and 60–69 (27.5%) in the non-diabetic group. In the Copenhagen stroke study, the diabetic stroke patients were 3.2 years younger than the non-diabetic stroke patient. The observation in the present study that the stroke occurs at a younger age in people with diabetes than in non-diabetics is similar to other studies.
We observed that men were at a greater risk for stroke in both diabetic and non-diabetic group. Women often did not seek health care and believed in natural cure or native medicine. This possibly explains the significant decrease in the female gender.
Diabetic stroke patients with a history of hypertension were 75% and that of non-diabetic group were 42.5%. Similar results were also found in the Copenhagen stroke study. Hypertension is the single most important factor for all vascular diseases, in general, cardiac and cerebral, in particular, closely followed by DM. When both are present, risk is greater. DM hastens atherosclerosis, and atherosclerosis promotes hypertension. Therefore, the prevalence of stroke is higher in diabetics, hypertensives and metabolic syndrome.
Diabetic stroke patients with a history of CAD were 32.5% and that of non-diabetic group were 27.5%. The observation in the present study that previous history of CAD was more common in the DM than in the non-diabetics was similar to another study. Coronary arteries as well as cerebral arteries are medium sized, and therefore, atherosclerotic changes contributory to the development of stroke also contribute to the higher incidence of stroke, more so, in diabetes.
In the present study, 77.5% of DM and 72.5% of non-diabetics had ischaemic strokes and confirmed on computed tomography (CT) brain. Further, 22.5% of DM and 27.5% of non-diabetics had haemorrhage on CT brain. In a study ischaemic stroke occurred more frequently in DM group (69%) as compared to non-diabetic group (45.8%). Haemorrhagic stroke was higher in non-diabetic group (52.7%) than in diabetic group (30.4%). In the Copenhagen stroke study, intracerebral haemorrhages were 6 times less frequent in DM patients. The observations of the present study prompt the need for studying a large number of patients, for scientific conclusions.
In the present study, diabetic patients had higher mean TG and lower HDL as compared to non-diabetic group. In a study higher TG levels were observed in the DM group (211.6 ± 80.2) as compared to the non-diabetic group (166.5 ± 35.8). Hypertriglyceridaemia and low HDL was reported in diabetic stroke patients in another study. In other studies,,, other stroke patients with DM had a poor outcome compared to stroke patients without DM. Our observations were similar.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Asplund K, Hägg E, Helmers C, Lithner F, Strand T, Wester PO, et al.
The natural history of stroke in diabetic patients. Acta Med Scand 1980;207:417-24.
Kuller LH, Dorman JS, Wolf PA. Cerebrovascular disease and diabetes. In: Harris MI, Hamman RF, editors. Diabetes in America. NIH publication No. 95-1468. Ch. 18. U.S.A: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1995.
Luitse MJ, Biessels GJ, Rutten GE, Kappelle LJ. Diabetes, hyperglycaemia, and acute ischaemic stroke. Lancet Neurol 2012;11:261-71.
Bruno A, Biller J, Adams HP Jr., Clarke WR, Woolson RF, Williams LS, et al.
Acute blood glucose level and outcome from ischemic stroke. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) investigators. Neurology 1999;52:280-4.
Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE, et al.
Hyperglycemia: An independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 2002;87:978-82.
Parsons MW, Barber PA, Desmond PM, Baird TA, Darby DG, Byrnes G, et al.
Acute hyperglycemia adversely affects stroke outcome: A magnetic resonance imaging and spectroscopy study. Ann Neurol 2002;52:20-8.
Anderson RE, Tan WK, Martin HS, Meyer FB. Effects of glucose and PaO2 modulation on cortical intracellular acidosis, NADH redox state, and infarction in the ischemic penumbra. Stroke 1999;30:160-70.
Kernan WN, Inzucchi SE, Viscoli CM, Brass LM, Bravata DM, Horwitz RI, et al.
Insulin resistance and risk for stroke. Neurology 2002;59:809-15.
Rothwell PM, Coull AJ, Giles MF, Howard SC, Silver LE, Bull LM, et al.
Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford vascular study). Lancet 2004;363:1925-33.
Almdal T, Scharling H, Jensen JS, Vestergaard H. The independent effect of type 2 diabetes mellitus on ischemic heart disease, stroke, and death: A population-based study of 13,000 men and women with 20 years of follow-up. Arch Intern Med 2004;164:1422-6.
Kissela BM, Khoury J, Kleindorfer D, Woo D, Schneider A, Alwell K, et al.
Epidemiology of ischemic stroke in patients with diabetes: The greater Cincinnati/Northern Kentucky stroke study. Diabetes Care 2005;28:355-9.
Stegmayr B, Asplund K. Diabetes as a risk factor for stroke. A population perspective. Diabetologia 1995;38:1061-8.
Béjot Y, Osseby GV, Gremeaux V, Durier J, Rouaud O, Moreau T, et al.
Changes in risk factors and preventive treatments by stroke subtypes over 20 years: A population-based study. J Neurol Sci 2009;287:84-8.
Ohira T, Shahar E, Chambless LE, Rosamond WD, Mosley TH Jr., Folsom AR, et al.
Risk factors for ischemic stroke subtypes: The atherosclerosis risk in communities study. Stroke 2006;37:2493-8.
Kolominsky-Rabas PL, Sarti C, Heuschmann PU, Graf C, Siemonsen S, Neundoerfer B, et al.
A prospective community-based study of stroke in Germany – The Erlangen stroke project (ESPro): Incidence and case fatality at 1, 3, and 12 months. Stroke 1998;29:2501-6.
White H, Boden-Albala B, Wang C, Elkind MS, Rundek T, Wright CB, et al.
Ischemic stroke subtype incidence among whites, blacks, and Hispanics: The Northern Manhattan study. Circulation 2005;111:1327-31.
Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, et al.
An updated definition of stroke for the 21st century: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:2064-89.
World Health Organization. WHO/IDF Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycemia. Geneva: World Health Organization; 2006.
Jørgensen H, Nakayama H, Raaschou HO, Olsen TS. Stroke in patients with diabetes. The Copenhagen stroke study. Stroke 1994;25:1977-84.
Sarkar RN, Banerjee S, Basu A. Comparative evaluation of diabetic and non-diabetic stroke – Effect of glycaemia on outcome. J Indian Med Assoc 2004;102:551-3.
Kamel A, Azim HA, Aziz SA, Ghaffar A, Okeely AE. Cerebral infarction in diabetes mellitus: A comparative study of diabetic and non-diabetic ischemic stroke. Egypt Neurol Psychiat Neurosurg 2006;43:167-77.
Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Predictors of stroke in middle-aged patients with non-insulin-dependent diabetes. Stroke 1996;27:63-8.
Megherbi SE, Milan C, Minier D, Couvreur G, Osseby GV, Tilling K, et al.
Association between diabetes and stroke subtype on survival and functional outcome 3 months after stroke: Data from the European BIOMED stroke project. Stroke 2003;34:688-94.
[Table 1], [Table 2]