What is the management of an acute cerebrovascular accident (CVA) in a 31-year-old patient with severe hyperglycemia?

From the Guidelines

A 31-year-old patient with an acute cerebrovascular accident (CVA or stroke) and severely elevated blood glucose of 857 mg/dL requires immediate medical attention with IV insulin therapy to gradually reduce glucose levels and prevent complications from rapid correction, as recommended by the most recent guidelines 1. The priority is to stabilize the patient with IV insulin therapy, typically starting with an insulin bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hour, with the goal of gradually reducing glucose by 50-75 mg/dL per hour to prevent complications from rapid correction.

• Concurrent IV fluids, typically normal saline at 15-20 mL/kg in the first hour followed by 4-14 mL/kg/hr, should be administered to address dehydration.
• For the stroke management, immediate neurological evaluation is essential, including brain imaging (CT or MRI) to determine if the stroke is ischemic or hemorrhagic.
• If ischemic and within 4.5 hours of symptom onset, IV thrombolysis with alteplase (0.9 mg/kg, maximum 90 mg, with 10% given as bolus and remainder over 60 minutes) may be considered, though the hyperglycemia increases hemorrhage risk and must be factored into the decision, as noted in previous guidelines 1. The hyperglycemia itself worsens stroke outcomes through increased inflammation, oxidative stress, and blood-brain barrier disruption, making aggressive glucose control crucial, as highlighted in the management of diabetes and hyperglycemia in the hospital 1. After stabilization, investigation into the cause of both the stroke in a young patient and the severe hyperglycemia (possibly new-onset diabetes or diabetic ketoacidosis) is essential for long-term management.
• The goal is to maintain blood glucose levels between 140-180 mg/dL, as recommended by the American Diabetes Association, to avoid excessive resources, labor, and risk 1.
• The use of subcutaneous insulin protocols can safely lower and maintain blood glucose levels below 180 mg/dL in acute stroke patients without excessive use of healthcare resources, as noted in the guidelines for the early management of patients with acute ischemic stroke 1.

From the Research

Acute CVA in 31-year-old with Glucose 857

• The patient's high glucose level of 857 is a significant concern in the management of acute cerebral vasculature accident (CVA) or stroke.
• According to the study 2, hyperglycemia has been associated with adverse outcomes in patients with acute ischemic stroke (AIS) and may influence outcomes after tissue plasminogen activator (tPA) treatment.
• The study 3 suggests that early insulin glycemic control combined with tPA thrombolysis may reduce acute brain tissue damage in diabetic rats with focal embolic stroke.
• In terms of human studies, 2 found that acute and chronic hyperglycemia are both associated with increased mortality and worse clinical outcomes in AIS patients treated with tPA.
• However, the study 4 suggests that routine prehospital blood glucose measurement in patients with suspected CVA may be unnecessary, unless there is a history suspicious for hypoglycemia or rescuer inability to obtain adequate patient information.
• It is essential to consider the patient's glucose level and potential diabetes history when making treatment decisions, including the use of tPA and insulin therapy, as supported by 5 and 3.
• The safety of intravenous thrombolysis for acute ischemic stroke in patients with subtherapeutic INR, as discussed in 6, may also be relevant in this case, although the patient's glucose level is the primary concern.