From the Guidelines
Hyperglycemia during acute ischemic stroke is associated with poor outcomes, and maintaining blood glucose levels between 140-180 mg/dL is recommended to balance the risks of hyperglycemia and hypoglycemia. Elevated blood glucose during acute ischemic stroke exacerbates brain damage through multiple mechanisms, including increasing the production of lactic acid, promoting inflammation and oxidative stress, and impairing blood-brain barrier integrity 1. This can lead to increased cerebral edema, risk of hemorrhagic transformation, and reduced effectiveness of clot-busting medications.
The American Heart Association/American Stroke Association guidelines recommend treating hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/dL and closely monitoring to prevent hypoglycemia 1. The SHINE trial, a multicenter randomized controlled trial, is currently being analyzed to assess the targeted glucose concentration that would be safe and result in improved 3-month poststroke outcome 1. However, based on the current evidence, maintaining blood glucose levels between 140-180 mg/dL is the recommended target range for acute stroke care.
Some key points to consider in clinical practice include:
- Documenting glucose levels on admission and in the poststroke state to evaluate severity and duration
- Initiating insulin therapy for treatment of persistent hyperglycemia starting at a threshold of 180 mg/dL
- Performing ongoing assessments to evaluate the response to glucose management and adjusting treatment as needed
- Avoiding excessive glucose control to prevent hypoglycemia, which can also worsen neurological outcomes 1.
Overall, the goal of glucose management in acute ischemic stroke is to maintain a balance between controlling hyperglycemia and avoiding hypoglycemia, with the aim of improving patient outcomes.
From the Research
Association Between Hyperglycemia and Poor Outcomes in Acute Ischemic Stroke
- Hyperglycemia is associated with worse outcomes in patients with acute ischemic stroke, regardless of the presence of pre-existing diabetes mellitus 2.
- Experimental data suggest that elevated blood glucose may directly contribute to infarct expansion through maladaptive metabolic pathways, and that treatment with insulin may attenuate these adverse effects 2.
- Studies have shown that hyperglycemia at admission is associated with increased odds of in-hospital mortality and symptomatic intracranial hemorrhage in patients with acute ischemic stroke treated with tissue plasminogen activator (tPA) 3.
- The relationship between hyperglycemia and poor outcomes in acute ischemic stroke is evident in patients with persistent hyperglycemia, patients without a known history of diabetes mellitus, and patients with cortical infarction 4.
Glycemic Control in Acute Ischemic Stroke
- Insulin infusion protocols have been shown to be effective in glycemic control for patients with acute ischemic stroke, but may require modification to improve efficacy and safety 5.
- Tight glycemic control has been recommended in international guidelines for the treatment of patients with acute ischemic stroke, despite a lack of clinical evidence supporting its use 4.
- The use of insulin treatment strategies to control hyperglycemia in patients with acute ischemic stroke is challenging and associated with an increased risk of hypoglycemia 4.
Clinical Outcomes and Hyperglycemia
- Acute and chronic hyperglycemia are both associated with increased mortality and worse clinical outcomes in patients with acute ischemic stroke treated with tPA 3.
- Increasing admission glucose levels and glycosylated hemoglobin (HbA1c) levels are associated with increased adjusted odds ratio of in-hospital mortality and symptomatic intracranial hemorrhage in patients with acute ischemic stroke 3.
- The association between hyperglycemia and poor outcomes in acute ischemic stroke is supported by evidence from multiple studies, including the Glucose Regulation in Acute Stroke Patients (GRASP) trial 6 and other research studies 2, 5, 3, 4.