Management of Hyperglycemia in Acute Ischemic Stroke
For this 70-year-old female with ischemic stroke and blood glucose of 12-13 mmol/L (216-234 mg/dL), you should initiate insulin therapy rather than observe, targeting a glucose range of 140-180 mg/dL (7.8-10 mmol/L). 1
Rationale for Active Treatment Over Observation
The patient's glucose level of 12-13 mmol/L (216-234 mg/dL) exceeds the treatment threshold established by the American Heart Association/American Stroke Association guidelines, which recommend initiating insulin therapy when glucose persistently exceeds 180 mg/dL (10 mmol/L). 1, 2, 3
Observation alone is not appropriate because:
- Persistent hyperglycemia >200 mg/dL during the first 24 hours independently predicts infarct expansion and worse neurological outcomes 2, 3
- Hyperglycemia is associated with hemorrhagic transformation and increased infarct volume 2, 3
- At 2 days post-stroke, the patient remains within the critical window where glucose control impacts outcomes 3
Insulin Protocol Selection
Use subcutaneous insulin rather than intravenous insulin infusion for this patient because:
- The patient is stable in a stroke unit (not critically ill) and has been appropriately resuscitated 1
- Subcutaneous insulin protocols can safely lower and maintain blood glucose below 180 mg/dL without excessive healthcare resources 1
- Intravenous insulin is reserved for patients who are critically ill, hemodynamically unstable, or receiving thrombolytic therapy 4, 5
The SHINE trial (2019) definitively demonstrated that intensive IV insulin targeting 80-130 mg/dL provided no benefit over standard treatment and increased severe hypoglycemia risk (2.6% vs 0%). 6 This is the highest quality and most recent evidence addressing this exact clinical scenario.
Target Glucose Range
Maintain blood glucose between 140-180 mg/dL (7.8-10 mmol/L). 1, 2, 3
This target is based on:
- American Diabetes Association recommendations for hospitalized patients 1
- American Heart Association/American Stroke Association consensus guidelines 1, 2, 3
- Evidence that tighter control (<140 mg/dL) increases hypoglycemia without improving outcomes 6
Monitoring Requirements
Implement the following monitoring protocol:
- Check blood glucose every 6 hours initially during the first 24-48 hours 2, 3
- Check potassium levels before and during insulin therapy to prevent hypokalemia 2, 3, 7
- Avoid glucose levels <80 mg/dL, as hypoglycemia may be more immediately dangerous than moderate hyperglycemia 2, 3, 5
Critical Pitfalls to Avoid
Do not pursue aggressive glucose normalization:
- The SHINE trial stopped early for futility when comparing intensive (80-130 mg/dL) versus standard (80-179 mg/dL) control 6
- Intensive protocols increase severe hypoglycemia risk without improving functional outcomes 6
- Symptomatic hypoglycemia occurred in 21% of patients in some intensive insulin studies 3, 8
Do not simply observe:
- The evidence strongly supports active glucose management with insulin rather than observation alone 2, 3
- Multiple observational studies consistently demonstrate worse outcomes with untreated hyperglycemia 1
Practical Implementation
Start with a subcutaneous insulin regimen that includes:
- Basal long-acting insulin 5
- Correction rapid-acting insulin for glucose out of range 5
- Prandial insulin if the patient is eating 5
The specific dosing should account for the patient's weight, renal function, and whether she has known diabetes (52% of acute stroke patients with hyperglycemia have known diabetes). 9