What is the management for a 70-year-old female patient, diagnosed with ischemic stroke 2 days ago, with a Random Blood Sugar (RBS) level of 12-13 mmol/L, and normal lab results, currently in the stroke unit?

Management of Hyperglycemia in Acute Ischemic Stroke

For this 70-year-old female with ischemic stroke 2 days ago and RBS of 12-13 mmol/L (216-234 mg/dL), insulin therapy should be initiated immediately—observation alone is inadequate and TPA is contraindicated at this time point. 1

Why Insulin Therapy is Required

The blood glucose level of 12-13 mmol/L (216-234 mg/dL) exceeds the treatment threshold of 200 mg/dL (11.1 mmol/L), mandating active glucose management rather than observation. 1, 2, 3

Evidence Supporting Active Treatment

• The American Heart Association/American Stroke Association guidelines explicitly recommend initiating treatment when blood glucose exceeds 200 mg/dL in acute ischemic stroke patients 1, 4
• Persistent hyperglycemia (>200 mg/dL) during the first 24 hours independently predicts expansion of infarct volume, hemorrhagic transformation, and worse neurological outcomes 1, 2, 3
• Even at 2 days post-stroke, the patient remains within the critical window where glucose control significantly impacts outcomes 2, 3
• Hyperglycemia increases the risk of hemorrhagic transformation by 75% per 100 mg/dL elevation 1

Target Glucose Range

Aim for glucose levels between 140-180 mg/dL (7.8-10.0 mmol/L) using insulin therapy. 1, 4, 2, 3, 5

• This target range balances the need to reduce hyperglycemia-related complications while avoiding dangerous hypoglycemia 4, 5
• Avoid glucose levels <80 mg/dL (<4.4 mmol/L), as hypoglycemia may be more immediately dangerous than moderate hyperglycemia 4, 2, 3

Insulin Protocol Selection

For a patient 2 days post-stroke with glucose >200 mg/dL, initiate subcutaneous basal-bolus insulin regimen with correction doses, as the hyperacute phase requiring IV insulin has passed. 5, 6

If Patient Were in First 24-48 Hours:

• Continuous intravenous insulin infusion would be preferred for patients with persistent hyperglycemia >200 mg/dL or those who received thrombolytic therapy 4, 5, 7, 6
• IV insulin allows more precise glucose control during the critical early period 7, 6

Current Situation (Day 2):

• Transition to subcutaneous basal long-acting insulin plus rapid-acting correction insulin 5, 6
• Add prandial rapid-acting insulin if patient is eating 5
• This approach provides better glycemic control than sliding scale insulin alone 5, 6

Monitoring Requirements

Implement intensive glucose monitoring with the following schedule: 1, 4, 2, 3

• Check glucose every 6 hours initially for the first 24-48 hours of treatment 1, 4, 3
• Monitor potassium levels before and during insulin therapy to prevent hypokalemia, which occurs in approximately 50% of cases during hyperglycemia treatment 4, 2, 3
• Increase monitoring frequency to every 1-2 hours if glucose remains >140 mg/dL and patient had received thrombolytic therapy (though not applicable at day 2) 1, 4

Why NOT the Other Options

Option A (Observe) is Incorrect:

• Observation alone is contraindicated when glucose exceeds 200 mg/dL in acute stroke patients 1, 2, 3
• The GIST trial showed that while glucose levels may spontaneously decline in some patients, active management is still required for levels this elevated 1
• Persistent hyperglycemia independently predicts infarct expansion and poor outcomes, making passive observation medically inappropriate 1, 2, 3

Option C (TPA) is Incorrect:

• TPA is absolutely contraindicated at 2 days post-stroke—the therapeutic window for thrombolysis is 3-4.5 hours from symptom onset 1
• This patient is 48 hours beyond the treatment window for any thrombolytic therapy 1
• The question asks about glucose management, not acute stroke treatment 2, 3

Critical Pitfalls to Avoid

Watch for hypoglycemia during insulin therapy: 4, 2, 3, 5, 7

• In one study, 35% of patients on aggressive insulin protocols experienced glucose <60 mg/dL, though only 13% had symptoms 7
• Hypoglycemia can mimic stroke symptoms and cause additional brain injury 1
• Never target glucose <80 mg/dL in stroke patients 4, 2, 3, 5

Monitor for hypokalemia: 4, 2, 3

• Insulin drives potassium intracellularly, potentially causing dangerous hypokalemia 4
• Severe hypokalemia (<2.5 mEq/L) is associated with increased inpatient mortality 4
• Check potassium before starting insulin and monitor during treatment 4, 2, 3

Avoid sliding scale insulin as sole therapy: 5, 6

• Reactive sliding scale insulin alone provides inadequate glycemic control 5, 6
• Use scheduled basal-bolus insulin with correction doses instead 5, 6

Long-Term Considerations

Evaluate for diabetes mellitus: 1, 2

• Hyperglycemia may represent undiagnosed diabetes, stress hyperglycemia, or inadequately controlled known diabetes 1
• Provide diabetes education regardless of whether this is new-onset or known diabetes 1
• Target HbA1c <7% for long-term management after discharge 2