What treatment should be given to a 40-year-old male presenting with left-sided limb weakness, slurred speech, hypertension (high blood pressure), and hyperglycemia (elevated random blood sugar)?

Acute Ischemic Stroke Management in a Hyperglycemic Patient

This patient requires immediate IV insulin therapy targeting glucose 140-180 mg/dL, urgent brain imaging (CT or MRI), and consideration for IV thrombolysis with rtPA if within the treatment window and no contraindications are found—however, the severe hyperglycemia (415 mg/dL = 23 mmol/L) substantially increases hemorrhagic risk and may preclude thrombolysis.

Immediate Priorities

Glucose Management - Critical First Step

• Initiate continuous IV insulin infusion immediately using regular insulin, starting at 0.5 units/hour and titrating to maintain glucose 140-180 mg/dL 1, 2
• Monitor blood glucose every 1-2 hours initially, as this level of hyperglycemia (415 mg/dL) significantly worsens stroke outcomes and dramatically increases risk of hemorrhagic transformation 1, 2
• Do NOT use subcutaneous insulin for glucose >400 mg/dL—IV insulin is mandatory for rapid, titratable control 2
• Use normal saline (0.9%) for IV fluids, avoiding any glucose-containing solutions 3, 1
• Check hemoglobin A1c to determine if this represents undiagnosed chronic diabetes or acute stress hyperglycemia 2

Critical Hyperglycemia Consideration for Thrombolysis

• Blood glucose >200 mg/dL (11.1 mmol/L) is associated with 25-36% symptomatic intracranial hemorrhage rate with thrombolysis 3
• The NINDS trial excluded patients with glucose >400 mg/dL (22.2 mmol/L), and this patient exceeds that threshold 3
• It may be prudent to restrict thrombolysis to patients with glucose <200 mg/dL (11.1 mmol/L) for safety reasons 3
• However, time is critical—every 30-minute delay decreases chance of good outcome by 8-14% 1

Stroke Protocol

Immediate Assessment

• Secure airway if depressed consciousness present 1
• Administer supplemental oxygen only if oxygen saturation is low (monitor continuously) 1
• Initiate continuous cardiac monitoring to detect atrial fibrillation and arrhythmias 1
• Obtain urgent non-contrast CT head to exclude hemorrhage 4, 1
• Consider MRI with diffusion-weighted imaging if CT is negative but clinical suspicion remains high 2

Blood Pressure Management

• Do NOT treat the blood pressure of 150/90 mmHg—antihypertensive therapy should be withheld unless systolic BP >220 mmHg or diastolic BP >120 mmHg 3, 1
• Lowering BP precipitously can extend the infarct 1, 2
• If thrombolysis is considered, BP must be reduced to <185/110 mmHg before rtPA administration and maintained ≤180/105 mmHg for 24 hours after 1

Thrombolysis Decision Algorithm

Given the 4-day history with acute worsening at 5 hours:

• The patient is likely outside the 3-4.5 hour window for standard IV rtPA, as symptoms began 4 days ago 4, 1
• However, if the acute worsening at 5 hours represents a new event or stroke-in-evolution, he may be within the window 4
• The severe hyperglycemia (415 mg/dL) is a major contraindication due to 25-36% hemorrhagic risk 3
• If within time window and glucose can be rapidly reduced to <200 mg/dL, consider rtPA 0.9 mg/kg (max 90 mg) 1
• Endovascular thrombectomy should be considered if large-vessel occlusion is identified within 6 hours 4

Supportive Care

Monitoring Protocol

• Neurological assessments using NIHSS every 1-2 hours initially 1
• Blood glucose monitoring every 1-2 hours until stable in target range 1, 2
• Continuous cardiac monitoring for at least 24 hours 1, 2
• Blood pressure monitoring continuously 1

Additional Management

• Maintain NPO status until swallow evaluation completed (aspiration risk) 2
• Treat fever if present (temperature >37.5°C) with antipyretics, as fever worsens stroke outcomes 1
• Correct hypotension if it develops with normal saline 1
• Administer aspirin 325 mg once hemorrhage is excluded (but NOT if thrombolysis is given) 2

Admission

• Admit to intensive care unit or stroke unit with continuous monitoring capability 2
• Initiate rehabilitation assessment within 48 hours 1

Critical Pitfalls to Avoid

• Do NOT delay glucose control—hyperglycemia worsens stroke outcomes and increases hemorrhagic transformation risk even without thrombolysis 3, 2
• Do NOT target glucose <140 mg/dL—this increases hypoglycemia risk without proven benefit, and hypoglycemia can cause permanent brain damage 1, 2
• Do NOT assume symptoms are purely metabolic—proceed with full stroke evaluation even with severe hyperglycemia, as both conditions coexist 2
• Do NOT give thrombolysis with glucose >200 mg/dL without careful risk-benefit discussion—hemorrhagic risk is substantially elevated 3
• Do NOT aggressively lower blood pressure—maintain permissive hypertension unless >220/120 mmHg 3, 1, 2