Hyperglycaemia in Acute Stroke – To Treat or Not to Treat

Abstract

Diabetes is common amongst patients with stroke and is associated with poorer outcome. Post-stroke hyperglycaemia is also recognised in up to half of the patients, and is independently associated with adverse sequelae: both increased mortality and poorer functional outcomes. Neither the aetiology nor the pathophysiology of such hyperglycaemia is fully understood. Both direct neurological toxicity and systemic consequences are postulated to occur. A distinction between occult diabetes and non-diabetic hyperglycaemia seems important as prognosis and effect of intervention differ in these two groups. The optimal management of the milder forms of hyperglycaemia associated with acute stroke is unknown. Randomised trial data remain limited but presently offer no strong support for aggressive intervention in stroke, though in other critical illness settings tight control of blood sugar appears beneficial. Studies based in coronary care and high dependency units have shown a possible beneficial effect of insulin, but evidence for intervention in acute stroke is at best limited. However, if glucose management is to be undertaken, this should be instituted while there is still salvageable tissue and the glucose reduction must be substantial. Intravenous insulin may be more effective than glucose-potassium-insulin infusion. Both interventions carry a risk of hypoglycaemia and any proposed intervention must balance safety, convenience and glycaemic control. Until further trial data are available, consensus guidelines may be followed, which are generally conservative for blood glucose levels below 10 mM (180 mg/dl).

Management of blood glucose in patients with stroke

“…Comparing guidance from the American Stroke Association [31], the UK Royal College of Physicians [40] and the European Stroke Organisation (ESO) [41], all agree that post-stroke hyperglycaemia is associated with poorer outcomes, that (major) hyperglycaemia should be prevented/treated and that iatrogenic hypoglycaemia must be avoided or promptly treated (Figure 1). However, there is no consensus on the frequency of glucose monitoring, thresholds for intervention or methods to achieve glucose control [42,43].…”

J-Shaped Association Between Serum Glucose and Functional Outcome in Acute Ischemic Stroke

“…Key Words: acute ischemic stroke Ⅲ functional outcome Ⅲ J-shaped association Ⅲ poststroke hyperglycemia Ⅲ serum glucose H yperglycemia is commonly encountered in patients with acute ischemic stroke, with estimates varying and depending on the frequency of glucose measurements and the criteria used to define hyperglycemia. 1 The incidence of poststroke hyperglycemia is estimated at 45% in studies with frequent glucose measurements and a threshold value of 7 mmol/L to define hyperglycemia. 2 Because the prevalence of previously diagnosed diabetes mellitus in stroke patients is estimated between 10% and 20%, diabetes mellitus is obviously not the only underlying pathophysiologic mechanism of poststroke hyperglycemia.…”

“…1 The incidence of poststroke hyperglycemia is estimated at 45% in studies with frequent glucose measurements and a threshold value of 7 mmol/L to define hyperglycemia. 2 Because the prevalence of previously diagnosed diabetes mellitus in stroke patients is estimated between 10% and 20%, diabetes mellitus is obviously not the only underlying pathophysiologic mechanism of poststroke hyperglycemia.…”

Insulin therapy of type 2 diabetes mellitus in the period of acute stroke: the importance of the insulin administration technique

“…Однако до настоящего време-ни остаются спорными как целевые уровни глике-мии [4], так и обязательность постоянной инфузии инсулина у таких больных. Исследование THIS [5], в котором сравнивали строгий (целевой уровень гликемии <7,2 ммоль/л с инфузией инсулина) и тра-диционный (целевой уровень <11,1 ммоль/л с под-кожным введением инсулина) контроль гликемии, показало несколько лучшие исходы инсульта в груп-пе строгого контроля, однако и гипогликемии на-блюдались исключительно в этой группе.…”