Management of hyperglycemia in acute ischemic stroke

There is considerable clinical evidence that hyperglycemia at the onset of acute ischemic stroke may negatively impact not only acute morbidity but also brain recovery. Establishing hyperglycemia treatment protocols is challenging, given the variation among patients and acute stroke care settings. Relatively few randomized trials have examined glycemic control protocols in this population, and there is not yet any clear evidence that "correcting" hyperglycemia in patients with acute stroke leads to better functional outcomes. Intensification of glucose regimens, using lower glucose targets, leads to more hypoglycemic events, but the immediate and long-term impact of these events on the acutely ischemic brain is unknown. It is reasonable to treat patients with acute ischemic stroke according to the American Diabetes Association inpatient glycemic control guidelines, initiating therapy to achieve glucose targets of 140 to 180 mg/dL if fasting glucose is greater than 140 mg/dL or random glucose is consistently higher than 180 mg/dL. Lower glucose targets (<140 mg/dL) may be appropriate for patients with well-controlled diabetes and those with stress hyperglycemia who were not known to be diabetic before admission, but glucose levels less than 80 mg/dL should be avoided. Patients who present with extreme or persistent hyperglycemia, are critically ill, or who are treated with thrombolytic therapy should be started on an established and standardized intravenous insulin protocol to improve blood glucose control for at least the first 24 to 48 h of hospitalization. They should then be transitioned to a subcutaneous insulin regimen that includes basal long-acting insulin along with correction rapid-acting insulin for glucose that is out of range. Prandial (meal) insulin should be added for patients who are eating; this would preferably be a rapid-acting insulin analogue that can be administered immediately before or after the meal. Caution and close glucose monitoring are necessary, especially for patients prone to hypoglycemia, such as those with type 1 diabetes mellitus or hepatic or renal impairment, or those on complicated feeding regimens.