Management of Hyperglycemia in Acute Stroke

Marc Fisher MD Kennedy Lees MD Section Editors: Current acute therapies for ischemic stroke are limited. Only a small proportion of stroke patients are eligible to receive fibrinolytic therapy; clinical trials of neuroprotectant drugs have yielded disappointing results, and other potential interventions are at very early stages of development.Against this background, coordinated stroke unit care is, however, of proven benefit; reduced mortality, institutionalization and dependency. Clinical trials demonstrating the benefit of stroke unit care have recognized the potential but unproven benefits that may be realized through rigorous physiological monitoring and intervention to correct derangements in the acute phase.This review will discuss the complex relationship between hyperglycemia and stroke, with particular emphasis on the role of glycemic control in the acute stroke patient.Whether acute hyperglycemia is a cause of neurological deterioration or an epiphenomenon, is a distinction pivotal in management of the stroke patient with hyperglycemia. Poststroke hyperglycemia is common and, at least in nondiabetic individuals, is associated with a poorer stroke outcome when compared to normoglycemia.1,2 In a systematic review of observational studies examining the prognostic significance of hyperglycemia in acute stroke, the unadjusted relative risk of in-hospital or 30-day mortality was 3.07 (95% CI, 2.50 to 3.79) in nondiabetic patients and 1.30 (95% CI, 0.49 to 3.43) in those with diabetes.3 The relative risk of poor functional outcome in hyperglycemic nondiabetic patients was 1.41 (95% CI 1.16 to 1.73). Using MRI it has been demonstrated that in patients with acute perfusion diffusion mismatch within 24 hours of stroke onset, acute hyperglycemia correlates with reduced salvage of mismatch tissue from infarction, greater final infarct size, and worse functional outcome.4 As a consequence, not only has a causal relationship between hyperglycemia and poor outcome been assumed, but also a benefical treatment effect from control of …