Hyperglycemia, Insulin, and Acute Ischemic Stroke

Garg, Rajesh; Chaudhuri, Ajay; Munschauer, Frederick E.; Dandona, Paresh

doi:10.1161/01.str.0000195175.29487.30

Cited by 207 publications

(97 citation statements)

References 68 publications

(63 reference statements)

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“…Half of them preferred correction, based on the results of monitoring (reactive), and one third made use of a proactive scheme, using different targets, between 120 to 150 mg/dL (6.6 to 8.3 mmol/L). Only 16% used IIT and near to one fifth of respondents showed adherence to a protocol or guidelines, reflecting the wide variability in practices of monitoring and treating HG in this patient population among the surveyed centers It is well-known that acute and persistent HG is associated with worse outcomes in patients with critical brain injury 3,11 . However, the lowest safe blood glucose level in neurocritical patients has not been defined yet.…”

Section: Discussionmentioning

confidence: 99%

“…When insulin was administered, two practice models were considered: a reactive, if sliding scale regimens were used to correct changes once they occurred; and a proactive, if regimens were started to maintain blood-glucose levels according to pre-established therapeutic ranges 3 .…”

Section: Definitionsmentioning

confidence: 99%

“…Hyperglycemia (HG) is common in nondiabetic patients during the acute phase of ischemic and hemorrhagic strokes [1][2][3][4][5] . Reported incidence averages 40%.…”

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confidence: 99%

“…The pathophysiology of HG in these patients is multifactorial [6][7][8][9][10] . Some experimental studies have demonstrated that HG contributes to brain damage through different mechanisms: increasing blood brain barrier (BBB) permeability 11 , provoking cerebral edema 11 , and promoting release of inflammatory mediators 3,9,11 . An additional mechanism of injury included ischemia, mediated by vasoconstriction and microcirculation thrombosis 3,11 .…”

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confidence: 99%

“…The prognostic value of HG has been extensively evaluated; however, to date, it is not clear whether HG directly contributes to a worsening outcome, or whether it just represents a surrogate marker of the severity of the stroke 3,6,11 . The management of HG in this setting is still controversial and varies worldwide 11,12 .…”

mentioning

confidence: 99%

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Hyperglycemia in nondiabetic patients during the acute phase of stroke

Godoy¹,

Soler²,

Videtta³

et al. 2012

Arq. Neuro-Psiquiatr.

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OBJECTIVE: To determine patterns of hyperglycemic (HG) control in acute stroke. METHODS: Anonymous survey through Internet questionnaire. Participants included Latin-American physicians specialized in neurocritical care. RESULTS: The response rate was 74%. HG definition varied widely. Fifty per cent considered it when values were >140 mg/dL (7.8 mmol/L). Intravenous (IV) regular insulin was the drug of choice for HG correction. One fifth of the respondents expressed adherence to a protocol. Intensive insulin therapy (IIT) was used by 23%. Glucose levels were measured in all participants at admission. Routine laboratory test was the preferred method for monitoring. Reactive strips were more frequently used when monitoring was intensive. Most practitioners (56.7%) monitored glucose more than two times daily throughout the Intensive Care Unit stay. CONCLUSIONS: There is considerable variability and heterogeneity in the management of elevated blood glucose during acute phase of stroke by the surveyed Latin-American physicians.

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Section: Discussionmentioning

confidence: 99%

Section: Definitionsmentioning

confidence: 99%

“…Hyperglycemia (HG) is common in nondiabetic patients during the acute phase of ischemic and hemorrhagic strokes [1][2][3][4][5] . Reported incidence averages 40%.…”

mentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Hyperglycemia in nondiabetic patients during the acute phase of stroke

Godoy¹,

Soler²,

Videtta³

et al. 2012

Arq. Neuro-Psiquiatr.

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Intensive vs Standard Treatment of Hyperglycemia and Functional Outcome in Patients With Acute Ischemic Stroke

Johnston

Bruno

Pauls

et al. 2019

JAMA

303

213

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IMPORTANCE Hyperglycemia during acute ischemic stroke is common and is associated with worse outcomes. The efficacy of intensive treatment of hyperglycemia in this setting remains unknown. OBJECTIVES To determine the efficacy of intensive treatment of hyperglycemia during acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS The Stroke Hyperglycemia Insulin Network Effort (SHINE) randomized clinical trial included adult patients with hyperglycemia (glucose concentration of >110 mg/dL if had diabetes or Ն150 mg/dL if did not have diabetes) and acute ischemic stroke who were enrolled within 12 hours from stroke onset at 63 US sites between April 2012 and August 2018; follow-up ended in November 2018. The trial included 1151 patients who met eligibility criteria. INTERVENTIONS Patients were randomized to receive continuous intravenous insulin using a computerized decision support tool (target blood glucose concentration of 80-130 mg/dL [4.4-7.2 mmol/L]; intensive treatment group: n = 581) or insulin on a sliding scale that was administered subcutaneously (target blood glucose concentration of 80-179 mg/dL [4.4-9.9 mmol/L]; standard treatment group: n = 570) for up to 72 hours. MAIN OUTCOMES AND MEASURES The primary efficacy outcome was the proportion of patients with a favorable outcome based on the 90-day modified Rankin Scale score (a global stroke disability scale ranging from 0 [no symptoms or completely recovered] to 6 [death]) that was adjusted for baseline stroke severity. RESULTS Among 1151 patients who were randomized (mean age, 66 years [SD, 13.1 years]; 524 [46%] women, 923 [80%] with diabetes), 1118 (97%) completed the trial. Enrollment was stopped for futilitybasedonprespecifiedinterimanalysiscriteria.Duringtreatment,themeanbloodglucoselevel was 118 mg/dL (6.6 mmol/L) in the intensive treatment group and 179 mg/dL (9.9 mmol/L) in the standard treatment group. A favorable outcome occurred in 119 of 581 patients (20.5%) in the intensive treatment group and in 123 of 570 patients (21.6%) in the standard treatment group (adjusted relative risk, 0.97 [95% CI, 0.87 to 1.08], P = .55; unadjusted risk difference, −0.83% [95% CI, −5.72% to 4.06%]). Treatment was stopped early for hypoglycemia or other adverse events in 65 of 581 patients (11.2%) in the intensive treatment group and in 18 of 570 patients (3.2%) in the standard treatment group. Severe hypoglycemia occurred only among patients in the intensive treatment group (15/581 [2.6%]; risk difference, 2.58% [95% CI, 1.29% to 3.87%]). CONCLUSIONS AND RELEVANCE Among patients with acute ischemic stroke and hyperglycemia, treatment with intensive vs standard glucose control for up to 72 hours did not result in a significant difference in favorable functional outcome at 90 days. These findings do not support using intensive glucose control in this setting.

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Stroke

Auer

Meher

2022

Encyclopedia of Life Sciences

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Blood vessels supplying the brain can either be blocked or broken, giving rise to the two kinds of stroke: infarcts and haemorrhages. The symptoms and their permanence depend on how much brain tissue is destroyed and in what location. Key Concepts Stroke is the third leading cause of death. There are two types of strokes: haemorrhagic or ischemic. The occlusive substance in ischemia arises from carotid atherosclerosis or underlying heart disease. ‘Time is Brain’: treating a patient in a timely manner is crucial for preventing increased neuronal loss. tPA is an effective clot‐busting drug, however, it can only be administered within 4.5 h of symptom onset. Endovascular therapy, a mechanical clot‐retrieving technique, is proven to be far more superior to tPA treatment. Brain swelling from oedema occurs secondary to stroke. There are two types of oedema that occurs poststroke, vasogenic or cytotoxic and are known to partly arise from the cerebrospinal fluid in and around the brain. Strokes can lead to severe long‐term motor, sensory and cognitive impairments. Stroke rehabilitation remains essential for relearning skills and regaining functional independence poststroke.

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Hyperglycemia, Insulin, and Acute Ischemic Stroke

Cited by 207 publications

References 68 publications

Hyperglycemia in nondiabetic patients during the acute phase of stroke

Hyperglycemia in nondiabetic patients during the acute phase of stroke

Intensive vs Standard Treatment of Hyperglycemia and Functional Outcome in Patients With Acute Ischemic Stroke

Stroke

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