Hyperglycemia in Acute Stroke

1. Hyperglycemia
in Acute Stroke
Ade Wijaya, MD
April 2018

2. Outline:
• Introduction
• Epidemiology
• Mechanism
• Pathophysiology
• Diagnosis
• Management
• Recommendation
• Summary

3. Introduction
• Ischaemic stroke  common  lead to morbidity and mortality
• Hyperglycemia usually occurs in acute stroke and lasting several days
• Related to prognosis or just a marker of acute stroke?
• Tight glycemic control  potential treatment to improve prognosis

4. Introduction
• Hyperglycemic state predicts:
- a larger infarct size,
- poor clinical outcome,
- a higher risk of mortality
Especially in patients without history of diabetes
- Increase risk of haemorrhagic stroke

5. Epidemiology
• Cut off: 110 mg/dL
• Until 88 hours after onset
• 8-63 % of non-diabetic patients
• 39-83 % of diabetic patients

6. Mechanism

7. Patophysiology

8. Diagnosis
• Stress hyperglycemia: hyperglycemia due to a stress response
- Fasting blood glucore > 126 mg / dL ; random blood glucose > 200 mg
/ dL  spontaneously return to normal after discharge
To differentiate with previous DM  OGTT / HbA1C
- HbA1C 5,7-6,4 (prediabetes); HbA1C > 6,5 (diabetes)

9. Management
• AHA/ESC: Fasting blood glucose level > 140 mg/dL or random blood glucose level > 180
mg/dL warrants insulin administration
• Endocrine consultation:
- Type 1 diabetes
- Persistent hyperglycemia
- Reccurent hypoglycemia
- Previously with insulin therapy
- Patients with renal replacement therapy
- Hyperosmolar state / DKA
- Enteral tube feeding or parenteral nutrition
- Hyperglycemia related to cystic fibrosis or pancreatic surgery
• Consistent bedside glucose monitoring

10. Insulin Drip
• DKA / hyperosmolar syndrome.
• Persistent or severe hyperglycemia.
• Continuous enteral tube feeding.
• Administration in 24-48 hours after admission.
• In patients receiving thrombolytic therapy. Blood Glucose target is
140-180 mg/dL
• Blood glucore level > 250 mg/dL, a 0.1 unit/kg initial bolus of IV
regular insulin can be given before thrombolytics are administered,
for immediate blood glucose lowering; this bolus must be followed by
an insulin drip

11. Insulin Drip
• If hyperosmolar state presents  osmolality > 320 mOsm/kg
- Glucose generally should not be lowered below 250 mg/dL until the
patient is alert and able to eat; doing so will help avoid large shifts in
osmolality that may worsen cerebral edema

12. Insulin Drip

13. Sliding Scale Insulin

14. SSI
• Simple
• Convenient
• Inconsistent in
improving glycemic
control
• Higher risk of
hypoglicemia
Oral antidiabetics
• Lower Blood Glucose
effectively
• May have
neuroprotective
properties
• Slower action
IV insulin drips
• DKA/hyperosmolar
state
• Severe or persistent
hyperglycemia
• Continuous enteral
feeding
• Blood glucose > 250 mg
/ dL in patients
receiving thrombolytic
therapy

15. Recommendation

16. Summary
• Glycemic control in acute stroke is important to improve prognosis
• Insulin should be administered in patients with random blood glucose
> 180 mg / dL (AHA/ESC)
• No guidelines established for protocol
• SSI  simple and convenient but with higher risk of hypoglycemia
• IV insulin drip is indicated in certain condition.

17. References
• Kruyt, N. D., Biessels, G. J., DeVries, J. H., & Roos, Y. B. (2010).
Hyperglycemia in acute ischemic stroke: pathophysiology and clinical
management. Nature Reviews Neurology, 6(3), 145.
• Baker, L., Juneja, R., & Bruno, A. (2011). Management of hyperglycemia in
acute ischemic stroke. Current treatment options in neurology, 13(6), 616.
• Castilla-Guerra, L., Fernández-Moreno, M. C., & Hewitt, J. (2016).
Treatment of hyperglycemia in patients with acute stroke. Revista Clínica
Española (English Edition), 216(2), 92-98.
• Guideline Stroke PERDOSSI. 2011
• http://diabetesinstitute.pitt.edu/files/reghumuliniss.pdf

18. THANK
YOU