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Hyperglycemia in acute ischemic stroke: pathophysiology and clinical management

Nature Reviews Neurology volume 6, pages 145–155 (2010)Cite this article

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Abstract

Patients with acute ischemic stroke frequently test positive for hyperglycemia, which is associated with a poor clinical outcome. This association between poor glycemic control and an unfavorable prognosis is particularly evident in patients with persistent hyperglycemia, patients without a known history of diabetes mellitus, and patients with cortical infarction. To date, however, only one large clinical trial has specifically investigated the effect of glycemic control on stroke outcome. This trial failed to show a clinical benefit, but had several limitations. Despite a lack of clinical evidence supporting the use of glycemic control in the treatment of patients with stroke, international guidelines recommend treating this subset of critically ill patients for hyperglycemia in the hospital setting. This treatment regime is, however, particularly challenging in patients with stroke, and is associated with an increased risk of the patient developing hypoglycemia. Here we review the available evidence linking hyperglycemia to a poor clinical outcome in patients with ischemic stroke. We highlight the pathophysiological mechanisms that might underlie the deleterious effects of hyperglycemia on acute stroke prognosis and systematically review the literature concerning tight glycemic control after stroke. Finally, we provide directions on the use of insulin treatment strategies to control hyperglycemia in this patient group.

Key Points

  • Hyperglycemia is frequently observed in patients with ischemic stroke, persists throughout the clinical course of the disorder and is associated with an increased infarct size and a poor clinical outcome

  • Several pathophysiological mechanisms could account for the detrimental effect of hyperglycemia observed in patients with acute ischemic stroke

  • No evidence exists that supports the use of glucose lowering therapy for the treatment of hyperglycemia in patients with acute ischemic stroke

  • Establishing glycemic control in patients with acute ischemic stroke is challenging and carries a substantial risk of the patient developing hypoglycemia

  • Studies that establish safe methods of improving glycemic control are awaited before randomized controlled trials that assess clinical outcome measures associated with glycemic control can be initiated

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Figure 1: Mechanisms leading to hyperglycemia in patients with ischemic stroke.
Figure 2: Schematic representation of infarct evolution over time.

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Acknowledgements

The authors wish to thank the following authors for providing additional data on their studies: N. Gentile, K. Johnston, N. MacDougall, Y. Samson and M. Walters. The research of N. D. K. and G. J. B. is supported by a grant from the Academic Medical Center, University of Amsterdam and the University Medical Center Utrecht, The Netherlands. The research of G. J. B. is also supported by grant 907-00-140 from the Netherlands Organization of Scientific Research (ZonMw).

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Authors and Affiliations

  1. Department of Neurology, Academic Medical Center, University of Amsterdam, PO Box 22700, Amsterdam, 1100, DE, The Netherlands

    Nyika D. Kruyt & Yvo B. Roos

  2. Department of Internal Medicine, Academic Medical Center, University of Amsterdam, PO Box 22700, Amsterdam, 1100, DE, The Netherlands

    J. Hans DeVries

  3. Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center, PO Box 85500, Utrecht, 3508, GA, The Netherlands

    Geert Jan Biessels

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  1. Nyika D. Kruyt
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Correspondence to Nyika D. Kruyt.

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Kruyt, N., Biessels, G., DeVries, J. et al. Hyperglycemia in acute ischemic stroke: pathophysiology and clinical management. Nat Rev Neurol 6, 145–155 (2010). https://doi.org/10.1038/nrneurol.2009.231

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