Management of Stroke in Diabetes

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Mukul Sharma MSc, MD, FRCPC Gordon J. Gubitz MD, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Full Text
  • References

Key Messages

  • The assessment and general management of persons with diabetes who experience a stroke, and of persons with a new diagnosis of diabetes after experiencing a stroke, are the same as those without a stroke.
  • A comprehensive, regularly updated, evidence-based approach to the assessment and management of all patients (including those with diabetes) with stroke across the continuum of care is available on the Canadian Stroke Strategy (CSS) Best Practices Recommendations website (1) (strokebestpractices.ca).

Introduction

Diabetes is an important modifiable risk factor for a first ischemic stroke, and the combination of diabetes and stroke is a major cause of morbidity and mortality worldwide (2). Evidence from large clinical trials performed in patients with diabetes supports the need for aggressive and early intervention to target the cardiovascular (CV) risks of patients to prevent the onset, recurrence and progression of acute stroke (2). Estimates of risk of ischemic stroke in people with diabetes range from a 2- to 3-fold increase in men and a 2- to 5-fold increase in women (3,4). Diabetes also doubles the risk of stroke recurrence, and stroke outcomes are significantly worse among patients with diabetes, with increased hospital and long-term stroke mortality, more residual neurological and functional disability, and longer hospital stays (2). From a clinical perspective, diabetes increases the risk of ischemic stroke more than hemorrhagic stroke, resulting in a greater ischemic to hemorrhagic stroke ratio in people with diabetes compared with the general population. The high stroke risk in diabetes may be due to the complex interplay between the various hemodynamic and metabolic components of the diabetes syndrome. Other than the many recognized risk factors associated with acute stroke (e.g. hypertension, dyslipidemia, atrial fibrillation), specific risk factors attributable to diabetes also have been reported, such as insulin resistance, central obesity, impaired glucose tolerance and hyperinsulinemia. Both individually and collectively, these factors are associated with an excess risk of stroke disease (2). Therefore, the comprehensive, multifactorial strategy addressing healthy behaviours, blood pressure, lipids, glucose and the possible use of vascular protective medications to reduce overall CV morbidity and mortality among people with diabetes (see Vascular Protection in People with Diabetes chapter, p. S100) is imperative to reduce the risk of this potentially devastating complication.

Diabetes Management in the Acute Period

The management of hyperglycemia in acute stroke (generally defined as within the first 24 hours of stroke symptom onset) remains controversial; the evidence to support tight glucose control immediately following acute ischemic stroke has not been supportive. A Cochrane Systematic Review evaluated randomized controlled trials comparing intensively monitored insulin therapy (target blood glucose range 4.0 to 7.5 mmol/L) vs. usual care in adult patients with acute ischemic stroke, with or without diabetes (5). The systematic review included 7 trials involving 1296 participants (639 participants in the intervention group and 657 in the control group). There was no difference between treatment and control groups in the outcome of death or disability and dependence (odds ratio [OR] 1.00, 95% confidence interval [CI] 0.78–1.28) or final neurological deficit (Standardized Mean Difference −0.12, 95% CI −0.23 to 0.00). The rate of symptomatic hypoglycemia was higher in the intervention group (OR 25.9, 95% CI 9.2–72.7). In the subgroup analysis of those with diabetes vs. those with no diabetes, no difference was found for the outcomes of death and dependency or neurological deficit. Of note, the control groups within the 7 studies achieved mean glucose levels of <10.5 mmol/L (6–12). It was concluded, by the authors, that the use of insulin to maintain a glucose of 4.0 to 7.5 mmol/L in the first 24 hours after stroke symptom onset is not beneficial compared to usual care and may, in fact, be harmful with increased hypoglycemia. Therefore, there is no glucose target specific to patients presenting with stroke. However, the recommendation for the majority of noncritically ill hospitalized patients to have their glucose levels maintained below 10.0 mmol/L (see In-hospital Management of Diabetes chapter, p. S77) remains applicable to those admitted with acute stroke.

Recommendations

  1. 1.Patients with ischemic stroke or transient ischemic attack (TIA) should be screened for diabetes with a fasting plasma glucose, glycated hemoglobin (A1C) or 75 g oral glucose tolerance test soon after admission to hospital [Grade D, Consensus].
  2. 2.All patients with diabetes and ischemic stroke or TIA should receive the same treatments that are recommended for patients with ischemic stroke or TIA without diabetes since they benefit equally [Grade D, Consensus].

References

  1. 1 The Canadian Best Practice Recommendations for Stroke Care. Available at: http://www.strokebestpractices.ca/ . Accessed February 27, 2013.
  2. 2 I. Idris G.A. Thomson J.C. Sharma Diabetes mellitus and stroke Int J Clin Pract 60 2006 48 56
  3. 3 T. Karapanayiotides B. Piechowski-Jozwiak G. van Melle Stroke patterns, etiology, and prognosis in patients with diabetes mellitus Neurology 62 2004 1558 1562
  4. 4 S. Lehto T. Rönnemaa K. Pyörälä Predictors of stroke in middle-aged patients with non-insulin-dependent diabetes Stroke 27 1996 63 68
  5. 5 M.F. Bellolio R.M. Gilmore L.G. Stead Insulin for glycaemic control in acute ischaemic stroke Cochrane Database Syst Rev 9 2011 CD005346
  6. 6 C.S. Gray A.J. Hildreth P.A. Sandercock Glucose-potassium insulin infusions in the management of post-stroke hyperglycaemia: the UK Glucose Insulin in Stroke Trial (GIST-UK) Lancet Neurol 6 2007 397 406
  7. 7 K.C. Johnston C.E. Hall B.M. Kissela GRASP Investigators Glucose Regulation in Acute Stroke Patients (GRASP) trial: a randomized pilot trial Stroke 40 2009 3804 3809
  8. 8 S.H. Kreisel U.M. Berschin H.P. Hammes Pragmatic management of hyperglycaemia in acute ischaemic stroke: safety and feasibility of intensive intravenous insulin treatment Cerebrovasc Dis 27 2009 167 175
  9. 9 A. Bruno T.A. Kent B.M. Coull Treatment of hyperglycemia in ischemic stroke (THIS): a randomized pilot trial Stroke 39 2008 384 389
  10. 10 S. Vinychuk V. Melnyk V. Margitich Hyperglycemia after acute ischemic stroke: prediction, significance and immediate control with insulin-potassium saline magnesium infusions Heart Drug 5 2005 197 204
  11. 11 M.R. Walters C.J. Weir K.R. Lees A randomised, controlled pilot study to investigate the potential benefit of intervention with insulin in hyperglycaemic acute ischaemic stroke patients Cerebrovasc Dis 22 2006 116 122
  12. 12 J. Staszewski B. Brodacki J. Kotowicz A. Stepien Intravenous insulin therapy in the maintenance of strict glycemic control in nondiabetic acute stroke patients with mild hyperglycemia J Stroke Cerebrovasc Dis 20 2011 150 154
 
Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.
 

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