Close Control of Blood Glucose following Acute CVA.

Report By: Tom Leckie - Specialist Registrar in Emergency Medicine
Institution: Manchester Royal Infirmary
Date Submitted: 8th February 2007
Last Modified: 8th February 2007
Status: Blue (submitted but not checked)

Three Part Question

in [patients with elevated blood glucose immediately following Stroke] does [close control of Blood Glucose] [improve outcome]

Clinical Scenario

A patient presents to the Emergency Department with acute onset of a left sided hemiplegia. The blood glucose is measured and found to be 12mmol/l. Would using insulin to control the blood glucose closely improve the patients outcome?

Search Strategy

OVID medline 1950 to January Week 5 2007
([exp Cerebrovascular Accident/ or cva.mp/ or stroke.mp] and [exp Blood Glucose/ or exp Hyperglycaemia/ or hyperglycaemia.mp] and [exp Insulin/ or insulin.mp]) LIMIT humans and english language

Search Outcome

210 papers were found with 1 relevant to the question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Scott JF. Robinson GM. French JM. O'Connell JE. Alberti KG. Gray CS. 1998 UK - Sunderland	>18 within 24hrs of acute CVA with a plasma glucose of 7.0 to 17 mmol/L. Exclusions - Heart Failure, renal failure, anaemia, pneumonia, coma, previous disabling stroke, dementia, insulin treated diabetes	Randomised to treatment with 10% glucose containing 20mmol KCl and 16U insulin in 500ml or normal saline. Infused at 100 ml per hour for first 24 hrs BM's between 4 and 7 mmol/L were aimed for in the treatment group.	Mortality at 4 weeks	Treatment group 7/25 (28% ) Control 8/25 (32%)	Small numbers. Non blinded. Short treatment period.
			Stroke scoring	No significant difference	Small numbers. Non blinded. Short treatment period.

Comment(s)

Although there is evidence that hyperglycaemia is associated with a poor outcome after stroke, there is no data showing that the use of a DIGAMI type regimen to closely control Blood Glucose improves outcome. More powerful studies are required to answer this question.

Clinical Bottom Line

There is no evidence of benefits from close control of blood glucose in moderately hyperglycaemic stroke patients. Local policies should be adhered to.

References

Scott JF. Robinson GM. French JM. O'Connell JE. Alberti KG. Gray CS. Glucose potassium insulin infusions in the treatment of acute stroke patients with mild to moderate hyperglycemia: the Glucose Insulin in Stroke Trial (GIST). Stroke April 1999; 793-799