Listen on the go
CORRECT!
Next question
touchNEUROLOGY touchNEUROLOGY
Stroke
Read Time: 2 mins

The Treatment of Diabetes after an Acute Ischaemic Stroke

Copy Link
Published Online: Jun 27th 2012 European Neurological Review, 2012;7(3):169-173 DOI: http://doi.org/10.17925/ENR.2012.07.03.169
Authors: Geert JanBiessels, L Jaap Kappelle
Quick Links:
Abstract
Article
Article Information
Abstract:
Overview

People with diabetes are at increased risk of ischaemic stroke and outcome after stroke is worse. This paper reviews the treatment of patients with diabetes after ischaemic stroke. First, management of hyperglycaemia in the acute stage will be addressed. We will make the point that, despite the fact that admission hyperglycaemia is a common risk factor for poor outcome after ischaemic stroke, there is still much uncertainty about whether intensive glucose-lowering therapy after stroke benefits clinical outcome. Secondary prevention of further cardiovascular events after stroke is the other main topic of this review. We will show that there are important opportunities for the reduction of stroke risk in diabetes, through a rigorous evaluation and treatment of associated risk factors.

Keywords

Diabetes, ischaemic stroke, prevention, treatment, outcome

Article:

Diabetes and ischaemic stroke are common conditions that often co-occur. The relationship between diabetes and stroke is bidirectional. On the one hand, people with diabetes have a more than two-fold increased risk of ischaemic stroke compared to people without diabetes.1 On the other hand, acute stroke can give rise to abnormalities in glucose metabolism, which in turn may affect outcome.2 In the current review, which is based on a recent paper from our group in the Lancet Neurology,3 we describe the management of diabetes both in the acute stage of stroke and in the longer term, with regard to secondary prevention.

Diabetes and the Risk of Stroke
A recent meta-analysis of prospective studies including 530,083 participants reported a hazard ratio for ischaemic stroke of 2.3 (95 % confidence interval [CI] 2.0–2.7) in people with versus people without diabetes.1 Considering that the estimated world-wide prevalence of diabetes in adults is around 10 %, this implies that one in eight to nine cases of stroke is attributable to diabetes.

Diabetes is associated with different aetiological subtypes of ischaemic stroke, including lacunar and athero- and cardioembolic strokes.4–6 Moreover, the risk of atrial fibrillation, the major cause of thromboembolic stroke, is increased by 40 % in diabetes.7 Diabetes-associated risk factors for stroke include diabetes-specific factors (e.g. hyperglycaemia) and vascular risk factors (e.g. hypertension, dyslipidaemia), but also genetic, demographic, and lifestyle factors. The contribution of these factors, many of which are strongly interrelated, is likely to differ according to diabetes type and age.

Hyperglycaemia and Stroke Outcome
Hyperglycaemia occurs in 30–40 % of patients with an acute ischaemic stroke.2,8 The majority of these patients does not have a known history of diabetes.2 In a proportion of patients hyperglycaemia reflects pre-existing but unrecognised diabetes, but more often it is due to an acute stress response, commonly named ‘stress hyperglycaemia’. Stress hyperglycaemia is defined as a fasting glucose >6.9 mmol/l or a random glucose >11.1 mmol/l during hospital stay that spontaneouslyreverts to normal range after discharge.9 Hence, glucose levels at admission generally do not distinguish between stress hyperglycaemia and diabetes. In this setting, elevated glycated haemoglobin (HbA1c) levels (≥6.5 %) can help to identify previously undiagnosed diabetes.9,10

To view the full article in PDF or eBook formats, please click on the icons above.

Article Information:
Disclosure

Geert Jan Biessels consults for and receives research support from Boehringer Ingelheim. L Jaap Kappelle has received speakers honoraria from Bayer and Boehringer Ingelheim.

Correspondence

Geert Jan Biessels, Department of Neurology, University Medical Centre Utrecht G03.232, PO Box 85500, 3508 GA Utrecht, The Netherlands. E: g.j.biessels@umcutrecht.nl

Support

The research of Geert Jan Biessels is supported by grant 2010T073 from the Netherlands Heart Foundation.

Received

2012-07-17T00:00:00

References

  1. Sarwar N, Gao P, Seshasai SR, et al., Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies, Lancet, 2010;375(9733):2215–22.
  2. Capes SE, Hunt D, Malmberg K, et al., Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview, Stroke, 2001;32(10):2426–32.
  3. Luitse MJ, Biessels GJ, Rutten GE, Kappelle LJ, Diabetes, hyperglycaemia, and acute ischaemic stroke, Lancet Neurol, 2012;11(3):261–71.
  4. Jackson C, Sudlow C, Are lacunar strokes really different? A systematic review of differences in risk factor profiles between lacunar and nonlacunar infarcts, Stroke, 2005;36(4):891–901.
  5. Cui R, Iso H, Yamagishi K, et al., Diabetes mellitus and risk of stroke and its subtypes among Japanese: the Japan public health center study, Stroke, 2011;42(9):2611–4.
  6. Ohira T, Shahar E, Chambless LE, et al., Risk factors for ischemic stroke subtypes: the Atherosclerosis Risk in Communities study, Stroke, 2006;37(10):2493–8.
  7. Huxley RR, Filion KB, Konety S, Alonso A, Meta-analysis of cohort and case-control studies of type 2 diabetes mellitus and risk of atrial fibrillation, Am J Cardiol, 2011;108(1):56–62.
  8. Uyttenboogaart M, Koch MW, Stewart RE, et al., Moderate hyperglycaemia is associated with favourable outcome in acute lacunar stroke, Brain, 2007;130(Pt 6):1626–30.
  9. Dungan KM, Braithwaite SS, Preiser JC, Stress hyperglycaemia, Lancet, 2009;373(9677):1798–807.
  10. American Diabetes Association, Standards of medical care in diabetes--2011, Diabetes Care, 2011;34 (Suppl. 1):S11–S61.
  11. Kruyt ND, Biessels GJ, Devries JH, Roos YB, Hyperglycemia in acute ischemic stroke: pathophysiology and clinical management, Nat Rev Neurol, 2010;6(3):145–55.
  12. Mishra NK, Ahmed N, Davalos A, et al., Thrombolysis outcomes in acute ischemic stroke patients with prior stroke and diabetes mellitus, Neurology, 2011;22;77(21):1866–72.
  13. Ahmed N, Davalos A, Eriksson N, et al., Association of admission blood glucose and outcome in patients treated with intravenous thrombolysis: results from the Safe Implementation of Treatments in Stroke International Stroke Thrombolysis Register (SITS-ISTR), Arch Neurol, 2010;67(9):1123–30.
  14. Van den Berghe G, Wouters P, Weekers F, et al., Intensive insulin therapy in the critically ill patients, N Engl J Med, 2001;345(19):1359–67.
  15. Van den Berghe G, Wilmer A, Milants I, et al., Intensive insulin therapy in mixed medical/surgical intensive care units: benefit versus harm, Diabetes, 2006;55(11):3151–9.
  16. Furnary AP, Gao G, Grunkemeier GL, et al., Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting, J Thorac Cardiovasc Surg, 2003;125(5):1007–21.
  17. Kansagara D, Fu R, Freeman M, et al., Intensive insulin therapy in hospitalized patients: a systematic review, Ann Intern Med, 2011;154(4):268–82.
  18. Vriesendorp TM, Roos YB, Kruyt ND, et al., Efficacy and safety of two 5 day insulin dosing regimens to achieve strict glycaemic control in patients with acute ischaemic stroke, J Neurol Neurosurg Psychiatry, 2009;80(9):1040–3.
  19. Kruyt ND, Biessels GJ, Vriesendorp TM, et al., Subjecting acute ischemic stroke patients to continuous tube feeding and an intensive computerized protocol establishes tight glycemic control, Neurocrit Care, 2010;12(1):62–8.
  20. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008, Cerebrovasc Dis, 2008;25(5):457–507.
  21. Adams HP Jr, del Zoppo G, Alberts MJ, et al., Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists, Circulation, 2007;115(20):e478–e534.
  22. Bellolio MF, Gilmore RM, Stead LG, Insulin for glycaemic control in acute ischaemic stroke, Cochrane Database Syst Rev, 2011;(9):CD005346.
  23. Gray CS, Hildreth AJ, Sandercock PA, et al., Glucosepotassium- insulin infusions in the management of poststroke hyperglycaemia: the UK Glucose Insulin in Stroke Trial (GIST-UK), Lancet Neurol, 2007;6(5):397–406.
  24. Johnston KC, Hall CE, Kissela BM, et al., Glucose Regulation in Acute Stroke Patients (GRASP) trial: a randomized pilot trial, Stroke, 2009;40(12):3804–9.
  25. Sone H, Tanaka S, Iimuro S, et al., Long-term lifestyle intervention lowers the incidence of stroke in Japanese patients with type 2 diabetes: a nationwide multicentre randomised controlled trial (the Japan Diabetes Complications Study), Diabetologia, 2010;53(3):419–28.
  26. Look AHEAD Research Group, Wing RR, Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: four–year results of the Look AHEAD trial, Arch Intern Med, 2010;170(17):1566–75.
  27. Wing RR, Lang W, Wadden TA, et al., Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes, Diabetes Care, 2011;34(7):1481–6.
  28. ADVANCE Collaborative Group, Patel A, MacMahon S, et al., Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes, N Engl J Med, 2008;12;358(24):2560–72.
  29. Duckworth W, Abraira C, Moritz T, et al., Glucose control and vascular complications in veterans with type 2 diabetes, N Engl J Med, 2009;360(2):129–39.
  30. Gerstein HC, Miller ME, Byington RP, et al., Effects of intensive glucose lowering in type 2 diabetes, N Engl J Med, 2008;358(24):2545–59.
  31. ACCORD Study Group, Gerstein HC, Miller ME, Genuth S, et al., Long-term effects of intensive glucose lowering on cardiovascular outcomes, N Engl J Med, 2011;364(9):818–28.
  32. Boussageon R, Bejan-Angoulvant T, Saadatian-Elahi M, et al., Effect of intensive glucose lowering treatment on all cause mortality, cardiovascular death, and microvascular events in type 2 diabetes: meta-analysis of randomised controlled trials, BMJ, 2011;343:d4169.
  33. Nathan DM, Cleary PA, Backlund JY, et al., Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes, N Engl J Med, 2005;353(25):2643–53.
  34. Bangalore S, Kumar S, Lobach I, Messerli FH, Blood pressure targets in subjects with type 2 diabetes mellitus/impaired fasting glucose: observations from traditional and bayesian random-effects meta-analyses of randomized trials, Circulation, 2011;123(24):2799–810, 9.
  35. Goldstein LB, Bushnell CD, Adams RJ, et al., Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association, Stroke, 2011;42(2):517–84.
  36. Collins R, Armitage J, Parish S, et al., MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial, Lancet, 2003;361(9374):2005–16.
  37. Keech A, Simes RJ, Barter P, et al., Effects of long-term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): randomised controlled trial, Lancet, 2005;366(9500):1849–61.
  38. Antithrombotic Trialists' Collaboration, Collaborative meta–analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients, BMJ, 2002;324(7329):71–86.
  39. De Berardis G, Sacco M, Strippoli GF, et al., Aspirin for primary prevention of cardiovascular events in people with diabetes: meta-analysis of randomised controlled trials, BMJ, 2009;339:b4531.
  40. Huxley RR, Alonso A, Lopez FL, et al., Type 2 diabetes, glucose homeostasis and incident atrial fibrillation: the Atherosclerosis Risk in Communities study, Heart, 2012;98(2):133–8.
  41. Lip GY, Nieuwlaat R, Pisters R, et al., Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation, Chest, 2010;137(2):263–72.
  42. European Heart Rhythm Association European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, et al., Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC), Europace, 2010;12(10):1360–420.
  43. Rothwell PM, Algra A, Amarenco P, Medical treatment in acute and long-term secondary prevention after transient ischaemic attack and ischaemic stroke, Lancet, 2011;377(9778):1681–92.
  44. Cunningham EJ, Bond R, Mehta Z, et al., Long-term durability of carotid endarterectomy for symptomatic stenosis and risk factors for late postoperative stroke, Stroke, 2002;33(11):2658–63.
  45. Debing E, Aerden D, Van den Brande P, Diabetes mellitus is a predictor for early adverse outcome after carotid endarterectomy. Vasc Endovascular Surg, 2011;45(1):28–32.
  46. Rerkasem K, Rothwell PM, Carotid endarterectomy for symptomatic carotid stenosis, Cochrane Database Syst Rev, 2011;(4):CD001081.

Further Resources

Share this Article
Related Content In Stroke
Stroke
Elevation of Serum Oncostatin M Level in Acute Ischaemic Stroke: A Review
Michael Christian, Youdong Wei Read Time: 8 mins

touchREVIEWS in Neurology. 2024;20(1):Online ahead of journal publication

Introduction The term ‘stroke’ is used to describe an adverse clinical state involving interference of blood circulation to the brain due to obstruction or rupture of blood vessels.1 Stroke was previously categorized into a cardiovascular disorder until the release of the International Classification of Disease 11 (ICF-11) in 2018, when stroke was recognized as a neurological […]

Stroke
Computed Tomography Perfusion Deficit as an Indicator for Reperfusion in Large-vessel Occlusions with Low National Institutes of Health Stroke Scale Scores in Acute Ischaemic Stroke: A Retrospective Review
Sachin A Kothari, Uttam Verma, Michael Nahhas Read Time: 10 mins

touchREVIEWS in Neurology 2022;18(2): 147-52 DOI: https://doi.org/10.17925/USN.2022.18.2.147

In clinical practice, the definition of penumbra is largely based on neuroimaging and indicates potentially salvageable tissue. Perfusion imaging has been useful in identifying this tissue when obeying ‘the mismatch concept’. The mismatch concept is a surrogate marker for salvageable brain tissue and refers to a lesion volume difference (mismatch) between the perfusion deficit (the […]

Stroke
A Review of Potential Mechanisms of Cryptogenic Stroke and a Recommended Approach to Diagnosis
Catherine E Arnold Read Time: 10 mins

touchREVIEWS in Neurology. 2021;17(2): 104–9 DOI: https://doi.org/10.17925/USN.2021.17.2.104

Ischaemic stroke may occur due to several potential mechanisms. Mechanisms are classically described as large artery atherosclerosis, small-vessel occlusion, cardioembolism, stroke of other determined aetiology (i.e. vasculitis, genetic disorder, etc.) and stroke of undetermined aetiology. Historically, the definition of stroke of undetermined aetiology has included strokes with multiple potential mechanisms, as well as those with […]

Trending In Stroke:

Elevation of Serum Oncostatin M Level in Acute Ischaemic Stroke: A Review
Stroke
    • Download PDF More Actions
    Copied to clipboard!
    accredited arrow-down-editablearrow-downarrow_leftarrow-right-bluearrow-right-dark-bluearrow-right-greenarrow-right-greyarrow-right-orangearrow-right-whitearrow-right-bluearrow-up-orangeavatarcalendarchevron-down consultant-pathologist-nurseconsultant-pathologistcrosscrossdownloademailexclaimationfeedbackfiltergraph-arrowinterviewslinkmdt_iconmenumore_dots nurse-consultantpadlock patient-advocate-pathologistpatient-consultantpatientperson pharmacist-nurseplay_buttonplay-colour-tmcplay-colourAsset 1podcastprinter scenerysearch share single-doctor social_facebooksocial_googleplussocial_instagramsocial_linkedin_altsocial_linkedin_altsocial_pinterestlogo-twitter-glyph-32social_youtubeshape-star (1)tick-bluetick-orangetick-red tick-whiteticktimetranscriptup-arrowwebinar Sponsored Department Location NEW TMM Corporate Services Icons-07NEW TMM Corporate Services Icons-08NEW TMM Corporate Services Icons-09NEW TMM Corporate Services Icons-10NEW TMM Corporate Services Icons-11NEW TMM Corporate Services Icons-12Salary £ TMM-Corp-Site-Icons-01TMM-Corp-Site-Icons-02TMM-Corp-Site-Icons-03TMM-Corp-Site-Icons-04TMM-Corp-Site-Icons-05TMM-Corp-Site-Icons-06TMM-Corp-Site-Icons-07TMM-Corp-Site-Icons-08TMM-Corp-Site-Icons-09TMM-Corp-Site-Icons-10TMM-Corp-Site-Icons-11TMM-Corp-Site-Icons-12TMM-Corp-Site-Icons-13TMM-Corp-Site-Icons-14TMM-Corp-Site-Icons-15TMM-Corp-Site-Icons-16TMM-Corp-Site-Icons-17TMM-Corp-Site-Icons-18TMM-Corp-Site-Icons-19TMM-Corp-Site-Icons-20TMM-Corp-Site-Icons-21TMM-Corp-Site-Icons-22TMM-Corp-Site-Icons-23TMM-Corp-Site-Icons-24TMM-Corp-Site-Icons-25TMM-Corp-Site-Icons-26TMM-Corp-Site-Icons-27TMM-Corp-Site-Icons-28TMM-Corp-Site-Icons-29TMM-Corp-Site-Icons-30TMM-Corp-Site-Icons-31TMM-Corp-Site-Icons-32TMM-Corp-Site-Icons-33TMM-Corp-Site-Icons-34TMM-Corp-Site-Icons-35TMM-Corp-Site-Icons-36TMM-Corp-Site-Icons-37TMM-Corp-Site-Icons-38TMM-Corp-Site-Icons-39TMM-Corp-Site-Icons-40TMM-Corp-Site-Icons-41TMM-Corp-Site-Icons-42TMM-Corp-Site-Icons-43TMM-Corp-Site-Icons-44TMM-Corp-Site-Icons-45TMM-Corp-Site-Icons-46TMM-Corp-Site-Icons-47TMM-Corp-Site-Icons-48TMM-Corp-Site-Icons-49TMM-Corp-Site-Icons-50TMM-Corp-Site-Icons-51TMM-Corp-Site-Icons-52TMM-Corp-Site-Icons-53TMM-Corp-Site-Icons-54TMM-Corp-Site-Icons-55TMM-Corp-Site-Icons-56TMM-Corp-Site-Icons-57TMM-Corp-Site-Icons-58TMM-Corp-Site-Icons-59TMM-Corp-Site-Icons-60TMM-Corp-Site-Icons-61TMM-Corp-Site-Icons-62TMM-Corp-Site-Icons-63TMM-Corp-Site-Icons-64TMM-Corp-Site-Icons-65TMM-Corp-Site-Icons-66TMM-Corp-Site-Icons-67TMM-Corp-Site-Icons-68TMM-Corp-Site-Icons-69TMM-Corp-Site-Icons-70TMM-Corp-Site-Icons-71TMM-Corp-Site-Icons-72