Glucose Management

Between 20% and 50% of acute stroke patients are hyperglycemic at presenta-tion.137 The degree of hyperglycemia correlates with both mortality and functional

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outcome, even despite successful recanalization after thrombolysis. In experimental models of cerebral ischemia, hyperglycemia is shown to exacerbate ischemic neuronal injury through a variety of mechanisms. Hyperglycemia amplifies extracellular glutamate accumulation, especially in the cortex,140 impairs lipid metabolism,141 reduces perfusion to the penumbra, promotes calcium influx through NMDA receptors, cytotoxic edema, oxidative stress, and free-radical production, and increases inflammation including expression of metalloproteinases (MMPs).142 The Glucose Insulin in Stroke Trial suggests that administration of glucose, insulin, and potassium during the first 24 hours after stroke onset is safe; this pilot study was underpowered to determine efficacy.143 Three studies addressing aggressive insulin therapy for euglycemia, the Glucose Regulation in Acute Stroke Patients Trial (GRASP), Glucose Insulin in Stroke Trial-UK (GIST-UK), and Treatment of Hyperglycemia in Ischemic Stroke (THIS), are ongoing.

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