Insulin for glycaemic control in acute ischaemic stroke

Background Patients with hyperglycaemia concomitant with an acute stroke have greater stroke severity and greater functional impairment when compared to those with normoglycaemia at stroke presentation. Objectives To determine whether maintaining serum glucose within a specific normal range (4 to 7.5 mmol/L) in the first 24 hours of acute ischaemic stroke influences outcome. Search strategy We searched the Cochrane Stroke Group Trials Register (June 2010), CENTRAL (The Cochrane Library 2010, Issue 2), MEDLINE (1950 to June 2010), EMBASE (1980 to June 2010), CINAHL (1982 to June 2010), Science Citation Index (1900 to June 2010), and Web of Science (ISI Web of Knowledge) (1993 to June 2010). In an effort to identify further published, unpublished and ongoing trials we searched ongoing trials registers and SCOPUS. Selection criteria Eligible studies were randomised controlled trials comparing intensively monitored insulin therapy versus usual care in adult patients with acute ischaemic stroke. Data collection and analysis Two review authors independently extracted the study characteristics, study quality, and data to estimate the odds ratio (OR) and 95% confidence interval (CI), mean difference (MD) and standardised mean difference (SMD) of outcome measures. Main results We included seven trials involving 1296 participants (639 participants in the intervention group and 657 in the control group). We found that there was no difference between treatment and control groups in the outcome of death or disability and dependence (OR 1.00, 95% CI 0.78 to 1.28) or final neurological deficit (SMD -0.12, 95% CI -0.23 to 0.00). The rate of symptomatic hypoglycaemia was higher in the intervention group (OR 25.9, 95% CI 9.2 to 72.7). In the subgroup analyses of diabetes mellitus (DM) versus non-DM, we found no difference for the outcomes of death and dependency or neurological deficit. Authors' conclusions With the current evidence, we found that the administration of intravenous insulin with the objective of maintaining serum glucose within a specific range in the first hours of acute ischaemic stroke does not provide benefit in terms of functional outcome, death, or improvement in final neurological deficit and significantly increased the number of hypoglycaemic episodes. Specifically, those who were maintained within a more tight range of glycaemia with intravenous insulin experienced a greater risk of symptomatic and asymptomatic hypoglycaemia than those individuals in the control group.