Published online before print September 13, 2007, doi: 10.1161/STROKEAHA.107.499202
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(Stroke. 2007;38:e139.)
© 2007 American Heart Association, Inc.
Letters to the Editor |
Response to Letters by Johnston et al and Bruno et al
Department of Neurology, University of Iowa College of Medicine, Iowa City, Iowa, US
Response:
I thank Dr Johnston and her colleagues and Dr Bruno and his associates for their letters in regard to the 2007 AHA/ASA Guidelines for the Early Management of Adults with Ischemic Stroke.1 I believe we all can agree that management of hyperglycemia in the setting of acute ischemic stroke, just as with other life-threatening illnesses, is a critical component of general management. Evidence about the effects of hyperglycemia on increasing the likelihood of poor outcomes after stroke, including among patients receiving tissue plasminogen activator, is compelling; some of this important evidence is provided by the authors of the letters.2–4 There also is increasing evidence that rigorous control of blood glucose levels improves outcomes among critically ill patients hospitalized in intensive care units.5–8 I assume the authors would also agree that the previous guidelines’ recommendations about the management of hyperglycemia in the setting of acute stroke needed to be revised and that the levels of serum glucose that necessitate treatment should be <300 mg/dL. In fact, the previous guidelines have been rightly criticized on this point. The new recommendations are not inconsistent with the recommendations provided by our colleagues in Europe.9
Obviously, the guidelines, which were published before the publication of the GIST-UK trial, did not include its results.10 In area of considerable active research, it is very likely that additional studies will be published in the future that could influence the recommendations of the guidelines. I would disagree with Dr Bruno and colleagues’ conclusion that the GIST-UK trial did not show benefit. The trial, which recruited 
40% of the subjects needed to test its primary hypothesis, failed to provide definitive data about the use (or lack thereof) of treatment of hyperglycemia in the setting of acute ischemic stroke. In fact, that appears to be the conclusion of the investigators.10
All physicians who manage patients with acute ischemic stroke would welcome solid information to help guide treatment. Until then, the guidelines need to be based on the other currently available data, including that available from treatment of other critically ill patients. I anticipate the authors of future acute stroke guidelines would be delighted to modify their statements based on the data provided by the authors of the letters. I believe the failure of the British study to provide an answer makes the research efforts of the groups led by Dr Johnston and Dr Bruno even more important. I sincerely hope that these data will be available as soon as possible.
Acknowledgments
Disclosures
None.
References
1. Adams HPJ, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EFM. 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. Stroke. 2007; 38: 1655–1711.
2. Williams LS, Rotich J, Qi R, Fineberg N, Espay A, Bruno A, Fineberg SE, Tierney WR. Effects of admission hyperglycemia on mortality and costs in acute ischemic stroke. Neurology. 2002; 59: 67–71.
3. Parsons MW, Barber A, Desmond PM, Baird TA, Darby DG, Byrnes G, Tress BM, Davis SM. Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study. Ann Neurol. 2002; 52: 20–28.[CrossRef][Medline] [Order article via Infotrieve]
4. Bruno A, Levine SR, Frankel M, Brott T, Lin Y, Tilley B, Lyden PD. Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial. Neurology. 2002; 59: 669–674.
5. Van den Berghe G, Schoonheydt K, Becx P, Bruyninckx F, Wouters PJ. Insulin therapy protects the central and peripheral nervous system of intensive care patients. Neurology. 2005; 64: 1348–1353.
6. Langley J, Adams G. Insulin-based regimens decrease mortality rates in critically ill patients: a systematic review. Diabetes Metab Res Rev. 2007; 23: 184–192.[CrossRef][Medline] [Order article via Infotrieve]
7. Plank J, Blaha J, Cordingley J, Wilinska ME, Chassin LJ, Morgan C, Squire S, Haluzik M, Kremen J, Svacina S, Toller W, Plasnik A, Ellmerer M, Hovorka R, Pieber TR. Multicentric, randomized, controlled trial to evaluate blood glucose control by the model predictive control algorithm versus routine glucose management protocols in intensive care unit patients. Diabetes Care. 2006; 29: 271–276.
8. Shann KG, Likosky DS, Murkin JM, Baker RA, Baribeau YR, DeFoe GR, Dickinson TA, Gardner TJ, Grocott HP, O’Connor GT, Rosinski DJ, Sellke FW, Willcox TW. An evidence-based review of the practice of cardiopulmonary bypass in adults: a focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response. The J Thorac Cardiovasc Surg. 2006; 132: 283.[CrossRef]
9. Toni D, Chamorro A, Kaste M, Lees K, Wahlgren NG, Hacke W. Acute treatment of ischemic stroke. Cerebrovasc Dis. 2004; 17 (Suppl 2): 30–46.[CrossRef][Medline] [Order article via Infotrieve]
10. Gray CS, Hildreth AJ, Sandercock PA, O’Connell JE, Johnston DE, Cartlidge NE, Bamford JM, James OF, Alberti KGM. Glucose-potassium-insulin infusions in the management of post-stroke hyperglycaemia: the UK Glucose Insulin in Stroke Trial (GIST-UK). The Lancet Neurology. 2007; 6: 397–406.[CrossRef]
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