MON-277 - Beyond Pancreatitis: Insulin Infusion for Severe Hypertriglyceridemia in Acute Ischemic Stroke

Background: Severe hypertriglyceridemia (HTG) is a well-recognized cause of acute pancreatitis, for which insulin infusion is an established therapy. However, severe HTG presenting in the setting of acute ischemic stroke is rare, and there is limited evidence to guide management. Optimal therapeutic strategies and outcomes in this context remain unclear.

Case Presentation: A 68-year-old woman with type 2 diabetes mellitus (non–insulin dependent), hypertension, and hypothyroidism presented with two days of persistent neurological symptoms, including left- sided upper and lower extremity weakness, paresthesia, and slurred speech. On admission, blood pressure was 160/84 mmHg, heart rate 111 bpm, afebrile with oxygen saturation of 96% on room air. Her weight was 63.2 kg with a BMI of 27.4 kg/m² Neurological examination revealed mild dysarthria and 4/5 strength in both left upper and lower extremities. Routine labs (CBC, CMP, troponin, TSH) were unremarkable except for hyperglycemia (glucose 220 mg/dL). Neuroimaging demonstrated an acute right pontine infarct. Further laboratory evaluation revealed severe new-onset hypertriglyceridemia with triglyceride levels of 2,676 mg/dL. She was started on dual antiplatelet therapy per neurology recommendation. Given the severity of HTG, an insulin infusion was initiated at 15 units/hour for four days, followed by transition to basal insulin. Concurrent aggressive lipid-lowering therapy was initiated with atorvastatin 80 mg, ezetimibe 10 mg, and fenofibrate 145 mg daily. Stroke etiology was suspected to be HTG-related atherosclerosis, supported by significant atherosclerotic disease in the distal V4 segments of both vertebral arteries. Triglyceride levels were monitored daily throughout treatment. After seven days, triglycerides decreased to 391 mg/dL. She was discharged on basal insulin, metformin, triple lipid therapy, and a low-fat diet. At one-month follow-up, she had lost nine pounds and showed marked neurological improvement.

Conclusion: This case highlights insulin infusion combined with aggressive lipid-lowering therapy as a potential management strategy for severe hypertriglyceridemia in the setting of acute ischemic stroke. Further studies are needed to establish standardized treatment approaches in this rare presentation.

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