BACKGROUND: The stress hyperglycemia ratio (SHR), originally proposed in 2015 by Robert et al., is more significantly relevant and predictive of critical illness than absolute hyperglycemia. Several studies have validated the association between stress hyperglycemia ratio and cerebrovascular disease. However, the value of stress hyperglycemia ratio for severe stroke patients admitted to the ICU remains uncertain. The aim of this study was to investigate the relationship between stress hyperglycemia ratio and clinical short- and long-term prognosis of critically ill patients with acute ischemic stroke (AIS). METHODS: Clinical data from 893 critically ill patients with ischemic stroke (IS) were extracted from the Medical Information Marketplace for Intensive Care (MIMIC-IV) database and 793 critically ill IS patients with 1 year of follow-up. The SHR is expressed by the formula: SHR = [(admission glucose (mg/dl)) / (28.7 × HbA1c (%) - 46.7)]. The study population was categorized into quartiles based on SHR level. Outcomes included ICU mortality, hospital mortality, and 1-year mortality. Cox proportional risk regression analysis and restricted cubic spline curves were used to elucidate the association between SHR and clinical prognosis in critically ill patients with AIS. RESULTS: There were 69 ICU deaths and 100 in-hospital deaths in cohort 1, and 229 patients experienced all-cause mortality during the 1-year follow-up in cohort 2. Multivariate Cox proportional risk analysis showed that elevated SHR was significantly associated with an increased risk of hospital and 1-year all-cause mortality. After adjusting for confounders, patients with elevated SHR were significantly associated with hospital mortality (adjusted risk ratio, 1.870
95 % confidence interval, 1.180-2.962
P = 0.008) and 1-year mortality (adjusted risk ratio, 2.325
95 % confidence, 1.729-3.127
P <
0.001). Restricted cubic spline bars showed that a progressively increasing risk of all-cause mortality was associated with an elevated SHR. CONCLUSION: Stress hyperglycemia ratios were significantly associated with in-hospital and 1-year all-cause mortality in critically ill IS patients. Moreover, we found that non-diabetic and prediabetic patients showed an increased risk of all-cause mortality. It is suggested that SHR may be useful in identifying ischemic stroke patients at high risk of all-cause mortality and providing personalized interventions as early as possible.