- Original article
- Open access
- Published:
Outcome of critically ill hyperglycemic stroke patients admitted to the intensive care unit
The Egyptian Journal of Internal Medicine volume 25, pages 185–190 (2013)
Abstract
Introduction
It has been suggested that admission hyperglycemia is a marker of extensive brain damage. Despite these observations, studies that have examined the relationship between glucose levels and the outcome after stroke in diabetic and nondiabetic patients have reported conflicting results.
Aim
We evaluated data on stroke patients admitted to the intensive care department to estimate the influence of hyperglycemia on the short-term mortality in both diabetic and nondiabetic patients.
Patients and methods
A total of 100 consecutive adult patients with stroke admitted to the ICU were studied over a period of 28 months. The patients were followed up for 28 days until discharge from the hospital or until death, whichever occurred first. The patients were divided into three broad groups, on the basis of fasting blood glucose or random sugar and HbA1c to rule out undetected diabetes patients.
Results
There were no significant differences in the stroke subtype or the baseline stroke severity between diabetic (group 3) and hyperglycemic (group 2) patients. Also, there was no significant association between the stroke severity and the glycosylated hemoglobin level in group 2 and group 3 (r = 0.26, P = 0.4; r = 0.19, P = 0.31; respectively). With regard to an excellent outcome of stroke, which was measured by the modified Rankin scale (0–1), there was no significant difference between group 2 and group 3. The unadjusted risk ratio was 1.85 (95% confidence interval 0.52–4.41) for group 2, whereas it was 1.25 (95% confidence interval 0.7 6–4.3) in group 3. Nondiabetic patients with hyperglycemia had a 1.6 times higher relative risk of in-hospital 28-day mortality than diabetic patients. There were four nonsurvivors (11%) out of 36 patients in the control nondiabetic (group 1), whereas eight (26%) of 31 patients died in group 2, which was statistically significant when compared with group 1 (P = 0.02). However, six nonsurvivors (18%) of 33 in group 3 when compared with group 2 was statistically significant (P = 0.04).
Conclusion
Our current study showed that nondiabetic patients with hyperglycemia had a 1.6 times higher relative risk of in-hospital 28-day mortality than diabetic patients. Stress hyperglycemia predicts an increased risk of in-hospital mortality after ischemic stroke; thus, we should not underestimate the potential harm, as patients with the highest admission glucose levels would have most likely been treated earlier and more aggressively.
References
Jorgensen H, Nakayama H, Raaschou HO, Olsen TS. Stroke in patients with diabetes: the Copenhagen Stroke Study. Stroke 1994; 25: 1977–1984.
Candelise L, Landi G, Orazio EN, Boccardi E. Prognostic significance of hyperglycemia in acute stroke. Arch Neurol 1985; 42: 661–663.
Melamed E. Reactive hyperglycaemia in patients with acute stroke. J Neurol Sci 1976; 29: 267–275.
Sewdarsen M, Jialal I, Vythilingum S, Govender G, Rajput MC. Stress hyperglycaemia is a predictor of abnormal glucose tolerance in Indian patients with acute myocardial infarction. Diabetes Res 1987; 6: 47–49.
Mankovsky BN, Metzger BE, Molitch ME, Biller J. Cerebrovascular disorders in patients with diabetes mellitus. J Diabetes Complications 1996; 10: 228–242.
Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 2000; 355: 773–778.
Hamilton MG, Tranmer BI, Auer RN. Insulin reduction of cerebral infarction due to transient focal ischemia. J Neurosurg 1995; 82: 262–268.
Kiers L, Davis SM, Larkins R, Hopper J, Tress B, Rossiter SC, et al. Stroke topography and outcome in relation to hyperglycemia and diabetes. J Neurol Neurosurg Psychiatry 1992; 55: 263–270.
Baird TA, Parsons MW, Phanh T, Butcher KS, Desmond PM, Tress BM, et al. Persistent poststroke hyperglycemia is independently associated with infarct volume expansion and worse clinical outcome. Stroke 2003; 34: 2208–2214.
Parsons MW, Barber PA, Desmond PM, Baird TA, Darby DG, Byrnes G, et al. Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study. Ann Neurol 2002; 52: 20–28.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13: 818–829.
Capes SE, Hunt D, Malmberg K, Pathak P, Gersstein Hc. Stress hyperglycemia and prognosis of stroke in diabetic and nondiabetic patients – a systematic review. Stroke 2001; 32: 2426–2432.
Scott JF, Robinson GM, French JM, O’Connell JE, Alberti KG, Gray CS. Glucose potassium insulin infusions in the treatment of acute stroke patients with mild or moderate hyperglycemia: the Glucose Insulin in Stroke Trial (GIST). Stroke 1999; 30: 793–799.
Jorgensen H, Nakayama H, Raaschou HO, Olssen TS Stroke in patients with diabetes in Copenhagen Stroke Study. Stroke 1994; 25: 1977–1984.
Bruno A, Biller J, Adams HP, Clark WR, Woolsson RF, Wiliams LS, Hansen MD. Acute blood glucose level and outcome from ischemic stroke: Trial of ORG 10172 in Acute Stroke Treatment (TOAST) investigators. Neurology 1999; 52: 280–284.
Van Kooten F, Hoogerbrugge N, Naarding P, Koudstaal PJ. Hyperglycemia in the acute phase of stroke is not caused by stress. Stroke 1993; 24: 1129–1132.
Masharani U, Karam JH. Diabetes mellitus and hypoglycemia. In: Tierney LM, McPhee SJ, Papadakis MA, editors. Current medical diagnosis and treatment. New York: Lange Medical Books; 2002. p. 1209.
Murros K, Fogelholm R, Kettunen S, Vuorela AL, Valve J. Blood glucose, glycosylated haemoglobin, and outcome of ischemic brain infarction. J Neurol Sci 1992; 111: 59–64.
Christensen H, Boysen G. Blood glucose increases early after stroke onset: a study on serial measurements of blood glucose in acute stroke. Eur J Neurol 2002; 9: 297–301.
Woo E, Chan YW, Yu YL, Huang CY. Admission glucose level in relation to mortality and morbidity outcome in 252 stroke patients. Stroke 1988; 19: 185–191.
Czlonkowska A, Ryglewicz D, Lechowicz W. Basic analytical parameters as the predictive factors for 30-day case fatality rate in stroke. Acta Neurol Scand 1997; 95: 121–124.
M’Buyamba-Kabangu J-R, Longo-Mbenza B, Tambwe MJ, Dikassa LN, Mbala-Mukendi M. J-shaped relationship between mortality and admission blood pressure in black patients with acute stroke. J Hypertens 1995; 13: 1863–1868.
Levine SR, Welch KM, Helpern JA, Chopp M, Bruce R, Selwa J, Smith MB. Prolonged deterioration of ischemic brain energy metabolism and acidosis associated with hyperglycemia: human cerebral infarction studied by serial 31P NMR spectroscopy. Ann Neurol 1988; 23: 416–418.
Siesjö BK, Bendek G, Koide T, Westerberg E, Wieloch T. Influence of acidosis on lipid peroxidation in brain tissues in vitro. J Cereb Blood Flow Metab 1985; 5: 253–258.
Ou Yang YB, Mellergård P, Kristián T, Kristiánova V, Siesjö BK. Influence of acid–base changes on the intracellular calcium concentration of neurons in primary culture. Exp Brain Res 1994; 101: 265–271.
Anderson RE, Tan WK, Martin HS, Meyer FB. Effects of glucose and Pao2 modulation on cortical intracellular acidosis, NADH redox state, and infarction in the ischemic penumbra. Stroke 1999; 30: 160–170.
Choi DW, Rothman SM. The role of glutamate neurotoxicity in hypoxic ischemic neuronal death. Ann Rev Neurosci 1990; 13: 171–182.
Olsen TS, Larsen B, Herning M, Skriver EB, Lassen NA. Blood flow and vascular reactivity in collaterally perfused brain tissue: evidence of an ischemic penumbra in patients with acute stroke. Stroke 1983; 14: 332–341.
Uyttenboogaart M, Koch MW, Stewart RE, Vroomen PC, Luijckx GJ, Keyser JD. Moderate hyperglycaemia is associated with favourable outcome in acute lacunar stroke. Brain 2007; 130: 1626–1630.
Yong M, Kaste M. Dynamic of hyperglycemia as a predictor of stroke outcome in the ECASS-II trial. Stroke 2008; 39: 2749–2755.
Sacco RL, Shi T, Zamanillo MC, Kargman DE. Predictors of mortality and recurrence after hospitalized cerebral infarction in an urban community: the Northern Manhattan Stroke Study. Neurology 1994; 44: 626–634.
Lee T-H, Ryu S-J, Chen S-T. The prognostic value of blood glucose in patients with acute stroke. J Formos Med Assoc 1991; 90: 456–470.
Ntaios G, Abatzi C, Alexandrou M, Lambrou D, Chatzopoulos S, Egli M, et al. Persistent hyperglycemia at 24–48 h in acute hyperglycemic stroke patients is not associated with a worse functional outcome. Cerebrovasc Dis 2011; 32: 561–566.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Mohamed, K.A., Saad, A. Outcome of critically ill hyperglycemic stroke patients admitted to the intensive care unit. Egypt J Intern Med 25, 185–190 (2013). https://doi.org/10.4103/1110-7782.124979
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.4103/1110-7782.124979