Hyperglycemia and neurological outcome in patients with head injury

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✓ To examine the relationship between serum glucose and the outcome of patients suffering from head injury, the authors retrospectively reviewed the clinical course of 169 patients admitted for treatment to Harborview Medical Center (a regional trauma center). All patients underwent craniotomy for evacuation of intracranial hematoma and/or placement of a subarachnoid bolt for intracranial pressure monitoring under general anesthesia. Patients with a Glasgow Coma Scale (GCS) score of 8 or less had significantly higher serum glucose levels than patients with GCS scores of 12 to 15 (mean ± standard error of the mean 192 ± 7 mg/dl vs. 130 ± 8 mg/dl or 10.7 ± 0.4 mmol/liter vs. 7.2 ± 0.4 mmol/liter) (p < 0.0001). Patients who subsequently remained in a vegetative state or died had significantly higher glucose levels both on admission and postoperatively than patients who had good outcome or moderate disability (217 ± 12 mg/dl vs. 167 ± 6 mg/dl or 12.1 ± 0.7 mmol/liter vs. 9.3 ± 0.3 mmol/liter on admission, and 240 ± 16 mg/dl vs. 156 ± 5 mg/dl or 13.3 ± 0.9 mmol/liter vs. 8.9 ± 0.3 mmol/liter postoperatively) (p < 0.0001). Among the more severely injured patients (GCS score ≤ 8), a serum glucose level greater than 200 mg/dl (11.1 mmol/liter) postoperatively is associated with a significantly worse outcome (p < 0.01). The authors conclude that severely head-injured patients frequently develop hyperglycemia and the elevated serum glucose level may aggravate ischemic insults and worsen the neurological outcome in such patients.

Article Information

Address reprint requests to: Arthur M. Lam, M.D., Department of Anesthesiology, Harborview Medical Center, 325 9th Avenue, Seattle, Washington 98104.

© AANS, except where prohibited by US copyright law.

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    Serum glucose levels in patients with good outcome vs. patients with poor outcome. Patients with Glasgow Outcome Scale score (GOS) 4/5 (vegetative/dead) have significantly higher serum glucose values than patients with GOS 1/2 (good/moderate disability (mod dis)), both during admission and postoperatively. Numbers in bars denote the actual number of patients in that category.

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    Outcome of patients with a Glasgow Coma Scale score of 8 or less categorized according to their postoperative glucose values (in mg/dl). Patients with postoperative glucose levels > 150 mg/dl or > 200 mg/ dl (right) had significantly worse outcome than patients with lower values. There was a higher proportion of patients with poor outcome in both hyperglycemic groups. Numbers in bars denote the actual number of patients in that category.

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    Outcome of patients with a Glasgow Coma Scale score of 8 or less categorized according to their admission glucose values (in mg/dl). Patients with admission glucose levels > 150 mg/dl (left) had significantly worse outcome than patients with glucose levels < 150 mg/dl. There was a higher proportion of patients with poor outcome in the group with glucose levels > 150 mg/dl but not in those with glucose levels > 200 mg/dl (right). Numbers in bars denote the actual number of patients in that category.

References

1.

Clifton GLZiegler MGGrossman RG: Circulating catecholamines and sympathetic activity after head injury. Neurosurgery 8:10141981Neurosurgery 8:

2.

D'Alecy LGLundy EFBarton KJet al: Dextrose containing intravenous fluid impairs outcome and increases death after eight minutes of cardiac arrest and resuscitation in dogs. Surgery 100:5055111986Surgery 100:

3.

de Courten-Myers GMyers RESchoolfield L: Hyperglycemia enlarges infarct size in cerebrovascular occlusion in cats. Stroke 19:6236301988Stroke 19:

4.

De Salles AAFMuizelaar JPYoung HF: Hyperglycemia, cerebrospinal fluid lactic acidosis, and cerebral blood flow in severely head-injured patients. Neurosurgery 21:45501987Neurosurgery 21:

5.

Fukuoka SYeh HSMandybur TIet al: Effect of insulin on acute experimental cerebral ischemia in gerbils. Stroke 20:3963991989Stroke 20:

6.

Ginsberg MDPrado RDietrich WDet al: Hyperglycemia reduces the extent of cerebral infarction in rats. Stroke 18:5705741987Stroke 18:

7.

Ginsberg MDWelsh FABudd WW: Deleterious effect of glucose pretreatment on recovery from diffuse cerebral ischemia in the cat: 1. Local cerebral blood flow and glucose utilization. Stroke 11:3473541980Stroke 11:

8.

Graham DIFord IAdams JHet al: Ischemic brain damage is still common in fatal non-missile head injury. J Neurol Neurosurg Psychiatry 52:3463501989J Neurol Neurosurg Psychiatry 52:

9.

Hörtnagl HHammerle AFHackl JMet al: The activity of the sympathetic nervous system following severe head injury. Intensive Care Med 6:1691771980Intensive Care Med 6:

10.

Jennett BBond M: Assessment of outcome after severe brain damage. A practical scale. Lancet 1:4804841975Lancet 1:

11.

King LRKnowles HC JrMcLaurin RLet al: Glucose tolerance and plasma insulin in cranial trauma. Ann Surg 173:3373431971Ann Surg 173:

12.

King LRMcLaurin RLLewis HPet al: Plasma cortisol levels after head injury. Ann Surg 172:9759841970Ann Surg 172:

13.

Kraig RPChesler M: Glial acid-base behavior in brain ischemia. J Cereb Blood Flow Metab 7 ( Suppl 1): 1261987 (Abstract)J Cereb Blood Flow Metab 7 (Suppl 1):

14.

Kraig RPPetito CKPlum Fet al: Hydrogen ions kill brain at concentrations reached in ischemia. J Cereb Blood Flow Metab 7:3793861987J Cereb Blood Flow Metab 7:

15.

Kushner MNencini PReivich Met al: Relation of hyperglycemia early in ischemic brain infarction to cerebral anatomy, metabolism, and clinical outcome. Ann Neurol 28:1291351990Ann Neurol 28:

16.

Lanier WLStangland KJScheithauer BWet al: The effects of dextrose infusion and head position on neurologic outcome after complete cerebral ischemia in primates: examination of a model. Anesthesiology 66:39481987Anesthesiology 66:

17.

Lemay DRGehua LZelenock GBet al: Insulin administration protects neurologic function in cerebral ischemia in rats. Stroke 19:141114191988Stroke 19:

18.

Longstreth WT JrInui TS: High blood glucose level on hospital admission and poor neurological recovery after cardiac arrest. Ann Neurol 15:59631984Ann Neurol 15:

19.

Marsh WRAnderson RESundt TM Jr: Effect of hyperglycemia on brain pH levels in areas of focal incomplete cerebral ischemia in monkeys. J Neurosurg 65:6936961986J Neurosurg 65:

20.

Merguerian PAPerel AWald Uet al: Persistent nonketotic hyperglycemia as a grave prognostic sign in head-injured patients. Crit Care Med 9:8388401981Crit Care Med 9:

21.

Nedergaard MDiemer NH: Focal ischemia of the rat brain, with special reference to the influence of plasma glucose concentration. Acta Neuropathol 73:1311371987Acta Neuropathol 73:

22.

Oyama TSaito TIsomatsu Tet al: Plasma levels of ACTH and cortisol in man during diethyl ether anesthesia and surgery. Anesthesiology 29:5595641968Anesthesiology 29:

23.

Parish RAWebb KS: Hyperglycemia is not a poor prognostic sign in head-injured children. J Trauma 28:5175191988J Trauma 28:

24.

Pentelényi TKammerer LPéter Fet al: Prognostic significance of the changes in the carbohydrate metabolism in severe head injury. Acta Neurochir Suppl 28:1031071979Acta Neurochir Suppl 28:

25.

Pulsinelli WALevy DESigsbee Bet al: Increased damage after ischemic stroke in patients with hyperglycemia with or without established diabetes mellitus. Am J Med 74:5405441983Am J Med 74:

26.

Rose JValtonen SJennett B: Avoidable factors contributing to death after head injury. Br Med J 2:6156181977Br Med J 2:

27.

Rosner MJNewsome HHBecker DP: Mechanical brain injury: the sympathoadrenal response. J Neurosurg 61:76861984J Neurosurg 61:

28.

Siesjö BKWieloch T: Cerebral metabolism in ischaemia: neurochemical basis for therapy. Br J Anaesth 57:47621985Br J Anaesth 57:

29.

Teasdale GJennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81841974Lancet 2:

30.

Woo EMa JTCRobinson JD: Hyperglycemia is a stress response in acute stroke. Stroke 19:135913641988Stroke 19:

31.

Young BOtt LDempsey Ret al: Relationship between admission hyperglycemia and neurologic outcome of severely brain-injured patients. Ann Surg 210:4664731989Ann Surg 210:

32.

Zasslow MAPearl RGShuer LMet al: Hyperglycemia decreases acute neuronal ischemic changes after middle cerebral artery occlusion in cats. Stroke 20:519523. 1989Stroke 20:519–523. 1989

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