Influência prognóstica adversa do diabetes mellitus e da hiperglicemia sobre a evolução do infarto cerebral

André, Charles; Novis, Sérgio Augusto Pereira

doi:10.1590/S0004-282X1992000200002

Resumos

Em uma série de 109 casos de infarto cerebral comprovado por tomografia computadorizada de crânio, diabetes mellitus esteve presente em 15,6%. Em 86 casos avaliados precocemente foi detectada hiper glicemia em 67,4%, e em 100% de 14 pacientes diabéticos. Houve aumento (não significativo) nas taxas de letalidade hospitalar precoce - até o 30º dia de internação - de pacientes diabéticos; suas chances de obter alta precocemente, porém, pareceram reduzidas. A evolução de pacientes com hiperglicemia também pareceu pior. Estes pacientes exibiram redução significativa das chances de obter alta hospitalar precoce. O risco de vida pareceu máximo em diabéticos hiperglicêmicos (42,9%). As aparentes diferenças de letalidade e necessidade de internação prolongada entre pacientes não diabéticos, normo ou hiperglicêmicos, não alcançaram significação estatística. Os achados do presente estudo parecem indicar uma somação de efeitos deletérios pela hiperglicemia e pelo diabetes no curso do infarto cerebral. Cabe agora a avaliação crítica da sugestão de que a normalização precoce de hiperglicemia poderia levar a redução do grau de lesão cerebral após AVE isquêmico.

infarto cerebral; diabetes mellitus; hiperglicemia; prognóstico

We acessed the potential impact of diabetes mellitus and hyperglycemia on early prognosis in a study of 100 cases of CT proved brain infarction. Main end-points of this study were 30-days case-fatality rates and the probability of early discharge or prolonged hospitalization. Proportions of patients exhibiting diverse evolutions were compared by Fisher's test and, when the number of observations permitted, by chi-square test. Diabetes mellitus was diagnosed by history in 15.6% (17 patients). In 86 cases analysed within 72 hours of admission, hyperglycemia (glucose level higher than 110 mg/dL.) was detected in 67.4% (including all 14 diabetic patients evaluated). A nonsignificant increase in case fatality rates was detected in diabetic patients (35.3% vs 21.7%; p=0.18), but these patients probably were discharged early less frequently (23.5% vs 51.1%; p==0.06). Compared to the normoglycemic patients, hyperglycemic patients also fared worse, when considering altogether the early discharge and case fatality rates and the need for prolonged hospitalization (p=0.06). They also exhibited a nonsignificant increase in early case fatality rate (31% vs 15.4%; p=0.21) and a markedly reduced chance of obtaining early hospital discharge (37.9% vs 65.4%; p=0.03). Case fatality rates were maximal in diabetic hyperglycemic patients (42.9%) and seemed intermediate in non-diabetic hyperglycemic patients (27.3%). Considering the three end-points evaluated, the apparent differences between non-diabetic hyper and normoglycemic patients did not reach statistical significance (p=0.19). These results suggest that both diabetes mellitus and hyperglycemia «per se» have deleterious effects on the clinical evolution of patients with cerebral infarction. It is now time to consider a prospective study on the potential benefits of early correction of hyperglycemia in these patients.

brain infarction; diabetes mellitus; hyperglycemia; prognosis

Charles André^I; Sérgio Augusto Pereira Novis^II

^IMédico Neurologista, Serviço de Neurologia, HUCCF-UFRJ. Trabalho realizado no Serviço de Neurologia do Hospital Clementino Fraga Filho da Universidade Federal do Rio de Janeiro (HUCFF-UFRJ)

^IIProfessor Titular de Neurologia, Chefe do Serviço de Neurologia, HUCFF-UFRJ. Trabalho realizado no Serviço de Neurologia do Hospital Clementino Fraga Filho da Universidade Federal do Rio de Janeiro (HUCFF-UFRJ)

RESUMO

Em uma série de 109 casos de infarto cerebral comprovado por tomografia computadorizada de crânio, diabetes mellitus esteve presente em 15,6%. Em 86 casos avaliados precocemente foi detectada hiper glicemia em 67,4%, e em 100% de 14 pacientes diabéticos. Houve aumento (não significativo) nas taxas de letalidade hospitalar precoce até o 30º dia de internação de pacientes diabéticos; suas chances de obter alta precocemente, porém, pareceram reduzidas. A evolução de pacientes com hiperglicemia também pareceu pior. Estes pacientes exibiram redução significativa das chances de obter alta hospitalar precoce. O risco de vida pareceu máximo em diabéticos hiperglicêmicos (42,9%). As aparentes diferenças de letalidade e necessidade de internação prolongada entre pacientes não diabéticos, normo ou hiperglicêmicos, não alcançaram significação estatística. Os achados do presente estudo parecem indicar uma somação de efeitos deletérios pela hiperglicemia e pelo diabetes no curso do infarto cerebral. Cabe agora a avaliação crítica da sugestão de que a normalização precoce de hiperglicemia poderia levar a redução do grau de lesão cerebral após AVE isquêmico.

Palavras-chave: infarto cerebral, diabetes mellitus, hiperglicemia, prognóstico.

SUMMARY

We acessed the potential impact of diabetes mellitus and hyperglycemia on early prognosis in a study of 100 cases of CT proved brain infarction. Main end-points of this study were 30-days case-fatality rates and the probability of early discharge or prolonged hospitalization. Proportions of patients exhibiting diverse evolutions were compared by Fisher's test and, when the number of observations permitted, by chi-square test. Diabetes mellitus was diagnosed by history in 15.6% (17 patients). In 86 cases analysed within 72 hours of admission, hyperglycemia (glucose level higher than 110 mg/dL.) was detected in 67.4% (including all 14 diabetic patients evaluated). A nonsignificant increase in case fatality rates was detected in diabetic patients (35.3% vs 21.7%; p=0.18), but these patients probably were discharged early less frequently (23.5% vs 51.1%; p==0.06). Compared to the normoglycemic patients, hyperglycemic patients also fared worse, when considering altogether the early discharge and case fatality rates and the need for prolonged hospitalization (p=0.06). They also exhibited a nonsignificant increase in early case fatality rate (31% vs 15.4%; p=0.21) and a markedly reduced chance of obtaining early hospital discharge (37.9% vs 65.4%; p=0.03). Case fatality rates were maximal in diabetic hyperglycemic patients (42.9%) and seemed intermediate in non-diabetic hyperglycemic patients (27.3%). Considering the three end-points evaluated, the apparent differences between non-diabetic hyper and normoglycemic patients did not reach statistical significance (p=0.19). These results suggest that both diabetes mellitus and hyperglycemia «per se» have deleterious effects on the clinical evolution of patients with cerebral infarction. It is now time to consider a prospective study on the potential benefits of early correction of hyperglycemia in these patients.

Key words: brain infarction, diabetes mellitus, hyperglycemia, prognosis.

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Dr. Sérgio A. Pereira Novis Rua Visconde de Pirajá 330, sala 513 - 22410 Rio de Janeiro RJ - Brasil.

1. Allen CMC. Predicting the outcome of acute stroke: a prognostic score. J Neurol Neurosurg Psychiatry 1984, 47:475-480.
2. André C. A morte na fiase aguda do infarto cerebral: Cronologia e causas de óbito e determinantes prognósticos adversos. Tese, INDC-UFRJ. Rio de Janeiro, 1991.
3. André C, Novis SAP. Influência prognóstica adversa do diabetes mellitus e da hiperglicemia sobre a evolução do infarto cerebral: uma revisão de suas causas, com menção aos mecanismos de gênese da hiperglicemia na fase aguda do AVE. Arq Neuro-Psiquiat (São Paulo) 1992, 50:151-155.
4. Asplund K, Haag E, Helmers C, Lithner F, Strand T, Wester PO. The natural history of stroke in diabetic patients. Acta Med Scand 1980, 207:417-424.
5. Berger L, Hakim AM. The association of hyperglycemia with cerebral edema in stroke. Stroke 1986, 17:865-871.
6. Candelise L, Dandi G, Orazio EN, Boccardi E. Prognostic significance of hyperglycemia in acute stroke. Arch Neurol 1985, 42:661-663.
7. Caronna JJ, Levy DE. Clinical predictors of outcome in ischemic stroke. Neurologic Clinics 1983, 1:103-117.
8. Chambers BR, Norris JH, Schurvell BL, Hachinski VC. Prognosis of acute stroke. Neurology 1987, 37:221-225.
9. Daalsgard-Nielsen T. Some clinical experience in the treatment of cerebral apoplexy (1000 cases). Acta Psychiat Scand 1956, Suppl, 108:101.
10. Harmsen P, Tibbling G. A stroke register in Göteborg, Sweden. Acta Med Scand 1972, 191:463-470.
11. Helgason CM. Blood glucose and stroke. Strok 1988, 19:1049-1053.
12. Miah K, Arbin MV, Britton M, Faire U, Helmers C, Maasing R. Prognosis in acute stroke with special reference to some cardiac factors. J Chron Dis 1983, 36:279-288.
13. Mohr JP, Caplan LR, Melski JW et al. The Harvard cooperative stroke registry: a prospective registry. Neurology 1978, 28:754-762.
14. Patrick BK, Ramirez-Lasseras M, Snyder BD. Temporal profile of vertebrobasilar territory infarction: prognostic implications. Stroke 1980, 11:643-648.
15. Pulsinelli WA, Levy DE, Sigsbee B et al. Increased damage after ischemic stroke in patients with hyperglycemia with or without established diabetes mellitus. Am J Med 1983, 74:540-544.
16. Pulsinelli WA, Waldman S, Rawlinson D, Plum F. Moderate hyperglycemia augments ischemic brain damage: a neuropathologie study in the rat. Neurology 1982, 32:1239-1246.
17. Pulsinelli WA, Waldman S, Sigsbee B, Rawlinson D, Seherer P, Plum F. Experimental hyperglycemia and diabetes mellitus worsen stroke outcome. Trans Am Neurol Assoc 1980, 105:21-24.
18. Robinson RW, Cohen WD, Higano N et al. Analysis of survival after cerebral thrombosis: ten-year experience. JAMA 1959, 169:1149-1152.
19. Robinson RW, Demirel M, LeBeau RJ. Natural history of cerebral thrombosis: nine to nineteen year follow-up. J Chron Dis 1968, 21:221-230.
20. Térent A, Anderson B. The prognosis for patients with cerebrovascular stroke and transient ischemic attacks. Upsala J Med Sci 1981, 86:63-74.
21. 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.
22. Woo E, Ma JTC, Robinson JD, Yu YL. Hyperglycemia is a stress response in acute stroke. Stroke 1988, 19:1359-1364.

Influência prognóstica adversa do diabetes mellitus e da hiperglicemia sobre a evolução do infarto cerebral

Adverse prognostic influence of diabetes mellitus and hyperglycemia on the clinical course of brain infarct.

Datas de Publicação

Publicação nesta coleção
22 Fev 2011
Data do Fascículo
Jun 1992

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Allen CMC. Predicting the outcome of acute stroke: a prognostic score. J Neurol Neurosurg Psychiatry 1984, 47:475-480.

[2] 2. André C. A morte na fiase aguda do infarto cerebral: Cronologia e causas de óbito e determinantes prognósticos adversos. Tese, INDC-UFRJ. Rio de Janeiro, 1991.

[3] 3. André C, Novis SAP. Influência prognóstica adversa do diabetes mellitus e da hiperglicemia sobre a evolução do infarto cerebral: uma revisão de suas causas, com menção aos mecanismos de gênese da hiperglicemia na fase aguda do AVE. Arq Neuro-Psiquiat (São Paulo) 1992, 50:151-155.

[4] 4. Asplund K, Haag E, Helmers C, Lithner F, Strand T, Wester PO. The natural history of stroke in diabetic patients. Acta Med Scand 1980, 207:417-424.

[5] 5. Berger L, Hakim AM. The association of hyperglycemia with cerebral edema in stroke. Stroke 1986, 17:865-871.

[6] 6. Candelise L, Dandi G, Orazio EN, Boccardi E. Prognostic significance of hyperglycemia in acute stroke. Arch Neurol 1985, 42:661-663.

[7] 7. Caronna JJ, Levy DE. Clinical predictors of outcome in ischemic stroke. Neurologic Clinics 1983, 1:103-117.

[8] 8. Chambers BR, Norris JH, Schurvell BL, Hachinski VC. Prognosis of acute stroke. Neurology 1987, 37:221-225.

[9] 9. Daalsgard-Nielsen T. Some clinical experience in the treatment of cerebral apoplexy (1000 cases). Acta Psychiat Scand 1956, Suppl, 108:101.

[10] 10. Harmsen P, Tibbling G. A stroke register in Göteborg, Sweden. Acta Med Scand 1972, 191:463-470.

[11] 11. Helgason CM. Blood glucose and stroke. Strok 1988, 19:1049-1053.

[12] 12. Miah K, Arbin MV, Britton M, Faire U, Helmers C, Maasing R. Prognosis in acute stroke with special reference to some cardiac factors. J Chron Dis 1983, 36:279-288.

[13] 13. Mohr JP, Caplan LR, Melski JW et al. The Harvard cooperative stroke registry: a prospective registry. Neurology 1978, 28:754-762.

[14] 14. Patrick BK, Ramirez-Lasseras M, Snyder BD. Temporal profile of vertebrobasilar territory infarction: prognostic implications. Stroke 1980, 11:643-648.

[15] 15. Pulsinelli WA, Levy DE, Sigsbee B et al. Increased damage after ischemic stroke in patients with hyperglycemia with or without established diabetes mellitus. Am J Med 1983, 74:540-544.

[16] 16. Pulsinelli WA, Waldman S, Rawlinson D, Plum F. Moderate hyperglycemia augments ischemic brain damage: a neuropathologie study in the rat. Neurology 1982, 32:1239-1246.

[17] 17. Pulsinelli WA, Waldman S, Sigsbee B, Rawlinson D, Seherer P, Plum F. Experimental hyperglycemia and diabetes mellitus worsen stroke outcome. Trans Am Neurol Assoc 1980, 105:21-24.

[18] 18. Robinson RW, Cohen WD, Higano N et al. Analysis of survival after cerebral thrombosis: ten-year experience. JAMA 1959, 169:1149-1152.

[19] 19. Robinson RW, Demirel M, LeBeau RJ. Natural history of cerebral thrombosis: nine to nineteen year follow-up. J Chron Dis 1968, 21:221-230.

[20] 20. Térent A, Anderson B. The prognosis for patients with cerebrovascular stroke and transient ischemic attacks. Upsala J Med Sci 1981, 86:63-74.

[21] 21. 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.

[22] 22. Woo E, Ma JTC, Robinson JD, Yu YL. Hyperglycemia is a stress response in acute stroke. Stroke 1988, 19:1359-1364.