Lisätietoa aiheesta

AVH-potilaan hyperglykemia ja sen hoito akuutissa vaiheessa

Lisätietoa aiheesta

30.6.2016

Juha Huhtakangas

Joka toisella aivoinfarktipotilaalla veren glukoosipitoisuus todetaan suurentuneeksi akuutissa vaiheessa «Bruno A, Biller J, Adams HP Jr ym. Acute blood glucose level and outcome from ischemic stroke. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. Neurology 1999;52:280-4 »1, «Bruno A, Levine SR, Frankel MR ym. Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial. Neurology 2002;59:669-74 »2, «Baird TA, Parsons MW, Phan T ym. Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome. Stroke 2003;34:2208-14 »3, «Broderick JP, Hagen T, Brott T ym. Hyperglycemia and hemorrhagic transformation of cerebral infarcts. Stroke 1995;26:484-7 »4. Veren glukoosipitoisuuden nousu on kuitenkin ei-diabeetikoilla usein väliaikaista «Dave JA, Engel ME, Freercks R ym. Abnormal glucose metabolism in non-diabetic patients presenting with an acute stroke: prospective study and systematic review. QJM 2010;103:495-503 »5, «Dziedzic T, Pera J, Trabka-Janik E ym. The impact of postadmission glycemia on stroke outcome: Glucose normalisation is associated with better survival. Atherosclerosis 2010;211:584-8 »6.
Hyperglykemian on osoitettu olevan yhteydessä akuutin vaiheen suurentuneeseen kuolleisuuteen sekä diabeetikoilla että ei-diabeetikoilla, koska se altistaa infarktin laajentumiselle ja aivoturvotukselle ja lisää selvästi infarktin vuotoriskiä, erityisesti rekanalisaation ja trombolyysin yhteydessä «Broderick JP, Hagen T, Brott T ym. Hyperglycemia and hemorrhagic transformation of cerebral infarcts. Stroke 1995;26:484-7 »4, «Weir CJ, Murray GD, Dyker AG ym. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study. BMJ 1997;314:1303-6 »8, «Jørgensen H, Nakayama H, Raaschou HO ym. Stroke in patients with diabetes. The Copenhagen Stroke Study. Stroke 1994;25:1977-84 »9, «Alvarez-Sabín J, Molina CA, Ribó M ym. Impact of admission hyperglycemia on stroke outcome after thrombolysis: risk stratification in relation to time to reperfusion. Stroke 2004;35:2493-8 »10, «Shimoyama T, Shibazaki K, Kimura K ym. Admission hyperglycemia causes infarct volume expansion in patients with ICA or MCA occlusion: association of collateral grade on conventional angiography. Eur J»11, «Luitse MJ, van Seeters T, Horsch AD ym. Admission hyperglycaemia and cerebral perfusion deficits in acute ischaemic stroke. Cerebrovasc Dis 2013;35:163-7 »12.
Toisaalta on tutkimusnäyttöä, että nimenomaan ei-diabeetikoilla hyperglykemia yhdistyy heikentyneeseen funktionaaliseen ennusteeseen «Shimoyama T, Kimura K, Uemura J ym. Elevated glucose level adversely affects infarct volume growth and neurological deterioration in non-diabetic stroke patients, but not diabetic stroke patients. Eur»13, «Hu GC, Hsieh SF, Chen YM ym. Relationship of initial glucose level and all-cause death in patients with ischaemic stroke: the roles of diabetes mellitus and glycated hemoglobin level. Eur J Neurol 201»14, «Hu GC, Hsieh SF, Chen YM ym. The prognostic roles of initial glucose level and functional outcomes in patients with ischemic stroke: difference between diabetic and nondiabetic patients. Disabil Rehab»15.
Hyperglykemia liittyy huonoon ennusteeseen potilailla, joilla liuotushoidon jälkeen todetaan rekanalisaatio. Lisäksi korkea veren glukoosipitoisuus näyttää heikentävän rekanalisaatioon johtaneen liuotushoidon edullista vaikutusta potilaan oireiden korjautumiseen «Alvarez-Sabín J, Molina CA, Ribó M ym. Impact of admission hyperglycemia on stroke outcome after thrombolysis: risk stratification in relation to time to reperfusion. Stroke 2004;35:2493-8 »10.
Akuuttivaiheen hyperglykemian (yli 8,0 mmol/l, eräiden tutkimusten mukaan jopa yli 6,1 mmol/l) on myös osoitettu olevan itsenäinen huonon ennusteen riskitekijä ei-diabeetikoilla iästä, AVH:n vaiheusasteesta ja etiologiasta riippumatta «Broderick JP, Hagen T, Brott T ym. Hyperglycemia and hemorrhagic transformation of cerebral infarcts. Stroke 1995;26:484-7 »4, «Jørgensen H, Nakayama H, Raaschou HO ym. Stroke in patients with diabetes. The Copenhagen Stroke Study. Stroke 1994;25:1977-84 »9.
Toisaalta on todettu, että tulovaiheen jälkeinen hyperglykemia assosioituu suurempaan kuoleman riskiin vuoden seuranta-aikana, mutta verensokeritason normalisoituminen tulovaiheen jälkeen assosioituu pienempään kuolleisuuteen «Dziedzic T, Pera J, Trabka-Janik E ym. The impact of postadmission glycemia on stroke outcome: Glucose normalisation is associated with better survival. Atherosclerosis 2010;211:584-8 »6, «Putaala J, Sairanen T, Meretoja A ym. Post-thrombolytic hyperglycemia and 3-month outcome in acute ischemic stroke. Cerebrovasc Dis 2011;31:83-92 »7, «Bellolio MF, Gilmore RM, Ganti L. Insulin for glycaemic control in acute ischaemic stroke. Cochrane Database Syst Rev 2014;:CD005346 »16.
Lyhytvaikutteista insuliinia suositellaan käytettäväksi peroraalisten diabeteslääkkeiden sijasta, kunnes potilas pystyy syömään «European Stroke Organisation (ESO) Executive Committee, ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008;25:457-507 »17, «Jauch EC, Saver JL, Adams HP Jr ym. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American St»18.
Ks. myös näytönastekatsaus Akuuttivaiheen glukoositason hoidosta «Suonensisäisellä hyperglykemian insuliinihoidolla ei ole osoitettu voitavan parantaa aivoinfarktipotilaan toipumisennustetta verrattuna tavanomaiseen hyperglykemian hoitoon.»C.

Kirjallisuutta

Bruno A, Biller J, Adams HP Jr ym. Acute blood glucose level and outcome from ischemic stroke. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. Neurology 1999;52:280-4 «PMID: 9932944»PubMed
Bruno A, Levine SR, Frankel MR ym. Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial. Neurology 2002;59:669-74 «PMID: 12221155»PubMed
Baird TA, Parsons MW, Phan T ym. Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome. Stroke 2003;34:2208-14 «PMID: 12893952»PubMed
Broderick JP, Hagen T, Brott T ym. Hyperglycemia and hemorrhagic transformation of cerebral infarcts. Stroke 1995;26:484-7 «PMID: 7886729»PubMed
Dave JA, Engel ME, Freercks R ym. Abnormal glucose metabolism in non-diabetic patients presenting with an acute stroke: prospective study and systematic review. QJM 2010;103:495-503 «PMID: 20430755»PubMed
Dziedzic T, Pera J, Trabka-Janik E ym. The impact of postadmission glycemia on stroke outcome: Glucose normalisation is associated with better survival. Atherosclerosis 2010;211:584-8 «PMID: 20303492»PubMed
Putaala J, Sairanen T, Meretoja A ym. Post-thrombolytic hyperglycemia and 3-month outcome in acute ischemic stroke. Cerebrovasc Dis 2011;31:83-92 «PMID: 21079397»PubMed
Weir CJ, Murray GD, Dyker AG ym. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study. BMJ 1997;314:1303-6 «PMID: 9158464»PubMed
Jørgensen H, Nakayama H, Raaschou HO ym. Stroke in patients with diabetes. The Copenhagen Stroke Study. Stroke 1994;25:1977-84 «PMID: 8091441»PubMed
Alvarez-Sabín J, Molina CA, Ribó M ym. Impact of admission hyperglycemia on stroke outcome after thrombolysis: risk stratification in relation to time to reperfusion. Stroke 2004;35:2493-8 «PMID: 15472110»PubMed
Shimoyama T, Shibazaki K, Kimura K ym. Admission hyperglycemia causes infarct volume expansion in patients with ICA or MCA occlusion: association of collateral grade on conventional angiography. Eur J Neurol 2013;20:109-16 «PMID: 22747888»PubMed
Luitse MJ, van Seeters T, Horsch AD ym. Admission hyperglycaemia and cerebral perfusion deficits in acute ischaemic stroke. Cerebrovasc Dis 2013;35:163-7 «PMID: 23429063»PubMed
Shimoyama T, Kimura K, Uemura J ym. Elevated glucose level adversely affects infarct volume growth and neurological deterioration in non-diabetic stroke patients, but not diabetic stroke patients. Eur J Neurol 2014;21:402-10 «PMID: 24517878»PubMed
Hu GC, Hsieh SF, Chen YM ym. Relationship of initial glucose level and all-cause death in patients with ischaemic stroke: the roles of diabetes mellitus and glycated hemoglobin level. Eur J Neurol 2012;19:884-91 «PMID: 22289016»PubMed
Hu GC, Hsieh SF, Chen YM ym. The prognostic roles of initial glucose level and functional outcomes in patients with ischemic stroke: difference between diabetic and nondiabetic patients. Disabil Rehabil 2012;34:34-9 «PMID: 21962153»PubMed
Bellolio MF, Gilmore RM, Ganti L. Insulin for glycaemic control in acute ischaemic stroke. Cochrane Database Syst Rev 2014;:CD005346 «PMID: 24453023»PubMed
European Stroke Organisation (ESO) Executive Committee, ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008;25:457-507 «PMID: 18477843»PubMed
Jauch EC, Saver JL, Adams HP Jr ym. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947 «PMID: 23370205»PubMed