Quinn T J, Lees K R
Division of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
Cerebrovasc Dis. 2009;27 Suppl 1:148-55. doi: 10.1159/000200453. Epub 2009 Apr 3.
Diabetes is common amongst patients with stroke and is associated with poorer outcome. Post-stroke hyperglycaemia is also recognised in up to half of the patients, and is independently associated with adverse sequelae: both increased mortality and poorer functional outcomes. Neither the aetiology nor the pathophysiology of such hyperglycaemia is fully understood. Both direct neurological toxicity and systemic consequences are postulated to occur. A distinction between occult diabetes and non-diabetic hyperglycaemia seems important as prognosis and effect of intervention differ in these two groups. The optimal management of the milder forms of hyperglycaemia associated with acute stroke is unknown. Randomised trial data remain limited but presently offer no strong support for aggressive intervention in stroke, though in other critical illness settings tight control of blood sugar appears beneficial. Studies based in coronary care and high dependency units have shown a possible beneficial effect of insulin, but evidence for intervention in acute stroke is at best limited. However, if glucose management is to be undertaken, this should be instituted while there is still salvageable tissue and the glucose reduction must be substantial. Intravenous insulin may be more effective than glucose-potassium-insulin infusion. Both interventions carry a risk of hypoglycaemia and any proposed intervention must balance safety, convenience and glycaemic control. Until further trial data are available, consensus guidelines may be followed, which are generally conservative for blood glucose levels below 10 mM (180 mg/dl).
糖尿病在中风患者中很常见，且与较差的预后相关。高达一半的中风患者也会出现中风后高血糖，其与不良后遗症独立相关，包括死亡率增加和功能预后较差。这种高血糖的病因和病理生理学尚未完全明确。推测其会出现直接神经毒性和全身影响。隐匿性糖尿病和非糖尿病性高血糖之间的区分似乎很重要，因为这两组患者的预后和干预效果不同。与急性中风相关的轻度高血糖的最佳管理方法尚不清楚。随机试验数据仍然有限，目前没有强有力的证据支持对中风进行积极干预，尽管在其他危重病情况下严格控制血糖似乎有益。基于冠心病监护病房和高依赖病房的研究表明胰岛素可能有有益作用，但对急性中风进行干预的证据充其量是有限的。然而，如果要进行血糖管理，应该在仍有可挽救组织时进行，并且血糖降低幅度必须足够大。静脉注射胰岛素可能比葡萄糖 - 钾 - 胰岛素输注更有效。两种干预措施都有低血糖风险，任何提议的干预都必须在安全性、便利性和血糖控制之间取得平衡。在获得更多试验数据之前，可以遵循共识指南，对于血糖水平低于10 mM（180 mg/dl）的情况，这些指南通常较为保守。
