Neurocritical Care

, 11:151 | Cite as

Clinical Impact of Early Hyperglycemia During Acute Phase of Traumatic Brain Injury

Original Article



While tight glucose control has been widely adopted in the critical care setting, the optimal target glucose level following acute traumatic brain injury (TBI) remains debatable. This observational study was conducted to delineate the relationship between glucose levels and clinical outcomes during acute phase (first 5 days) of TBI.


We retrospectively identified 429 TBI patients admitted to the intensive care unit (ICU) from January 2005 to December 2006. Of those, 380 patients were retained for final analysis. Collected data included demographics, admission Glasgow Coma Scale (GCS), and APACHE II, glucose on admission and during the first 5 days of admission, and insulin use. Clinical outcomes included mortality, ICU, and hospital length of stay.


The overall hospital mortality was 13.2% (n = 50). Demographics were similar between survivor and nonsurvivor groups; however, nonsurvivors were older and had worse disease severity on admission. Nonsurvivors also had significantly higher glucose levels at admission and during the first 24 h of admission (P < 0.001). Based on the receiver operating characteristic (ROC) curve, admission and day-1 peak glucose were better predictors for mortality compared to hospital days 2–5 glucose levels, with day-1 peak glucose being the best predictor of mortality (AUC = 0.820). A Kaplan–Meier survival analysis also showed that patients with glucose <160 mg/dl during the first day of ICU admission had a significantly better survival rate compared to those with glucose ≥160 mg/dl (P < 0.001). Two glucose bands, <60 and ≥160 mg/dl, were identified to be associated with increased mortality irrespective of injury severity (OR = 1.130; 95% CI 1.034–1.235; P = 0.007; OR = 1.034; 95% CI 1.021–1.047, P < 0.001; respectively).


Findings from our study suggest a glucose level ≥160 mg/dl within the first 24 h of admission following TBI is associated with poor outcomes irrespective of severity of injury, and this presents a timeframe for which active therapeutic interventions may improve clinical outcomes. Prospective efficacy trials are needed to corroborate these findings.


Hyperglycemia Glucose Glucose control Traumatic brain injury Mortality 


  1. 1.
    Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke. 2001;32(10):2426–32. doi:10.1161/hs1001.096194.PubMedCrossRefGoogle Scholar
  2. 2.
    Young B, Ott L, Dempsey R, Haack D, Tibbs P. Relationship between admission hyperglycemia and neurologic outcome of severely brain-injured patients. Ann Surg. 1989;210(4):466–72. doi:10.1097/00000658-198910000-00007. discussion 472–3.PubMedCrossRefGoogle Scholar
  3. 3.
    Lam AM, Winn HR, Cullen BF, Sundling N. Hyperglycemia and neurological outcome in patients with head injury. J Neurosurg. 1991;75(4):545–51.PubMedCrossRefGoogle Scholar
  4. 4.
    Jeremitsky E, Omert L, Dunham CM, Protetch J, Rodriguez A. Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia, and hypoperfusion. J Trauma. 2003;54(2):312–9. doi:10.1097/01.TA.0000037876.37236.D6.PubMedCrossRefGoogle Scholar
  5. 5.
    Poungvarin N, Viriyavejakul A. Spontaneous supratentorial intracerebral haemorrhage: a prognostic study. J Med Assoc Thai. 1990;73(4):206–11.PubMedGoogle Scholar
  6. 6.
    Levetan CS. Effect of hyperglycemia on stroke outcomes. Endocr Pract. 2004;10(Suppl 2):34–9.PubMedGoogle Scholar
  7. 7.
    Lee TH, Ryu SJ, Chen ST. The prognostic value of blood glucose in patients with acute stroke. J Formos Med Assoc. 1991;90(5):465–70.PubMedGoogle Scholar
  8. 8.
    Jeremitsky E, Omert LA, Dunham CM, Wilberger J, Rodriguez A. The impact of hyperglycemia on patients with severe brain injury. J Trauma. 2005;58(1):47–50. doi:10.1097/01.TA.0000135158.42242.B1.PubMedCrossRefGoogle Scholar
  9. 9.
    Margulies DR, Hiatt JR, Vinson D Jr, Shabot MM. Relationship of hyperglycemia and severity of illness to neurologic outcome in head injury patients. Am Surg. 1994;60(6):387–90.PubMedGoogle Scholar
  10. 10.
    Rovlias A, Kotsou S. The influence of hyperglycemia on neurological outcome in patients with severe head injury. Neurosurgery. 2000;46(2):335–42. doi:10.1097/00006123-200002000-00015. discussion 342–3.PubMedCrossRefGoogle Scholar
  11. 11.
    Vespa P, Boonyaputthikul R, McArthur DL, et al. Intensive insulin therapy reduces microdialysis glucose values without altering glucose utilization or improving the lactate/pyruvate ratio after traumatic brain injury. Crit Care Med. 2006;34(3):850–6. doi:10.1097/01.CCM.0000201875.12245.6F.PubMedCrossRefGoogle Scholar
  12. 12.
    Adams HP Jr, Adams RJ, Brott T, et al. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke. 2003;34(4):1056–83. doi:10.1161/01.STR.0000064841.47697.22.PubMedCrossRefGoogle Scholar
  13. 13.
    Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24(Suppl 1):S1–106. doi:10.1089/neu.2006.0209.Google Scholar
  14. 14.
    Broderick J, Connolly S, Feldmann E, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007;38(6):2001–23. doi:10.1161/STROKEAHA.107.183689.PubMedCrossRefGoogle Scholar
  15. 15.
    van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345(19):1359–67. doi:10.1056/NEJMoa011300.PubMedCrossRefGoogle Scholar
  16. 16.
    Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008;358(2):125–39. doi:10.1056/NEJMoa070716.PubMedCrossRefGoogle Scholar
  17. 17.
    Bergsneider M, Hovda DA, Shalmon E, et al. Cerebral hyperglycolysis following severe traumatic brain injury in humans: a positron emission tomography study. J Neurosurg. 1997;86(2):241–51.PubMedCrossRefGoogle Scholar
  18. 18.
    Diringer MN. Is aggressive treatment of hyperglycemia for everyone? Crit Care Med. 2006;34(3):930–1. doi:10.1097/01.CCM.0000202433.99341.D6.PubMedCrossRefGoogle Scholar
  19. 19.
    Strong AJ, Boutelle MG, Vespa PM, Bullock MR, Bhatia R, Hashemi P. Treatment of critical care patients with substantial acute ischemic or traumatic brain injury. Crit Care Med. 2005;33(9):2147–9. doi:10.1097/01.CCM.0000179029.95415.51. author reply 2149.PubMedCrossRefGoogle Scholar
  20. 20.
    Vespa PM, McArthur D, O’Phelan K, et al. Persistently low extracellular glucose correlates with poor outcome 6 months after human traumatic brain injury despite a lack of increased lactate: a microdialysis study. J Cereb Blood Flow Metab. 2003;23(7):865–77. doi:10.1097/01.WCB.0000076701.45782.EF.PubMedCrossRefGoogle Scholar
  21. 21.
    Oddo M, Schmidt JM, Mayer SA, Chiolero RL. Glucose control after severe brain injury. Curr Opin Clin Nutr Metab Care. 2008;11(2):134–9. doi:10.1097/MCO.0b013e3282f37b43.PubMedCrossRefGoogle Scholar
  22. 22.
    Welsh FA, Ginsberg MD, Rieder W, Budd WW. Deleterious effect of glucose pretreatment on recovery from diffuse cerebral ischemia in the cat. II. Regional metabolite levels. Stroke. 1980;11(4):355–63.PubMedGoogle Scholar
  23. 23.
    Zygun DA, Steiner LA, Johnston AJ, et al. Hyperglycemia and brain tissue pH after traumatic brain injury. Neurosurgery. 2004;55(4):877–81. doi:10.1227/01.NEU.0000137658.14906.E4. discussion 882.PubMedCrossRefGoogle Scholar
  24. 24.
    Godoy DA, Pinero GR, Svampa S, Papa F, Di Napoli M. Hyperglycemia and short-term outcome in patients with spontaneous intracerebral hemorrhage. Neurocrit Care. 2008;9(2):217–29. doi:10.1007/s12028-008-9063-1.PubMedCrossRefGoogle Scholar
  25. 25.
    Abi-Saab WM, Maggs DG, Jones T, et al. Striking differences in glucose and lactate levels between brain extracellular fluid and plasma in conscious human subjects: effects of hyperglycemia and hypoglycemia. J Cereb Blood Flow Metab. 2002;22(3):271–9. doi:10.1097/00004647-200203000-00004.PubMedCrossRefGoogle Scholar
  26. 26.
    Hopwood SE, Parkin MC, Bezzina EL, Boutelle MG, Strong AJ. Transient changes in cortical glucose and lactate levels associated with peri-infarct depolarisations, studied with rapid-sampling microdialysis. J Cereb Blood Flow Metab. 2005;25(3):391–401. doi:10.1038/sj.jcbfm.9600050.PubMedCrossRefGoogle Scholar
  27. 27.
    Parkin M, Hopwood S, Jones DA, et al. Dynamic changes in brain glucose and lactate in pericontusional areas of the human cerebral cortex, monitored with rapid sampling on-line microdialysis: relationship with depolarisation-like events. J Cereb Blood Flow Metab. 2005;25(3):402–13. doi:10.1038/sj.jcbfm.9600051.PubMedCrossRefGoogle Scholar

Copyright information

© Humana Press Inc. 2009

Authors and Affiliations

  • Xi Liu-DeRyke
    • 1
  • Dave S. Collingridge
    • 2
  • James Orme
    • 3
  • Dean Roller
    • 4
  • John Zurasky
    • 4
  • Denise H. Rhoney
    • 5
  1. 1.Orlando Regional Medical CenterOrlandoUSA
  2. 2.Statistical Data Center, LDS HospitalSalt Lake CityUSA
  3. 3.Critical Care Medicine, LDS HospitalSalt Lake CityUSA
  4. 4.Neurovascular Medicine, LDS HospitalSalt Lake CityUSA
  5. 5.Eugene Applebaum College of Pharmacy and Health SciencesWayne State UniversityDetroitUSA

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