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Nervenheilkunde 2003; 22(01): 11-14
DOI: 10.1055/s-0038-1624363
Original- und Übersichtsarbeiten/Original and Review Articles
Schattauer GmbH

Hypoglykämische Enzephalopathie

Hypoglycemic encephalopathy
J. G. Heckmann
1   Neurologische Klinik und Poliklinik der Universität Erlangen-Nürnberg
,
C. J. G. Lang
1   Neurologische Klinik und Poliklinik der Universität Erlangen-Nürnberg
,
B. Neundörfer
1   Neurologische Klinik und Poliklinik der Universität Erlangen-Nürnberg
› Author Affiliations
Further Information

Publication History

Publication Date:
15 January 2018 (online)

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Zusammenfassung

Eine Hypoglykämie liegt bei einem Blutzuckerspiegel <40 mg/100 ml vor und kann durch zahlreiche Ursachen hervorgerufen werden, meist im Zusammenhang mit inadäquater Insulingabe und/oder unzureichender Nahrungsaufnahme beim Patienten mit insulinpflichtigem Diabetes mellitus. Als weitere Faktoren sind der endogene Insulinüberschuss (Insulinom), die Hormondefizienz (GH, Kortisol), der Alkoholmissbrauch, die Medikamenteneinnahme (Amphetamine u.a.), Leber-, Nieren-und Stoffwechselerkrankungen zu berücksichtigen.

Bei anhaltender Hypoglykämie kommt es neurophysiologisch zu einer verminderten und schließlich fehlenden hirnelektrischen EEG-und evozierten Potenzial-Aktivität sowie zu epileptischen Entladungen. Pathomorphologisch finden sich Mikrovakuolationen, Schrumpfungen und Zellnekrosen sowohl an Neuronen als auch an Gliazellen. Biochemisch tritt bei Hypoglykämie eine eskalierende Schädigungskaskade mit Anstieg des intrazellulären Kalziums und Freisetzung freier Radikale sowie destruktiver Enzyme auf. Die Oxygenation und der zerebrale Blutfluss bleiben jedoch erhalten. Klinisch werden bei Hypoglykämie delirante Syndrome, epileptische Anfälle, transiente neurologische Symptome, anhaltende fokal-neurologische Zeichen und in schweren Fällen Stupor und Koma beobachtet, die z.T. in schwere neurologische Defektsyndrome (akinetischer Mutismus, apallisches Syndrom) einmünden. Aufgrund der erheblichen Schädigungspotenz von Hypoglykämien kommt der Prophylaxe große Bedeutung zu. Bei Risikopatienten ist ein intensives Hypoglykämiewahrnehmungstraining sinnvoll.

Summary

Hypoglycemia is defined as a glucose level of <40 mg/100 ml and is caused by a number of clinical conditions. Mostly it is associated with inadequate insuline treatment and/or insufficient caloric intake in diabetics. Occasionally there are other causes such as insulin overdose (insulinoma), hormone deficiency (cortisole, GH), alcohol abuse, drugs (amphetamine, etc.), hepatic and renal diseases, genetic metabolic disorders etc.

Neurophysiologically prolonged and severe hypoglycemia leads to a diminished and finally flat electroencephalographic and evoked potential activity as well as epileptic discharges. Neuropathological studies revealed neuronal and glial microvacuolations, shrinkage and cell necrosis. In biochemical studies hypoglycemia induced a cascade of damage including a dramatic increase in intracellular calcium, release of free radicals and autodestructive enzymes. In contrast, the cerebral oxygenation and blood flow were preserved. In clinical practice hypoglycemia manifests itself as delirium, epileptic seizures, transient neurological signs and symptoms, persistent focal disorders and in extreme cases as stupor or coma. If the patients survive, marked neurological defect syndromes such as akinetic mutism or even persistent vegetative state may occur.

Hypoglycemia should be quickly diagnosed and treated accordingly. In patients with risk of hypoglycemia hypoglycemia awareness education is advisable.

Schlüsselwörter

Glukose - Diabetes mellitus - Hypoglykämie - Enzephalopathie

Keywords

Glucose - diabetes mellitus - hypoglycemia - encephalopathy
 

  • Literatur

  • 1 Alix M. Diabetes in the elderly. Presse Med 2000; 29: 2150-5.
    PubMedGoogle Scholar
  • 2 Allicar MP, Megas F, Houzard S, Baroux A, Le Thai F, Augendre-Ferrante B. Frequency and costs of hospital stays for hypoglycemia in France in 1995. Presse Med 2000; 29: 657-61.
    PubMedGoogle Scholar
  • 3 Auer RN, Siesjö BK. Biological differences between ischemia, hypoglycemia and epilepsy. Ann Neurol 1988; 24: 699-707.
    CrossrefPubMedGoogle Scholar
  • 4 Auer RN, Siesjö BK. Hypoglycaemia: brain neurochemistry and neuropathology. Baillieres Clin Endocrinol Metab 1993; 07: 611-25.
    CrossrefPubMedGoogle Scholar
  • 5 Barkovich AJ, Ali FA, Rowley HA, Bass N. Imaging patterns of neonatal hypoglycemia. Am J Neuroradiol 1998; 19: 523-8.
    PubMedGoogle Scholar
  • 6 Basile F. The increasing prevalence of diabetes and its economic burden. Am J Manag Care 2000; 06: 1077-81.
    Google Scholar
  • 7 Bolli GB. Hypoglycaemia unawareness. Diabetes Metab 1997; (Suppl) 03: 29-35.
    Google Scholar
  • 8 Boyle PJ, Nagy RJ, O´Connor AM, Kempers SF, Yeo RA, Qualls C. Adaption of brain glucose uptake following recurrent hypoglycemia. Proc Natl Acad Sci USA 1994; 91: 9352-6.
    CrossrefPubMedGoogle Scholar
  • 9 Cooper AJ. Attempted suicide using insulin by a non diabetic: a case study demonstrating the acute and chronic consequences of profound hypoglycemia. Can J Psychiatry 1994; 39: 103-7.
    CrossrefPubMedGoogle Scholar
  • 10 Davis SN, Shavers C, Mosqueda-Garcia R, Costa F. Effects of differing antecedent hypoglycemia on subsequent counterregulation in normal humans. Diabetes 1997; 46: 1328-35.
    CrossrefPubMedGoogle Scholar
  • 11 Davis SN, Shavers C, Costa F. Gender-related differences in counterregulatory responses to antecedent hypoglycemia in normal humans. J Clin Endocrinol Metabol 2000; 85: 2148-57.
    PubMedGoogle Scholar
  • 12 Davis SN, Mann S, Galassetti P, Neill RA, Tate D, Ertl AC, Costa F. Effects of differing durations of antecedent hypoglycemia on counterregulatory responses to subsequent hypoglycemia in normal humans. Diabetes 2000; 49: 1897-903.
    CrossrefPubMedGoogle Scholar
  • 13 Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulindependent diabetes mellitus. N Engl J Med 1993; 329: 977-86.
    CrossrefPubMedGoogle Scholar
  • 14 Dolinak D, Smith C, Graham DL. Hypoglycemia is a cause of axonal injury. Neuropathol Appl Neurobiol 2000; 26: 448-53.
    CrossrefPubMedGoogle Scholar
  • 15 Elman I, Sokoloff L, Adler CM, Weisenfeld N, Beier A. The effects of pharmacological doses of 2-deoxyglucose on cerebral blood flow in healthy volunteers. Brain Res 1999; 815: 243-9.
    CrossrefPubMedGoogle Scholar
  • 16 Fehm-Wolfsdorf G. Hypoglykämien erkennen und vermeiden lernen mit dem Blutglukose-Wahrnehmungstraining (BGAT). Med Klin 2001; 96: 65 (Abstract).
    Google Scholar
  • 17 Fujioka M, Okuchi K, Hiramatsu KI, Sakaki T, Sakaguchi S, Ishii Y. Specific changes in human brain after hypoglycemic injury. Stroke 1997; 28: 584-7.
    CrossrefPubMedGoogle Scholar
  • 18 Heckmann JG, Dietrich W, Hohenberger W, Klein P, Hanke B, Neundörfer B. Hypoglycemic sensorimotor polyneuropathy associated with insulinoma. Muscle Nerve 2000; 23: 1891-4.
    CrossrefPubMedGoogle Scholar
  • 19 Heckmann JG, Lang CJG, Neundörfer B. Hypoglykämische Schäden am zentralen und peripheren Nervensystem. Diabetes & Stoffwechsel 2001; 10: 270-6.
    Google Scholar
  • 20 Hirschmüller A. Die Insulinkrampfbehandlung der Schizophrenie oder: Wie erweist sich die Unwirksamkeit einer Therapiemethode. Nervenheilkunde 2001; 20: 217-26.
    Google Scholar
  • 21 Kaschka W, Negele-Arnetsberger J, Lang CJG, Feistel H, Huk WJ. Demenz-Syndrom nach Suizidversuch mit Glibenclamid. MMW 1989; 131: 745-8.
    Google Scholar
  • 22 Kern W, Kerner W, Pietrowsky R, Fehm HL, Born J. Effects of insulin and hypoglycemia on the auditory brain stem response in humans. J Neurophysiol 1994; 72: 678-83.
    CrossrefPubMedGoogle Scholar
  • 23 Mehnert H. Typ-2-Diabetes auf dem Weg zu einer weltweiten Epidemie. Innovartis 2001; 01: 5-7.
    Google Scholar
  • 24 Mühlhauser I, Berger M, Sonnenberg G, Koch J, Jorgens V, Schernthaner G, Scholz V, Padagogin D. Incidence and management of severe hypoglycemia in 434 adults with insulin-dependent diabetes mellitus. Diabetes Care 1985; 08: 268-73.
    CrossrefPubMedGoogle Scholar
  • 25 Nehlig A. Cerebral energy metabolism, glucose transport and blood flow: changes with maturation and adaption to hypoglycaemia. Diabetes Metab 1997; 23: 18-29.
    PubMedGoogle Scholar
  • 26 Shimada A, Morita T, Ikeda N, Torii S, Haruna H. Hypoglycaemic brain lesions in a dog with insulinoma. J Comp Pathol 2000; 122: 67-71.
    CrossrefPubMedGoogle Scholar
  • 27 Siesjö BK. Hypoglycemia, brain metabolism and brain damage. Diabetes Metab Rev 1988; 04: 113-44.
    CrossrefPubMedGoogle Scholar
  • 28 Standl E. Patientenschulung – Anleitung zum „Self-Management”. Innovartis 2001; 01: 27-9.
    Google Scholar
  • 29 Strachan MW, Abraha HD, Sherwood RA, Lammie GA, Deary IJ, Ewing FM, Perros P, Frier BM. Evaluation of serum markers of neuronal damage following severe hypoglycemia in adults with insulin-treated diabetes mellitus. Diabetes Metab Res Rev 1999; 15: 5-12.
    CrossrefPubMedGoogle Scholar
  • 30 ter Braak EW, Appelman AM, van de Laak M, Stolk RP, van Haeften TW, Erkelens DW. Clinical characteristics of type 1 diabetic patients with and without hypoglycemia. Diabetes Care 2000; 23: 1467-71.
    CrossrefPubMedGoogle Scholar
  • 31 Tunbridge WM. Factors contributing to deaths of diabetics under fifty years of age. On behalf of the medical services study group and british diabetic association. Lancet 1981; 8246: 569-72.
    Google Scholar
  • 32 Vannucci RC, Vannucci SJ. Glucose metabolism in the developing brain. Semin Perinatol 2000; 24: 107-15.
    CrossrefPubMedGoogle Scholar
  • 33 Vauzelle-Kervroedan F, Delcourt C, Forhan A, Jougla E, Hatton F, Papoz L. Analysis of mortality in French diabetic patients from death certificates: a comparative study. Diabetes Metab 1999; 25: 404-11.
    PubMedGoogle Scholar
  • 34 Wilkinson DS, Prockop LD. Hypoglycemia: effects on the central nervous system. In: Vinken PJ, Bruyn GW. (eds). Handbook of clinical neurology. Vol. 27. Amsterdam: North-Holland Publishing Company; 1976: 53-78.
    Google Scholar
  • 35 Young CB, DeRubais DA. Metabolic encephalopathies. In: Young GB, Ropper AH, Bolton CF. (eds). Coma and impaired consciousness. New York: McGraw-Hill; 1998: 307-92.
    Google Scholar