{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T17:58:19Z","timestamp":1790618299412,"version":"4.1.0"},"reference-count":45,"publisher":"MDPI AG","issue":"19","license":[{"start":{"date-parts":[[2026,9,27]],"date-time":"2026-09-27T00:00:00Z","timestamp":1790467200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background\/Objectives: The early postoperative stress hyperglycemia ratio (SHR) may capture acute glycemic stress relative to chronic glycemia, but its association with infection-related events after cranial neurosurgery remains uncertain. We evaluated these associations in critically ill patients after cranial neurosurgical procedures. Methods: We retrospectively analyzed 1408 adults in MIMIC-IV after eligible cranial neurosurgical procedures. SHR was calculated from the first serum glucose measurement 6\u201324 h after surgery and estimated average glucose was derived from HbA1c. Primary outcomes were electronic health record (EHR)-defined suspected infection, culture-positive infection from any qualifying specimen, Sepsis-3-defined sepsis, and an EHR-based septic shock proxy. The secondary outcome was 90-day mortality. Results: In fully adjusted models, each 0.1-unit increase in SHR was associated with suspected infection (OR 1.08, 95% CI 1.04\u20131.12), culture-positive infection (OR 1.05, 95% CI 1.01\u20131.09), Sepsis-3-defined sepsis (OR 1.07, 95% CI 1.03\u20131.11), and septic shock (OR 1.10, 95% CI 1.05\u20131.15). In nested analyses, each 1-SD increase in SHR was associated with 90-day mortality (OR 1.59, 95% CI 1.29\u20131.96). Associations persisted in 24-h lag analyses. Adding SHR yielded small, non-significant AUC increases but improved reclassification for Sepsis-3-defined sepsis and septic shock. Conclusions: Higher early postoperative SHR was associated with EHR-derived, all-source infection-related and sepsis-related events and 90-day mortality in a heterogeneous postoperative neurocritical care cohort. These findings do not establish that SHR predicts postoperative neurosurgical infection; prospective external validation is required before clinical use.<\/jats:p>","DOI":"10.3390\/jcm15197505","type":"journal-article","created":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T16:50:54Z","timestamp":1790614254000},"page":"7505","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Association of Postoperative Stress Hyperglycemia Ratio with Suspected Infection, Culture Positivity, Sepsis, and Septic Shock in 1408 Patients After Cranial Neurosurgery"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6691-0355","authenticated-orcid":false,"given":"Dong","family":"Tang","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, China"},{"name":"National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, China"},{"name":"Cerebrovascular Diseases Research Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, China"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1381-0355","authenticated-orcid":false,"given":"Tianxiang","family":"Huang","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, China"},{"name":"National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, China"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"methodology","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e800","DOI":"10.1016\/j.wneu.2024.02.133","article-title":"Incidence and Risk Factors of Surgical Site Infection After Cranial Surgery for Patients with Brain Tumors: A Systematic Review and Meta-Analysis","volume":"185","author":"Lee","year":"2024","journal-title":"World Neurosurg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1080\/02688697.2016.1253827","article-title":"Post-craniotomy intracranial infection in patients with brain tumors: A retrospective analysis of 5723 consecutive patients","volume":"31","author":"Shi","year":"2017","journal-title":"Br. J. Neurosurg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e123","DOI":"10.1016\/j.ajic.2017.06.009","article-title":"Risk factors of neurosurgical site infection after craniotomy: A systematic review and meta-analysis","volume":"45","author":"Fang","year":"2017","journal-title":"Am. J. Infect. Control"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"509","DOI":"10.3171\/2013.9.JNS13843","article-title":"Risk factors and outcomes associated with surgical site infections after craniotomy or craniectomy","volume":"120","author":"Chiang","year":"2014","journal-title":"J. Neurosurg."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Zhou, J., Luo, X.Y., Chen, G.Q., Li, H.L., Xu, M., Liu, S., Yang, Y.L., Shi, G., Zhou, J.X., and Zhang, L. (2022). Incidence, Risk Factors and Outcomes of Sepsis in Critically Ill Post-craniotomy Patients: A Single-Center Prospective Cohort Study. Front. Public Health, 10.","DOI":"10.3389\/fpubh.2022.895991"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1016\/j.jocn.2020.06.015","article-title":"Sepsis after elective neurosurgery: Incidence, outcomes, and predictive factors","volume":"78","author":"Pertsch","year":"2020","journal-title":"J. Clin. Neurosci."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1186\/s13613-019-0562-3","article-title":"Incidence and impact of sepsis on long-term outcomes after subarachnoid hemorrhage: A prospective observational study","volume":"9","author":"Goncalves","year":"2019","journal-title":"Ann. Intensive Care"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1798","DOI":"10.1016\/S0140-6736(09)60553-5","article-title":"Stress hyperglycaemia","volume":"373","author":"Dungan","year":"2009","journal-title":"Lancet"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"4490","DOI":"10.1210\/jc.2015-2660","article-title":"Relative Hyperglycemia, a Marker of Critical Illness: Introducing the Stress Hyperglycemia Ratio","volume":"100","author":"Roberts","year":"2015","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1624","DOI":"10.1097\/01.CCM.0000170106.61978.D8","article-title":"Acute hyperglycemia and the innate immune system: Clinical, cellular, and molecular aspects","volume":"33","author":"Turina","year":"2005","journal-title":"Crit. Care Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1016\/j.amjms.2015.11.011","article-title":"The Effect of Short-Term Hyperglycemia on the Innate Immune System","volume":"351","author":"Jafar","year":"2016","journal-title":"Am. J. Med. Sci."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1168","DOI":"10.1007\/s00125-024-06102-x","article-title":"Diabetes and infection: Review of the epidemiology, mechanisms and principles of treatment","volume":"67","author":"Holt","year":"2024","journal-title":"Diabetologia"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1016\/S2213-8587(19)30405-X","article-title":"Cerebral microvascular complications of type 2 diabetes: Stroke, cognitive dysfunction, and depression","volume":"8","author":"Sedaghat","year":"2020","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"20962","DOI":"10.1038\/s41598-024-71778-5","article-title":"Association between the stress hyperglycemia ratio and mortality in patients with acute ischemic stroke","volume":"14","author":"Zhang","year":"2024","journal-title":"Sci. Rep."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"412","DOI":"10.1186\/s12933-024-02454-1","article-title":"The association between the stress hyperglycaemia ratio and mortality in cardiovascular disease: A meta-analysis and systematic review","volume":"23","author":"Esdaile","year":"2024","journal-title":"Cardiovasc. Diabetol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1186\/s12933-024-02265-4","article-title":"Association between the stress hyperglycemia ratio and 28-day all-cause mortality in critically ill patients with sepsis: A retrospective cohort study and predictive model establishment based on machine learning","volume":"23","author":"Yan","year":"2024","journal-title":"Cardiovasc. Diabetol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"613","DOI":"10.1186\/s40001-025-02868-x","article-title":"Predictive performance of stress hyperglycemia ratio for poor prognosis in critically ill patients: A systematic review and dose-response meta-analysis","volume":"30","author":"Chen","year":"2025","journal-title":"Eur. J. Med. Res."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Xie, H., Hao, T., Qi, R., Zhang, L., An, Y., Jia, D., Wang, H., Niu, W., Han, X., and Sha, Y. (2025). Association between stress hyperglycemia ratio and all-cause mortality among ICU patients with sepsis: A systematic review and meta-analysis. Front. Med., 12.","DOI":"10.3389\/fmed.2025.1741993"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1097\/BOT.0b013e31825d60e5","article-title":"Stress-induced hyperglycemia as a risk factor for surgical-site infection in nondiabetic orthopedic trauma patients admitted to the intensive care unit","volume":"27","author":"Richards","year":"2013","journal-title":"J. Orthop. trauma."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1070","DOI":"10.1097\/TA.0000000000000177","article-title":"Stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries","volume":"76","author":"Richards","year":"2014","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e505","DOI":"10.1016\/j.wneu.2023.03.132","article-title":"Association of Preoperative Glycated Hemoglobin and Early Postoperative Infections After Elective Craniotomy: A Retrospective Cohort Study","volume":"175","author":"Kulikov","year":"2023","journal-title":"World Neurosurg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"801","DOI":"10.1001\/jama.2016.0287","article-title":"The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)","volume":"315","author":"Singer","year":"2016","journal-title":"JAMA"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1038\/s41597-022-01899-x","article-title":"MIMIC-IV, a freely accessible electronic health record dataset","volume":"10","author":"Johnson","year":"2023","journal-title":"Sci. Data"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1093\/bioinformatics\/btr597","article-title":"MissForest--Non-parametric missing value imputation for mixed-type data","volume":"28","author":"Stekhoven","year":"2012","journal-title":"Bioinformatics"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1186\/s12933-023-02005-0","article-title":"Prognostic significance of the stress hyperglycemia ratio in critically ill patients","volume":"22","author":"Li","year":"2023","journal-title":"Cardiovasc. Diabetol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"762","DOI":"10.1001\/jama.2016.0288","article-title":"Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)","volume":"315","author":"Seymour","year":"2016","journal-title":"JAMA"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1082","DOI":"10.1213\/ANE.0000000000005912","article-title":"Severe Intraoperative Hyperglycemia and Infectious Complications After Elective Brain Neurosurgical Procedures: Prospective Observational Study","volume":"135","author":"Kulikov","year":"2022","journal-title":"Anesth. Analg."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1016\/j.jocn.2024.04.031","article-title":"Implementation of perioperative blood glucose monitoring and insulin infusion protocol can decrease postoperative infection rate in diabetic patients undergoing elective craniotomy: An observational study","volume":"124","author":"Kulikov","year":"2024","journal-title":"J. Clin. Neurosci."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1016\/j.jocn.2021.08.024","article-title":"The impact of poor post-operative glucose control on neurosurgical surgical site infections (SSI)","volume":"93","author":"Weber","year":"2021","journal-title":"J. Clin. Neurosci."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1093\/neuros\/nyz405","article-title":"Persistent Postoperative Hyperglycemia as a Risk Factor for Operative Treatment of Deep Wound Infection After Spine Surgery","volume":"87","author":"Pennington","year":"2020","journal-title":"Neurosurgery"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"106100","DOI":"10.1016\/j.clineuro.2020.106100","article-title":"Post-operative hyperglycemia and its association with surgical site infection after instrumented spinal fusion","volume":"197","author":"Upadhyaya","year":"2020","journal-title":"Clin. Neurol. Neurosurg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1007\/s00776-013-0518-7","article-title":"High preoperative hemoglobin A1c is a risk factor for surgical site infection after posterior thoracic and lumbar spinal instrumentation surgery","volume":"19","author":"Hikata","year":"2014","journal-title":"J. Orthop. Sci."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1100","DOI":"10.1016\/j.spinee.2017.03.017","article-title":"Perioperative hemoglobin A1c as a predictor of deep infection following single-level lumbar decompression in patients with diabetes","volume":"17","author":"Cancienne","year":"2017","journal-title":"Spine J."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"408","DOI":"10.2337\/dc15-1817","article-title":"Diabetes and the Association of Postoperative Hyperglycemia with Clinical and Economic Outcomes in Cardiac Surgery","volume":"39","author":"Greco","year":"2016","journal-title":"Diabetes Care"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1177\/1457496917731190","article-title":"Hyperglycemic Episodes Are Associated with Postoperative Infections After Cardiac Surgery","volume":"107","author":"Khan","year":"2018","journal-title":"Scand. J. Surg."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"e673","DOI":"10.1097\/CCM.0000000000004968","article-title":"Determining the Electronic Signature of Infection in Electronic Health Record Data","volume":"49","author":"Churpek","year":"2021","journal-title":"Crit. Care Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1805","DOI":"10.1097\/CCM.0000000000002648","article-title":"Investigating the Impact of Different Suspicion of Infection Criteria on the Accuracy of Quick Sepsis-Related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores","volume":"45","author":"Churpek","year":"2017","journal-title":"Crit. Care Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"973","DOI":"10.1007\/s00134-014-3287-7","article-title":"Dysglycaemia in the critically ill and the interaction of chronic and acute glycaemia with mortality","volume":"40","author":"Plummer","year":"2014","journal-title":"Intensive Care Med."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"21","DOI":"10.4158\/EP.10.S2.21","article-title":"Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: The Portland Diabetic Project","volume":"10","author":"Furnary","year":"2004","journal-title":"Endocr. Pract."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"203","DOI":"10.1016\/j.ecl.2017.10.005","article-title":"Perioperative Management of Hyperglycemia and Diabetes in Cardiac Surgery Patients","volume":"47","author":"Galindo","year":"2018","journal-title":"Endocrinol. Metab. Clin. N. Am."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"547","DOI":"10.1097\/ALN.0000000000001515","article-title":"Perioperative Hyperglycemia Management: An Update","volume":"126","author":"Duggan","year":"2017","journal-title":"Anesthesiology"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"242","DOI":"10.1016\/j.bja.2023.02.039","article-title":"Current practice in the perioperative management of patients with diabetes mellitus: A narrative review","volume":"131","author":"Crowley","year":"2023","journal-title":"Br. J. Anaesth."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1283","DOI":"10.1056\/NEJMoa0810625","article-title":"Intensive versus conventional glucose control in critically ill patients","volume":"360","author":"Finfer","year":"2009","journal-title":"N. Engl. J. Med."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1227\/NEU.0000000000001432","article-title":"Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition","volume":"80","author":"Carney","year":"2017","journal-title":"Neurosurgery"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"388","DOI":"10.1007\/s11606-013-2595-x","article-title":"Pitfalls in hemoglobin A1c measurement: When results may be misleading","volume":"29","author":"Radin","year":"2014","journal-title":"J. Gen. Intern. Med."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7505\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T17:16:52Z","timestamp":1790615812000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7505"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,27]]},"references-count":45,"journal-issue":{"issue":"19","published-online":{"date-parts":[[2026,10]]}},"alternative-id":["jcm15197505"],"URL":"https:\/\/doi.org\/10.3390\/jcm15197505","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,27]]}}}