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Article(id=1198202431805944361, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198202427301265552, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.1556.2024.0506, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1700668800000, receivedDateStr=2023-11-23, revisedDate=null, revisedDateStr=null, acceptedDate=1708185600000, acceptedDateStr=2024-02-18, onlineDate=1763603321266, onlineDateStr=2025-11-20, pubDate=1730044800000, pubDateStr=2024-10-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1763603321266, onlineIssueDateStr=2025-11-20, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1763603321266, creator=13701087609, updateTime=1763603321266, updator=13701087609, issue=Issue{id=1198202427301265552, tenantId=1146029695717560320, journalId=1189873630562394117, year='2024', volume='49', issue='10', pageStart='1099', pageEnd='1220', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1763603320193, creator=13701087609, updateTime=1763603941762, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1198205034396746241, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198202427301265552, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1198205034396746242, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198202427301265552, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=1117, endPage=1122, ext={EN=ArticleExt(id=1198202432024048173, articleId=1198202431805944361, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Analysis of influencing factors of perioperative ischemic stroke in non-cardiac and non-neurosurgical surgeries, columnId=1198202428035268754, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Special Issue on Mechanisms and Protective Strategies of Perioperative Organ Injury Ⅱ, runingTitle=null, highlight=null, articleAbstract=

Objective To explore the incidence and risk factors of perioperative ischemic stroke in non-cardiac and non-neurosurgical surgeries and its correlation with preoperative risk assessment of cerebrovascular events, so as to guide perioperative risk management. Methods A retrospective study was conducted on 40 patients aged ≥18 years who underwent non-cardiac and non-neurosurgical surgeries and experienced perioperative ischemic stroke in the First Affiliated Hospital of Henan University of Science and Technology from January 2015 to January 2022, forming the stroke group. A control group of 160 patients without perioperative ischemic stroke was selected in a 1:4 case-control ratio, matched for gender, age, date of operation, and the surgeon. Clinical data and preoperative risk assessment of cerebrovascular events (including the single or combined application of head CT/MRI, transcranial Doppler ultrasound, carotid ultrasound, and neurological consultation) of the two groups of patients were collected and statistically analyzed. Multiple logistic regression analysis was used to identify risk factors associated with perioperative ischemic stroke. Results The incidence of perioperative ischemic stroke was 0.042%. Multiple logistic analysis results showed that hypertension (OR=7.858, 95%CI 2.175-28.388, P=0.002), hyperlipidemia (OR=4.457, 95%CI 1.320-15.049, P=0.016), renal insufficiency (OR=8.277, 95%CI 1.480-46.282, P=0.016), and intraoperative hypotension (OR=3.862, 95%CI 1.211-12.317, P=0.022) were independent risk factors for perioperative ischemic stroke in non-cardiac and non-neurological surgeries; preoperative cerebrovascular risk assessment (OR=0.130, 95%CI 0.031-0.542, P=0.005) was a protective factor against it. Conclusions The incidence of perioperative ischemic stroke in non-cardiac and non-neurosurgical surgery is low but has a poor prognosis. Hypertension, hyperlipidemia, renal insufficiency, and postoperative hypotension are risk factors for perioperative ischemic stroke, while preoperative cerebrovascular event risk assessment is beneficial to reducing its incidence.

, correspAuthors=Qi-Zhi Fu, authorNote=null, correspAuthorsNote=
E-mail:
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目的 探讨非心脏非神经外科手术围手术期缺血性卒中的发病率、危险因素及其与术前脑血管事件风险评估的相关性，以指导围手术期风险管理。方法 回顾性选取2015年1月－2022年1月在河南科技大学第一附属医院接受非心脏非神经外科手术、发生围手术期缺血性卒中、年龄≥18岁的40例患者作为卒中组；按照性别、年龄、手术日期、手术医师匹配，病例比1:4，选取160例未发生围手术期缺血性卒中的患者作为对照组。收集两组患者的临床资料及术前脑血管事件风险评估情况(包括单独或联合应用头颅CT/MRI、经颅多普勒超声、颈动脉超声、神经科会诊)进行统计分析。采用多因素logistic回归分析筛选围手术期缺血性卒中的危险因素。结果 围手术期缺血性卒中的发生率为0.042%。多因素logistic回归分析结果显示，高血压(OR=7.858，95%CI 2.175~28.388，P=0.002)、高脂血症(OR=4.457，95%CI 1.320~15.049，P=0.016)、肾功能不全(OR=8.277，95%CI 1.480~46.282，P=0.016)、术中低血压(OR=3.862，95%CI 1.211~12.317，P=0.022)是非心脏非神经外科手术围手术期缺血性卒中的独立危险因素；术前脑血管事件风险评估(OR=0.130，95%CI 0.031~0.542，P=0.005)是非心脏非神经外科手术围手术期缺血性卒中的保护因素。结论 围手术期缺血性卒中的发生率较低，但预后较差；其危险因素有高血压、高脂血症、肾功能不全和术中低血压，术前脑血管事件风险评估有利于降低其发生率。

, correspAuthors=富奇志, authorNote=null, correspAuthorsNote=
富奇志，E-mail：
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柏亚真，硕士研究生，主要从事脑血管疾病的临床与基础研究

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柏亚真，硕士研究生，主要从事脑血管疾病的临床与基础研究

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柏亚真，硕士研究生，主要从事脑血管疾病的临床与基础研究

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Anesthesiology, 2012. 116(3): 658-664., articleTitle=Intraoperative hypotension and perioperative ischemic stroke after general surgery: a nested case-control study, refAbstract=null), Reference(id=1198563932181984062, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202431805944361, doi=null, pmid=null, pmcid=null, year=2021, volume=35, issue=2, pageStart=246, pageEnd=253, url=null, language=null, rfNumber=[13], rfOrder=12, authorNames=Mazzeffi M, Chow JH, Anders M, journalName=J Anesth, refType=null, unstructuredReference=Mazzeffi M, Chow JH, Anders M, et al. Intraoperative hypotension and perioperative acute ischemic stroke in patients having major elective non-cardiovascular non-neurological surgery[J]. 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Update on preoperative evaluation and optimisation[J]. Indian J Anaesth, 2023, 67(1): 39-47., articleTitle=Update on preoperative evaluation and optimisation, refAbstract=null), Reference(id=1198563932718854982, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202431805944361, doi=null, pmid=null, pmcid=null, year=2022, volume=31, issue=8, pageStart=106584, pageEnd=null, url=null, language=null, rfNumber=[21], rfOrder=20, authorNames=Komatsu K, Mikami T, Kimura Y, journalName=J Stroke Cerebrovasc Dis, refType=null, unstructuredReference=Komatsu K, Mikami T, Kimura Y, et al. Validity of preoperative screening before open-heart surgery in reduction of perioperative ischemic stroke[J]. 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General data of 40 patients with perioperative ischemic stroke in non-cardiac and non-neurosurgical surgeries

, figureFileSmall=null, figureFileBig=null, tableContent=
指标 例(%)
术后发病时间(d)
0~3 25(62.5)
4~7 10(25.0)
8~21 5(12.5)
梗死部位
前循环 23(57.5)
后循环 8(20.0)
前循环+后循环 9(22.5)
首发症状
急性肢体无力/麻木 24(60.0)
言语问题 6(15.0)
意识障碍 18(45.0)
面瘫 2(5.0)
其他 2(5.0)
出院结局(mRS评分)
0分 5(12.5)
1分 13(32.5)
2分 2(5.0)
3分 4(10.0)
4分 8(20.0)
5分 7(17.5)
6分 1(2.5)
), ArticleFig(id=1198563930298741541, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202431805944361, language=CN, label=表1, caption=

40例非心脏非神经外科手术围手术期缺血性卒中患者的一般资料

, figureFileSmall=null, figureFileBig=null, tableContent=
指标 例(%)
术后发病时间(d)
0~3 25(62.5)
4~7 10(25.0)
8~21 5(12.5)
梗死部位
前循环 23(57.5)
后循环 8(20.0)
前循环+后循环 9(22.5)
首发症状
急性肢体无力/麻木 24(60.0)
言语问题 6(15.0)
意识障碍 18(45.0)
面瘫 2(5.0)
其他 2(5.0)
出院结局(mRS评分)
0分 5(12.5)
1分 13(32.5)
2分 2(5.0)
3分 4(10.0)
4分 8(20.0)
5分 7(17.5)
6分 1(2.5)
), ArticleFig(id=1198563930374239014, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202431805944361, language=EN, label=Tab.2, caption=

Comparison of clinica data between stroke group and control group of non-cardiac and non-neurosurgical patients

, figureFileSmall=null, figureFileBig=null, tableContent=
指标 卒中组(n=40) 对照组(n=160) χ2/Z P
性别 [女, 例(%)] 21(52.5) 84(52.5) <0.001 1.000
年龄 [岁, M(Q1, Q3)] 68.0(60.3, 76.0) 68.0(60.0, 75.0) 0.295 0.768
既往病史 [例(%)]
卒中史 15(37.5) 21(13.1) 12.881 <0.001
高血压 29(74.5) 56(35) 18.414 <0.001
糖尿病 15(37.5) 23(14.4) 11.119 0.001
冠状动脉疾病 11(27.5) 22(13.8) 4.391 0.036
低心排血量 1(2.5) 7(4.4) 0.008 0.928
心房纤颤 2(5.0) 4(2.5) 0.097 0.756
COPD 6(15.0) 4(2.5) 8.059 0.005
高脂血症 18(45.0) 29(18.1) 12.856 <0.001
肾功能不全 10(25.0) 10(6.3) 10.503 0.001
吸烟 11(27.5) 39(24.4) 0.167 0.683
术前药物应用 [例(%)]
抗血小板/抗凝药 5(12.5) 15(9.4) 0.535 0.464
他汀类 2(5.0) 12(7.5) <0.001 1.000
止血药 4(10.0) 25(15.6) 0.841 0.359
术前实验室检查 [例(%)]
D-二聚体升高# 17(53.1) 37(31.1) 5.329 0.021
血小板数目 1.663 0.096
<100×109/L 5(12.5) 8(5.0)
(100~300)×109/L 33(82.5) 138(86.3)
>300×109/L 2(5.0) 14(8.8)
手术情况 [例(%)]
手术时机(急诊) 11(27.5) 8(5.0) 16.317 <0.001
麻醉方式(全麻) 34(85.0) 128(80.0) 0.52 0.471
术中输血 6(15.0) 30(18.8) 0.305 0.581
术中低血压 20(50.0) 43(26.9) 7.931 0.005
手术时长 [h, M(Q1, Q3)] 2.00(1.35, 3.00) 2.75(1.50, 4.00) 1.798 0.072
脑血管事件风险评估 [例(%)] 7(17.5) 56(35.0) 4.542 0.033
), ArticleFig(id=1198563930449736487, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202431805944361, language=CN, label=表2, caption=

卒中组与对照组非心脏非神经外科手术患者的临床资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标 卒中组(n=40) 对照组(n=160) χ2/Z P
性别 [女, 例(%)] 21(52.5) 84(52.5) <0.001 1.000
年龄 [岁, M(Q1, Q3)] 68.0(60.3, 76.0) 68.0(60.0, 75.0) 0.295 0.768
既往病史 [例(%)]
卒中史 15(37.5) 21(13.1) 12.881 <0.001
高血压 29(74.5) 56(35) 18.414 <0.001
糖尿病 15(37.5) 23(14.4) 11.119 0.001
冠状动脉疾病 11(27.5) 22(13.8) 4.391 0.036
低心排血量 1(2.5) 7(4.4) 0.008 0.928
心房纤颤 2(5.0) 4(2.5) 0.097 0.756
COPD 6(15.0) 4(2.5) 8.059 0.005
高脂血症 18(45.0) 29(18.1) 12.856 <0.001
肾功能不全 10(25.0) 10(6.3) 10.503 0.001
吸烟 11(27.5) 39(24.4) 0.167 0.683
术前药物应用 [例(%)]
抗血小板/抗凝药 5(12.5) 15(9.4) 0.535 0.464
他汀类 2(5.0) 12(7.5) <0.001 1.000
止血药 4(10.0) 25(15.6) 0.841 0.359
术前实验室检查 [例(%)]
D-二聚体升高# 17(53.1) 37(31.1) 5.329 0.021
血小板数目 1.663 0.096
<100×109/L 5(12.5) 8(5.0)
(100~300)×109/L 33(82.5) 138(86.3)
>300×109/L 2(5.0) 14(8.8)
手术情况 [例(%)]
手术时机(急诊) 11(27.5) 8(5.0) 16.317 <0.001
麻醉方式(全麻) 34(85.0) 128(80.0) 0.52 0.471
术中输血 6(15.0) 30(18.8) 0.305 0.581
术中低血压 20(50.0) 43(26.9) 7.931 0.005
手术时长 [h, M(Q1, Q3)] 2.00(1.35, 3.00) 2.75(1.50, 4.00) 1.798 0.072
脑血管事件风险评估 [例(%)] 7(17.5) 56(35.0) 4.542 0.033
), ArticleFig(id=1198563930525233960, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202431805944361, language=EN, label=Tab.3, caption=

Analysis of risk factor hierarchy in stroke group and control group of non-cardiac and non-neurosurgical patients [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
危险因素层级† 卒中组(n=40) 对照组(n=160) Z P
低风险 3(7.5) 85(53.1) 6.296 <0.001
中风险 18(45.0) 57(35.6)
高风险 10(25.0) 17(10.6)
极高风险 9(22.5) 1(0.6)
), ArticleFig(id=1198563930609120041, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202431805944361, language=CN, label=表3, caption=

卒中组与对照组非心脏非神经外科手术患者的危险因素层级分析[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
危险因素层级† 卒中组(n=40) 对照组(n=160) Z P
低风险 3(7.5) 85(53.1) 6.296 <0.001
中风险 18(45.0) 57(35.6)
高风险 10(25.0) 17(10.6)
极高风险 9(22.5) 1(0.6)
), ArticleFig(id=1198563930667840298, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202431805944361, language=EN, label=Tab.4, caption=

Univariate logistic regression analysis of influencing factors of perioperative ischemic stroke in non-cardiac and non-neurosurgical patients

, figureFileSmall=null, figureFileBig=null, tableContent=
变量 P OR 95%CI
卒中史 0.001 3.971 1.807~8.730
高血压 <0.001 4.896 2.275~10.535
糖尿病 0.001 3.574 1.642~7.778
冠状动脉疾病 0.040 2.379 1.040~5.441
COPD 0.004 6.882 1.841~25.723
高脂血症 0.001 3.696 1.761~7.758
肾功能不全 0.001 5.000 1.914~13.061
D-二聚体升高 0.023 2.512 1.134~5.565
急诊手术 <0.001 7.207 2.668~19.464
术中低血压 0.006 2.721 1.336~5.543
脑血管事件风险评估 0.038 0.394 0.164~0.948
), ArticleFig(id=1198563930730754859, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202431805944361, language=CN, label=表4, caption=

非心脏非神经外科手术患者围手术期缺血性卒中影响因素的单因素logistic回归分析结果

, figureFileSmall=null, figureFileBig=null, tableContent=
变量 P OR 95%CI
卒中史 0.001 3.971 1.807~8.730
高血压 <0.001 4.896 2.275~10.535
糖尿病 0.001 3.574 1.642~7.778
冠状动脉疾病 0.040 2.379 1.040~5.441
COPD 0.004 6.882 1.841~25.723
高脂血症 0.001 3.696 1.761~7.758
肾功能不全 0.001 5.000 1.914~13.061
D-二聚体升高 0.023 2.512 1.134~5.565
急诊手术 <0.001 7.207 2.668~19.464
术中低血压 0.006 2.721 1.336~5.543
脑血管事件风险评估 0.038 0.394 0.164~0.948
), ArticleFig(id=1198563930831418156, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202431805944361, language=EN, label=Tab.5, caption=

Multivariate logistic regression analysis of influencing factors of perioperative ischemic stroke in non-cardiac and non-neurosurgical patients

, figureFileSmall=null, figureFileBig=null, tableContent=
影响因素 β SE Wald χ2 P OR(95%CI)
卒中史 0.823 0.646 1.625 0.202 2.278(0.642~8.081)
高血压 2.062 0.655 9.895 0.002 7.858(2.175~28.388)
糖尿病 0.609 0.608 1.005 0.361 1.839(0.559~6.057)
冠状动脉疾病 0.184 0.684 0.072 0.788 1.202(0.314~4.597)
COPD 1.737 1.075 2.611 0.106 5.682(0.691~46.739)
高脂血症 1.485 0.621 5.796 0.016 4.457(1.320~15.049)
肾功能不全 2.113 0.878 5.791 0.016 8.277(1.480~46.282)
D-二聚体升高 0.750 0.600 1.559 0.212 2.116(0.652~6.865)
急诊手术 0.355 0.920 0.149 0.699 1.427(0.235~8.652)
术中低血压 1.351 0.592 5.213 0.022 3.862(1.211~12.317)

脑血管事件

风险评估

 -2.043 0.730 7.836 0.005 0.130(0.031~0.542)
), ArticleFig(id=1198563930902721325, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202431805944361, language=CN, label=表5, caption=

非心脏非神经外科手术患者围手术期缺血性卒中影响因素的多因素logistic回归分析结果

, figureFileSmall=null, figureFileBig=null, tableContent=
影响因素 β SE Wald χ2 P OR(95%CI)
卒中史 0.823 0.646 1.625 0.202 2.278(0.642~8.081)
高血压 2.062 0.655 9.895 0.002 7.858(2.175~28.388)
糖尿病 0.609 0.608 1.005 0.361 1.839(0.559~6.057)
冠状动脉疾病 0.184 0.684 0.072 0.788 1.202(0.314~4.597)
COPD 1.737 1.075 2.611 0.106 5.682(0.691~46.739)
高脂血症 1.485 0.621 5.796 0.016 4.457(1.320~15.049)
肾功能不全 2.113 0.878 5.791 0.016 8.277(1.480~46.282)
D-二聚体升高 0.750 0.600 1.559 0.212 2.116(0.652~6.865)
急诊手术 0.355 0.920 0.149 0.699 1.427(0.235~8.652)
术中低血压 1.351 0.592 5.213 0.022 3.862(1.211~12.317)

脑血管事件

风险评估

 -2.043 0.730 7.836 0.005 0.130(0.031~0.542)
), ArticleFig(id=1198563930974024494, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202431805944361, language=EN, label=Tab.6, caption=

Preoperative risk assessment of cerebrovascular events based on the independent risk factors in stroke group and control group

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独立危险因素个数 卒中组(n=40) 对照组(n=160) 未校正OR 校正后OR
例数(%) 术前脑血管事件风险评估例数(%) 例数(%) 术前脑血管事件风险评估例数(%)
合计 40(100.0) 7(17.5) 160(100.0) 56(35.0) 0.394(P=0.033) 0.365(P=0.038)
0或1个(低风险) 13(32.5) 2(15.4) 128(80.0) 44(34.4) 0.347
2~4个(高风险) 27(67.5) 5(18.5) 32(20.0) 12(37.5) 0.397
), ArticleFig(id=1198563931049521967, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202431805944361, language=CN, label=表6, caption=

基于独立危险因素数量的卒中组与对照组术前脑血管事件风险评估*

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独立危险因素个数 卒中组(n=40) 对照组(n=160) 未校正OR 校正后OR
例数(%) 术前脑血管事件风险评估例数(%) 例数(%) 术前脑血管事件风险评估例数(%)
合计 40(100.0) 7(17.5) 160(100.0) 56(35.0) 0.394(P=0.033) 0.365(P=0.038)
0或1个(低风险) 13(32.5) 2(15.4) 128(80.0) 44(34.4) 0.347
2~4个(高风险) 27(67.5) 5(18.5) 32(20.0) 12(37.5) 0.397
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非心脏非神经外科手术围手术期缺血性卒中的影响因素分析
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柏亚真 1 , 郑童童 1 , 范孟楠 2 , 尚益如 1 , 杜敢琴 3 , 富奇志 3, *
解放军医学杂志 | 围手术期器官损伤机制及保护策略专题Ⅱ 2024,49(10): 1117-1122
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解放军医学杂志 | 围手术期器官损伤机制及保护策略专题Ⅱ 2024, 49(10): 1117-1122
非心脏非神经外科手术围手术期缺血性卒中的影响因素分析
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柏亚真1, 郑童童1, 范孟楠2, 尚益如1, 杜敢琴3, 富奇志3, *
作者信息
  • 1河南科技大学临床医学院，河南洛阳 471003
  • 2河南科技大学第一附属医院病案统计室，河南洛阳 471003
  • 3河南科技大学第一附属医院神经内科，河南洛阳 471003

    • 柏亚真，硕士研究生，主要从事脑血管疾病的临床与基础研究

通讯作者:

富奇志，E-mail：
Analysis of influencing factors of perioperative ischemic stroke in non-cardiac and non-neurosurgical surgeries
Ya-Zhen Bai1, Tong-Tong Zheng1, Meng-Nan Fan2, Yi-Ru Shang1, Gan-Qin Du3, Qi-Zhi Fu3, *
Affiliations
  • 1College of Clinical Medicine, Henan University of Science and Technology, Luoyang, Henan 471003, China
  • 2Department of Medical Records Statistics, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan 471003, China
  • 3Department of Neurology, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan 471003, China
出版时间: 2024-10-28 doi: 10.11855/j.issn.0577-7402.1556.2024.0506
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摘要
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目的 探讨非心脏非神经外科手术围手术期缺血性卒中的发病率、危险因素及其与术前脑血管事件风险评估的相关性，以指导围手术期风险管理。方法 回顾性选取2015年1月－2022年1月在河南科技大学第一附属医院接受非心脏非神经外科手术、发生围手术期缺血性卒中、年龄≥18岁的40例患者作为卒中组；按照性别、年龄、手术日期、手术医师匹配，病例比1:4，选取160例未发生围手术期缺血性卒中的患者作为对照组。收集两组患者的临床资料及术前脑血管事件风险评估情况(包括单独或联合应用头颅CT/MRI、经颅多普勒超声、颈动脉超声、神经科会诊)进行统计分析。采用多因素logistic回归分析筛选围手术期缺血性卒中的危险因素。结果 围手术期缺血性卒中的发生率为0.042%。多因素logistic回归分析结果显示，高血压(OR=7.858，95%CI 2.175~28.388，P=0.002)、高脂血症(OR=4.457，95%CI 1.320~15.049，P=0.016)、肾功能不全(OR=8.277，95%CI 1.480~46.282，P=0.016)、术中低血压(OR=3.862，95%CI 1.211~12.317，P=0.022)是非心脏非神经外科手术围手术期缺血性卒中的独立危险因素；术前脑血管事件风险评估(OR=0.130，95%CI 0.031~0.542，P=0.005)是非心脏非神经外科手术围手术期缺血性卒中的保护因素。结论 围手术期缺血性卒中的发生率较低，但预后较差；其危险因素有高血压、高脂血症、肾功能不全和术中低血压，术前脑血管事件风险评估有利于降低其发生率。

非心脏非神经外科手术  /  围手术期  /  缺血性卒中  /  危险因素  /  风险评估

Objective To explore the incidence and risk factors of perioperative ischemic stroke in non-cardiac and non-neurosurgical surgeries and its correlation with preoperative risk assessment of cerebrovascular events, so as to guide perioperative risk management. Methods A retrospective study was conducted on 40 patients aged ≥18 years who underwent non-cardiac and non-neurosurgical surgeries and experienced perioperative ischemic stroke in the First Affiliated Hospital of Henan University of Science and Technology from January 2015 to January 2022, forming the stroke group. A control group of 160 patients without perioperative ischemic stroke was selected in a 1:4 case-control ratio, matched for gender, age, date of operation, and the surgeon. Clinical data and preoperative risk assessment of cerebrovascular events (including the single or combined application of head CT/MRI, transcranial Doppler ultrasound, carotid ultrasound, and neurological consultation) of the two groups of patients were collected and statistically analyzed. Multiple logistic regression analysis was used to identify risk factors associated with perioperative ischemic stroke. Results The incidence of perioperative ischemic stroke was 0.042%. Multiple logistic analysis results showed that hypertension (OR=7.858, 95%CI 2.175-28.388, P=0.002), hyperlipidemia (OR=4.457, 95%CI 1.320-15.049, P=0.016), renal insufficiency (OR=8.277, 95%CI 1.480-46.282, P=0.016), and intraoperative hypotension (OR=3.862, 95%CI 1.211-12.317, P=0.022) were independent risk factors for perioperative ischemic stroke in non-cardiac and non-neurological surgeries; preoperative cerebrovascular risk assessment (OR=0.130, 95%CI 0.031-0.542, P=0.005) was a protective factor against it. Conclusions The incidence of perioperative ischemic stroke in non-cardiac and non-neurosurgical surgery is low but has a poor prognosis. Hypertension, hyperlipidemia, renal insufficiency, and postoperative hypotension are risk factors for perioperative ischemic stroke, while preoperative cerebrovascular event risk assessment is beneficial to reducing its incidence.

non-cardiac, non-neurological surgery  /  perioperative  /  ischemic stroke  /  risk factor  /  risk assessment
柏亚真, 郑童童, 范孟楠, 尚益如, 杜敢琴, 富奇志. 非心脏非神经外科手术围手术期缺血性卒中的影响因素分析. 解放军医学杂志, 2024 , 49 (10) : 1117 -1122 . DOI: 10.11855/j.issn.0577-7402.1556.2024.0506
Ya-Zhen Bai, Tong-Tong Zheng, Meng-Nan Fan, Yi-Ru Shang, Gan-Qin Du, Qi-Zhi Fu. Analysis of influencing factors of perioperative ischemic stroke in non-cardiac and non-neurosurgical surgeries[J]. Medical Journal of Chinese People’s Liberation Army, 2024 , 49 (10) : 1117 -1122 . DOI: 10.11855/j.issn.0577-7402.1556.2024.0506
正文
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围手术期卒中通常被定义为在术中至术后30 d内发生的卒中；其发病率因手术类型而异，在接受普通手术的患者中缺血性卒中发生率为0.1%~1.0%[1]，而在复杂的心脏手术中可高达10%[2]。临床研究显示，围手术期缺血性卒中易发生于心脏、大血管及神经外科手术，而非心脏非神经外科手术相关卒中常被忽略[3]。围手术期缺血性卒中导致患者预后不良及病死率增高[4]，术前风险评估是预防其发生的重要环节，但目前相关指南及研究报道尚无明确推荐的术前脑血管风险评估体系，脑血管事件风险评估主要关注既往脑血管病危险因素病史。围手术期脑血管事件风险评估手段通常包括请神经专科医师会诊，完善头颅CT、头颅MRI平扫、脑血管成像、经颅多普勒超声(transcranial Doppler ultrasound，TCD)及颈部超声，对脑实质及颅内外动脉血管进行评估[5]。本文探讨非心脏非神经外科手术围手术期缺血性卒中的发病率、危险因素及术前脑血管事件风险评估与围手术期缺血性卒中的相关性，旨在为围手术期风险管理和减少缺血性卒中的发生提供参考。
1 资料与方法
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1.1 研究对象
本研究为病例对照研究。选取2015年1月－2022年1月在河南科技大学第一附属医院接受非心脏非神经外科手术、发生围手术期缺血性卒中的40例患者作为卒中组。纳入标准：(1)行非心脏、非大血管、非神经外科手术，年龄≥18岁；(2)围手术期出现全身或局灶性神经功能障碍，并经脑部CT/MRI检查确认，经神经专科医师评估判断为新发急性缺血性卒中[6]。排除标准：(1)影像学资料不完整；(2)手术前3个月发生过急性脑梗死；(3)住院期间出现急性起病的神经功能缺损，持续时间<24 h，或经颅脑CT、MRI诊断为其他疾病。另外，按照与卒中组患者性别、年龄(±3岁)、手术日期(±6个月)、手术医师匹配，病例比1:4，选取同一医院未发生围手术期缺血性卒中的160例患者为对照组。本研究获河南科技大学第一附属医院伦理委员会审批(2023-1172)，所有研究对象均签署知情同意书。
1.2 患者资料收集
(1)一般情况：性别、年龄；(2)术前相关因素：高血压、糖尿病、高脂血症、冠状动脉疾病、肾功能不全、低心排血量(左室射血分数<55%)、心房颤动、卒中史、吸烟史、血液高凝状态(D-二聚体升高)、血小板数目、术前药物应用(抗凝/抗血小板药、止血药)、是否行脑血管事件风险评估(头颅CT、头颅MRI、颈部血管超声、TCD、神经内科专科会诊任意一项或组合)；(3)手术相关因素：手术时机、麻醉方式(全身麻醉/局部麻醉)、手术时长、术中低血压及输血情况；(4)卒中相关情况：发生时间、病灶定位、首发症状、出院时改良Rankin量表(modified Rankin scale，mRS)评分等。
1.3 观察指标
比较两组患者的术前、术中相关危险因素及术前脑血管事件风险评估情况，并分析其相关性。比较两组在危险因素层级方面的差异性；采用单因素和多因素logistic回归分析筛选独立危险因素及术前脑血管事件风险评估与围手术期缺血性卒中发生的相关性。按照独立危险因素个数分层，比较两组在脑血管事件风险评估方面的相关性。
1.4 统计学处理
采用SPSS 26.0软件进行统计分析。计数资料以例(%)表示，组间比较采用χ2检验；计量资料(不符合正态分布)以M(Q1，Q3)表示，组间比较采用秩和检验。采用logistic回归分析确定围手术期缺血性卒中的影响因素及术前脑血管事件风险评估与围手术期缺血性卒中发生的相关性。P<0.05为差异有统计学意义。
2 结果
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2.1 一般情况
2015年1月－2022年1月，共95 632例≥18岁患者在本院接受了非心脏非神经外科及非大血管手术；经头部CT/MRI检查和神经内科医师会诊，40例确诊为围手术期急性缺血性卒中，发生率为0.042%。手术类型包括普外科(腹部)手术17例(42.5%)，头颈(五官)科手术8例(20.0%)，胸外科手术6例(15.0%)，泌尿外科手术4例(10.0%)，骨科手术3例(7.5%)，妇科及外周血管手术各1例(2.5%)。围手术期缺血性卒中出现的时间为术后0~21 d，其中术后0~3 d 25例(62.5%)，术后4~7 d 10例(25.0%)，术后8~21 d 5例(12.5%)。卒中病灶部位：前循环23例(57.5%)，后循环8例(20.0%)，二者皆有9例(22.5%)。首发症状：急性肢体无力/麻木24例(60.0%)，意识障碍18例(45.0%)、言语问题6例(15.0%)，面瘫2例(5.0%)及其他症状2例(5.0%)。卒中患者出院结局(mRS评分)为0~6分，其中0~2分20例(50.0%)，3~5分19例(47.5%)，6分(死亡)1例(2.5%)。有6例患者因病情危重选择自动出院。术后缺血性卒中患者的特征见表1。
2.2 围手术期缺血性卒中的相关危险因素
与对照组比较，围手术期缺血性卒中患者的卒中史、高血压、糖尿病、冠状动脉疾病、慢性阻塞性肺疾病(COPD)、高脂血症、肾功能不全、D-二聚体异常、手术时机、术中低血压、术前脑血管事件风险评估等方面，差异有统计学意义(P<0.05)；两组低心排血量、吸烟、术前抗血小板/抗凝药、他汀类及止血药物应用、麻醉方式、手术时长、术中输血等指标差异无统计学意义(P>0.05，表2)。此外，两组在危险因素层级方面差异有统计学意义(P<0.001)，即卒中患者有更多的术前并发症(表3)。
2.3 围手术期缺血性卒中危险因素的logistic回归分析
单因素logistic回归分析结果显示，卒中史、高血压、糖尿病、冠状动脉疾病、COPD、高脂血症、肾功能不全、D-二聚体升高、急诊手术、术中低血压、术前脑血管事件风险评估可能是非心脏非神经外科手术围手术期缺血性卒中的危险因素(P<0.05，表4)。多因素logistic回归分析结果显示，高血压、高脂血症、肾功能不全、术中低血压是非心脏非神经外科手术围手术期缺血性卒中的独立危险因素(P<0.05)；术前行脑血管事件风险评估是围手术期缺血性卒中的保护因素(OR=0.130，P<0.05，表5)。
2.4 脑血管事件风险评估与围手术期缺血性卒中发生的分层分析
根据存在的独立危险因素数量进行分层，通过Cochran-Mantel-Haenszel方法获得的脑血管事件风险评估调整后的OR值(0.365)，与用logistic回归模型计算的调整后的OR值(0.130)相近(表6)。
3 讨论
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本研究中，非心脏非神经外科手术围手术期缺血性卒中的发病率为0.042%，与国外报道的发病率0.028%~0.800%基本一致[1]。本研究观察到术后卒中发生的时间趋势与既往国内外文献报道相一致[7-8]，大多数患者发生在术后7 d内，尤其是术后3 d内。本组资料中截至出院时，围手术期缺血性卒中患者中-重度残疾(mRS 评分3~5分)率高达47.5%；院内病死率为2.5%，与国内报道一致[9]。在卒中患者首先出现的临床表现中，偏侧肢体无力/麻木与意识障碍为常见的首发症状。由于麻醉及术后卧床等因素，这些症状轻微时易被忽视或延迟发现，需临床医师特别关注患者术后的神经功能状况。
与既往研究类似[4,10]，本研究中围手术期缺血性卒中发生的危险因素包括高血压、肾功能不全、高脂血症及术中低血压。多因素分析结果显示，卒中史及糖尿病与围手术期卒中未见明显的相关性，与既往研究结果不一致，考虑是由于选择偏倚及研究的样本量有限导致。此外，作为卒中的传统危险因素，心房颤动及糖尿病患者发生围手术期缺血性卒中相关死亡的可能性更大[11]。血压水平一直是近年研究关注的重点，本研究中发现高血压患者发生围手术期缺血性卒中的风险增加7倍，长期高血压易造成脑内小血管痉挛，导致血流灌注减少和动脉血栓形成。此外，长期高血压导致机体脑血流自动调节功能受损，从而对术中可能发生的低血压耐受能力减弱。然而，术中低血压是否会增加围手术期缺血性卒中的风险尚存在争议，这可能与不同研究对于术中低血压的定义不同有关。有研究显示，相对于基线的术中低血压定义能更客观地预测患者不良结局风险，而不应忽视患者的基础病史，使用固定的血压阈值[12]。结合先前的研究[12-13]，本研究选择平均动脉压<60 mmHg或平均动脉压较基线下降>30%作为术中低血压的定义，结果显示，术中低血压可能增加术后卒中的发生风险。
一般认为围手术期缺血性卒中是多种因素共同作用的结果。高脂血症是围手术期缺血性卒中的独立危险因素之一[14]。一项对5029例接受择期脊柱手术患者的单中心研究报道了类似的结果[15]。有研究显示，低水平高密度脂蛋白胆固醇(HDL-C)是围手术期缺血性卒中的独立危险因素[4]。作为人体逆向运输胆固醇的唯一途径，高密度脂蛋白胆固醇具有抗动脉粥样硬化的作用，而动脉粥样硬化是缺血性卒中的常见病因[16]。有研究推荐正在接受他汀类药物治疗并接受手术的患者应继续服用他汀类药物[1,17]。多项研究显示，肾功能不全与缺血性卒中相关[4,18]，与本研究结果一致。肾功能不全患者的高血压、糖尿病患病率更高[19]，脂质代谢紊乱及酸碱平衡代谢障碍更严重。此外，肾功能不全是急性缺血性卒中30 d生存率的负面预测因素[18]。
本研究显示，术前脑血管事件风险评估与围手术期缺血性卒中的发生具有相关性，且在控制了独立危险因素后，脑血管事件风险评估有明显的保护作用(OR=0.365，P=0.038)。在既往文献中，术前脑血管事件风险评估手段多采用各种风险评分和预测模型[4,20]，且多限于患者既往疾病，本研究采用术前脑血管形态和功能的影像学评估和专科会诊评估围手术期缺血性卒中的危险因素，且进行了层级比较，有利于客观规范地评估围手术期缺血性卒中的发生风险。有研究显示，心脏手术前行脑血管影像学评估与围手术期卒中的发生无明显相关性，这可能是由于心脏手术后的大多数卒中与大血管闭塞之间无明显相关性，而更可能是由手术相关操作或其他原因引起的[21-22]。风险评估的重要目的是在手术前进行必要的干预，有效的术前评估有利于减少术后并发症的发生。对于非心脏非神经外科手术患者，术前行脑血管事件风险评估不仅可指导围手术期用药，还可明确颅内外血流动力学基础状况，为术中麻醉及术后管理提供更为直观的指导依据。
本研究有助于规范非心脏非神经外科手术围手术期缺血性卒中高危患者的风险管理。首先，对既往高血压、高脂血症、肾功能不全等高危因素患者进行手术时应予以重视，术前可行脑实质成像或颈部超声甚至TCD评估颅内外血管情况，由专科医师会诊行个体化评估，并记录神经功能基线信息；其次，术中应尽量避免低血压的发生，以保证脑灌注的稳定；最后，术后7 d内，尤其是术后3 d内，应加强患者的神经功能监测，并与术前基线记录对比，如出现新发异常，应尽快联系卒中绿色通道医师进行专业评估并完善相关检查。
本研究采用手术日期及外科医师匹配的研究设计自动匹配了相同的医疗条件和外科医师的手术经验，因此卒中组与对照组之间执行的手术类型也是匹配的。两组在麻醉方式、手术时间和术中输血方面无差异可较好地反映配对设计的完整性。这种方法基本剔除了手术和麻醉相关技术的混杂影响，围手术期缺血性卒中的真实风险因素可更具体地呈现出来。此外，本研究还排除了大血管及血管内介入相关手术，进一步控制了手术本身因素导致的缺血性卒中的高发病率，有利于准确反映围手术期缺血性卒中的风险。
本研究为单中心回顾性研究，存在一定的局限性。首先，轻微或无症状性脑梗死易被忽视，故真实世界围手术期缺血性卒中的发病率可能更高；其次，仅整体分析了术前缺血性卒中事件风险评估与围手术期缺血性卒中的相关性，受样本量限制并未进一步探讨不同评估方式与围手术期卒中的相关性。因此，未来可在本研究的基础上进一步完善，扩大样本量并开展多中心前瞻性研究。
综上，本研究结果显示，高血压、高脂血症、肾功能不全和术中低血压是非心脏非神经外科手术围手术期缺血性卒中的重要危险因素，术前脑血管事件风险评估是其保护因素。尽管非心脏非神经外科围手术期缺血性卒中较少见，但其预后较差。临床医师应对具有高危因素的患者进行早期识别预警，重视术前脑血管事件风险评估与管理，预防围手术期缺血性卒中的发生。
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  • 河南省重大科技专项(221100210500)
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2024年第49卷第10期
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doi: 10.11855/j.issn.0577-7402.1556.2024.0506
  • 接收时间：2023-11-23
  • 首发时间：2025-11-20
  • 出版时间：2024-10-28
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  • 收稿日期：2023-11-23
  • 录用日期：2024-02-18
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Major Science and Technology Projects of Henan Province(221100210500)
河南省重大科技专项(221100210500)
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    1河南科技大学临床医学院，河南洛阳 471003
    2河南科技大学第一附属医院病案统计室，河南洛阳 471003
    3河南科技大学第一附属医院神经内科，河南洛阳 471003

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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
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