围手术期脑卒中
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Perioperative Stroke.
背景与目的
围手术期脑卒中发病率和死亡率都很高，发病率可能也往往被低估。在本文中，我们对围手术期中风的意义，病理生理，危险因素进行了调查，据此制定出了围手术期脑卒中的预防和管理临床推荐指南。
方 法
这是一篇以PubMed数据库中检索广泛手术人群有关的围术期脑卒中所得文献为基础支持得到的叙述性综述。对神经学协会最近公布的麻醉与危重病的循证医学在脑卒中高风险患者的围手术期管理中的建议进行了分析并纳入此篇综述。
结 果
在心脏和大血管手术患者中围手术期典型脑卒中发生率最高，尽管原始数据表明，隐匿型脑卒中发病率在非心脏手术的患者可能高达10%。围手术期卒中的发生涉及不同途径的病理生理学机制。炎症加重和血液高凝状态可导致血栓性脑卒中发生，心房颤动及β受体阻滞剂和贫血引起的组织缺氧这种疾病状态可导致心源性卒中。大型数据库的研究表明，围手术期脑卒中常见的危险因素包括高龄、脑血管病史、缺血性心脏病、充血性心力衰竭、心房纤颤以及肾脏疾病。对围手术期脑卒中的预防和管理的临床推荐指南是不断发展的，但需要对围手术期的抗凝、抗血小板治疗、适当的输血阈值以及围手术期β受体阻滞剂的使用这些已经明确提出来的可改变危险因素做进一步的研究。
结 论
围手术期脑卒中给临床工作带来很重的负担。围手术期脑卒中的发生率可能也比先前我们所认识的要高，并有多种病理生理机制。围手术期预防卒中的病理生理学机制，预防和管理都需我们抓住机会做进一步的调查。
原始文献摘要
Phillip Vlisides and George A. Mashour.Perioperative Stroke.Can J Anaesth. 2016 Feb; 63(2): 193–204. doi: 10.1007/s12630-015-0494-9.
Purpose
Perioperative stroke is associated with significant morbidity and mortality, with an incidence that may be underappreciated. In this review, we examine the significance, pathophysiology, risk factors, and evidence-based recommendations for prevention and management of perioperative stroke.
Source
This is a narrative review based on literature from the PubMed Databaseregarding perioperative stroke across a broad surgical population. The Society for Neuroscience in Anesthesiology and Critical Care recently published evidence-based recommendations for perioperative management of patients at high risk for stroke; these recommendations were analyzed and incorporated into this review.
Principal Findings
The incidence of overt perioperative stroke is highest in patients presenting for cardiac and major vascular surgery, although preliminary data suggest that the incidence of covertstroke may be as high as 10% in non-cardiac surgery patients. The pathophysiology of perioperative stroke involves different pathways. Thrombotic stroke can result from increased inflammation and hypercoagulability, cardioembolic stroke can result from disease states such as atrial fibrillation, and tissue hypoxia from anemia can result from the combination of anemia and beta-blockade. Across large-scale database studies, common risk factors for perioperative stroke include advanced age, history of cerebrovascular disease, ischemic heart disease, congestive heart failure, atrial fibrillation, and renal disease. Recommendations for prevention and management of perioperative stroke are evolving, though further work is needed to clarify the role of proposed modifiable risk factors such as perioperative anticoagulation, anti-platelet therapy, appropriate transfusion thresholds, and perioperative beta-blockade.
Conclusions
Perioperative stroke carries a significant clinical burden. The incidence of perioperative stroke may be higher than previously recognized, and there are diverse pathophysiologic mechanisms. There are many opportunities for further investigation of perioperative stroke pathophysiology, prevention, and management.
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