感染性心内膜炎合并脑卒中的瓣膜手术：手术时机和围手术期神经并发症。
Valve surgery for infective endocarditis complicated by stroke: surgical timing and perioperative neurological complications.
机构信息
Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
Division of Neurocritical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
出版信息
Eur J Neurol. 2020 Dec;27(12):2430-2438. doi: 10.1111/ene.14438. Epub 2020 Aug 23.
BACKGROUND AND PURPOSE
Ischaemic and hemorrhagic strokes are dreaded complications of infective endocarditis (IE). The timing of valve surgery for IE patients with stroke remains uncertain. The aim was to study perioperative neurological complications in relation to surgical timing.
METHODS
The study cohort consisted of patients diagnosed with acute IE from January 2010 to December 2016. Early surgery was defined as valve surgery within 14 days of IE diagnosis, and late surgery as after 14 days. Neurological complications that occurred within 14 days post-surgery were considered perioperative and classified as new ischaemic stroke or hemorrhagic stroke, expansion of an existing intracranial hemorrhage and new-onset seizures. Perioperative neurological complications were compared by surgical timing and other variables, including pre-surgical imaging.
RESULTS
Overall, 183 patients underwent valve surgery: 92 had early surgery at a median of 8 days (interquartile range 6-11); 91 had late surgery at a median of 28 days (interquartile range 19-50). Twenty patients (10.9%) had 24 complications: 11 ischaemic, six intraparenchymal hemorrhages, three subarachnoid hemorrhages (SAHs) and four new-onset seizures. Rates of neurological complications were similar for early and late surgery groups (10.9% vs. 11%). Enterococcal IE was more common amongst patients with perioperative neurological complications (35% vs. 12.3%, P < 0.01). An acute infarct was present on pre-surgical magnetic resonance imaging of 134 patients (74%) and was not associated with perioperative neurological complications. Thirty-five patients (19.3%) had intracranial hemorrhage on pre-surgical imaging. SAH on pre-surgical imaging was associated with developing SAH perioperatively (66.7% vs. 13.5%, P < 0.01).
CONCLUSION
Early valve surgery for patients with IE complicated by stroke was not associated with perioperative neurological complications.
背景与目的
感染性心内膜炎（IE）可引起缺血性和出血性脑卒中，这是令人担忧的并发症。IE 合并脑卒中患者行瓣膜手术的时机仍不确定。本研究旨在探讨与手术时机相关的围手术期神经系统并发症。
方法
研究队列纳入了 2010 年 1 月至 2016 年 12 月期间诊断为急性 IE 的患者。早期手术定义为 IE 诊断后 14 天内行瓣膜手术，晚期手术定义为 IE 诊断后 14 天后行瓣膜手术。术后 14 天内发生的神经系统并发症被认为是围手术期并发症，并分为新发缺血性脑卒中或出血性脑卒中、现有颅内出血扩大和新发癫痫发作。通过手术时机和其他变量（包括术前影像学）比较围手术期神经系统并发症。
结果
共 183 例患者行瓣膜手术：92 例早期手术，中位时间为 8 天（四分位间距 6-11 天）；91 例晚期手术，中位时间为 28 天（四分位间距 19-50 天）。20 例（10.9%）患者发生 24 种并发症：11 例缺血性脑卒中，6 例脑实质内出血，3 例蛛网膜下腔出血（SAH）和 4 例新发癫痫发作。早期和晚期手术组的神经系统并发症发生率相似（10.9% vs. 11%）。肠球菌性 IE 在围手术期神经系统并发症患者中更为常见（35% vs. 12.3%，P<0.01）。134 例患者（74%）术前磁共振成像显示存在急性梗死，但与围手术期神经系统并发症无关。35 例患者（19.3%）术前影像学显示颅内出血。术前影像学显示 SAH 与术后发生 SAH 相关（66.7% vs. 13.5%，P<0.01）。
结论
IE 合并脑卒中患者行早期瓣膜手术与围手术期神经系统并发症无关。
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