Zhou Peng, Xu Jing, Zhuang Dayong, Li Xiaolei, Yue Tao, Hu Huaiqiang, He Qingqing
Department of Thyroid and Breast Surgery, The 960th Hospital of People's Liberation Army, Jinan, China.
Department of Neurology, The 960th Hospital of People's Liberation Army, Jinan, China.
Front Neurosci. 2023 May 11;17:1153453. doi: 10.3389/fnins.2023.1153453. eCollection 2023.
Secondary Hyperparathyroidism (SHPT) is a common complication of end-stage renal disease (ESRD), and parathyroid surgery (PTX) is an effective way to treat patients with severe SHPT. ESRD has multiple associations with cerebrovascular diseases. For example, the incidence of stroke in patients with ESRD is 10 times higher than that in the general population, the risk of death after acute stroke is three times higher, and the risk of hemorrhagic stroke is significantly higher. High/low serum calcium, high PTH, low serum sodium, high white blood cell count, previous occurrences of cerebrovascular events, polycystic kidney disease (as a primary disease), and the use of anticoagulants are independent risk factors for hemorrhagic stroke in hemodialysis patients with uremia. The risk of stroke in patients who undergo PTX decreases significantly in the second year of follow-up and persist thereafter. However, studies on the risk of perioperative stroke in SHPT patients are limited. After undergoing PTX, the PTH levels in SHPT patients drop suddenly, they undergo physiological changes, bone mineralization increases, and calcium in the blood gets redistributed, often accompanied by severe hypocalcemia. Serum calcium might influence the occurrence and development of hemorrhagic stroke at various stages. To prevent bleeding from the operated area, the use of anticoagulants after surgery is reduced in some cases, which often decreases the frequency of dialysis and increases the quantity of fluid in the body. An increase in the variation in blood pressure, instability of cerebral perfusion, and extensive intracranial calcification during dialysis promote hemorrhagic stroke, but these clinical problems have not received enough attention. In this study, we reported the death of an SHPT patient who suffered a perioperative intracerebral hemorrhage. Based on this case, we discussed the high-risk factors for perioperative hemorrhagic stroke in patients who undergo PTX. Our findings might help in the identification and early prevention of the risk of profuse bleeding in patients and provide reference for the safe performance of such operations.
继发性甲状旁腺功能亢进（SHPT）是终末期肾病（ESRD）的常见并发症，甲状旁腺手术（PTX）是治疗重度SHPT患者的有效方法。ESRD与脑血管疾病有多种关联。例如，ESRD患者的中风发病率比普通人群高10倍，急性中风后的死亡风险高3倍，出血性中风风险显著更高。高/低血清钙、高甲状旁腺激素（PTH）、低血清钠、高白细胞计数、既往脑血管事件、多囊肾病（作为原发性疾病）以及使用抗凝剂是尿毒症血液透析患者出血性中风的独立危险因素。接受PTX的患者在随访第二年中风风险显著降低，并持续至此后。然而，关于SHPT患者围手术期中风风险的研究有限。接受PTX后，SHPT患者的PTH水平突然下降，会经历生理变化，骨矿化增加，血液中的钙重新分布，常伴有严重低钙血症。血清钙可能在各个阶段影响出血性中风的发生和发展。为防止手术区域出血，某些情况下术后抗凝剂的使用会减少，这往往会降低透析频率并增加体内液体量。透析期间血压波动增加、脑灌注不稳定以及广泛的颅内钙化会促进出血性中风，但这些临床问题尚未得到足够重视。在本研究中，我们报告了1例围手术期发生脑出血的SHPT患者死亡。基于该病例，我们讨论了接受PTX患者围手术期出血性中风的高危因素。我们的发现可能有助于识别和早期预防患者大出血风险，并为此类手术的安全实施提供参考。
