有中风病史的心脏外科手术患者的神经损伤

Neurologic injury in cardiac surgical patients with a history of stroke.

作者信息

Redmond J M, Greene P S, Goldsborough M A, Cameron D E, Stuart R S, Sussman M S, Watkins L, Laschinger J C, McKhann G M, Johnston M V, Baumgartner W A

机构信息

Division of Cardiac Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.

出版信息

Ann Thorac Surg. 1996 Jan;61(1):42-7. doi: 10.1016/0003-4975(95)00903-5.

DOI:10.1016/0003-4975(95)00903-5

PMID:8561618

Abstract

BACKGROUND

Controversy still exists as to whether patients with previous stroke are at increased risk for neurologic complications after heart operations.

METHODS

We performed a prospective analysis of 1,000 consecutive patients undergoing cardiac operations requiring cardiopulmonary bypass, without hypothermic circulatory arrest. Of the 1,000 patients, 71 had previously documented stroke (study group); 2 control patients with no history of stroke were selected for each of these patients (control group, n = 142). There were no significant differences between the study and control patients with respect to established risk factors for neurologic complications.

RESULTS

Compared with controls, study patients took longer to awaken (12.6 +/- 10.9 versus 3.5 +/- 2.1 hours; p < 0.0001) and longer to extubate (29.5 +/- 29.3 versus 9.1 +/- 5.2 hours; p < 0.001), and had a greater incidence of reintubation (7 of 71, 9.9% versus 2 of 142, 1.4%; p < 0.01) and postoperative confusion (26 of 71, 36.6% versus 7 of 142, 4.9%; p < 0.001). There was a higher incidence of focal neurologic deficit among study patients (31 of 71, 43.7% versus 2 of 142, 1.4%; p < 0.001). These deficits included new stroke (6 of 71, 8.5%) as well as the reappearance of previous deficits (19 of 71, 26.8%) or worsening of previous deficits (6 of 71, 8.5%), without new abnormalities on head computed tomography or magnetic resonance imaging. Study patients with neurologic deficit had longer cardiopulmonary bypass times than did study patients without deficit (146 +/- 48.5 versus 110 +/- 43.3 minutes; p < 0.001). The 30-day mortality rate was greater in study patients than in controls (5 of 71, 7% versus 1 of 142, 0.7%; p < 0.02), with four deaths among the 6 study patients with a new stroke (66.7%).

CONCLUSION

This analysis identifies a group of patients at high risk for neurologic sequelae and confirms the vulnerability of the previously injured brain to cardiopulmonary bypass, as evidenced by reappearance or exacerbation of focal deficits in such patients.

摘要

背景

既往有中风病史的患者在心脏手术后发生神经并发症的风险是否增加仍存在争议。

方法

我们对1000例连续接受需要体外循环且无低温循环停止的心脏手术患者进行了前瞻性分析。在这1000例患者中，71例有既往中风记录（研究组）；为每例研究组患者选取2例无中风病史的对照患者（对照组，n = 142）。研究组和对照组患者在已确定的神经并发症危险因素方面无显著差异。

结果

与对照组相比，研究组患者苏醒时间更长（12.6±10.9小时对3.5±2.1小时；p<0.0001），拔管时间更长（29.5±29.3小时对9.1±5.2小时；p<0.001），再次插管发生率更高（71例中的7例，9.9%对142例中的2例，1.4%；p<0.01），术后谵妄发生率更高（71例中的26例，36.6%对142例中的7例，4.9%；p<0.001）。研究组患者局灶性神经功能缺损发生率更高（71例中的31例，43.7%对142例中的2例，1.4%；p<0.001）。这些缺损包括新发中风（71例中的6例，8.5%）以及既往缺损的再次出现（71例中的19例，26.8%）或既往缺损的加重（71例中的6例，8.5%），头部计算机断层扫描或磁共振成像无新的异常。有神经功能缺损的研究组患者体外循环时间比无缺损的研究组患者更长（146±48.5分钟对110±43.3分钟；p<0.001）。研究组患者30天死亡率高于对照组（71例中的5例，7%对142例中的1例，0.7%；p<0.02），6例新发中风的研究组患者中有4例死亡（66.7%）。