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[Lancet在线发表]:接受非心脏手术患者围手术期的隐匿型卒中:前瞻性队列研究
2019年08月23日 时讯速递, 进展交流 暂无评论

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Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study

The NeuroVISION Investigators

Lancet epub August 15, 2019 DOI:https://doi.org/10.1016/S0140-6736(19)31795-7

Summary

Background 背景

In non-surgical settings, covert stroke is more common than overt stroke and is associated with cognitive decline. Although overt stroke occurs in less than 1% of adults after non-cardiac surgery and is associated with substantial morbidity, we know little about perioperative covert stroke. Therefore, our primary aim was to investigate the relationship between perioperative covert stroke (ie, an acute brain infarct detected on an MRI after non-cardiac surgery in a patient with no clinical stroke symptoms) and cognitive decline 1 year after surgery.

在非手术情况下,隐匿型卒中较明显卒中更为常见,且与认知功能下降相关。尽管不足1%的非心脏外科术后成年患者发生明显卒中,且伴随明显的罹患率,但我们对围手术期隐匿型卒中知之甚少。因此,主要研究目的在于探讨围手术期隐匿型卒中(即非心脏术后没有卒中症状患者MRI显示急性脑梗塞)与术后1年认知功能下降的相关性。

Methods 方法

NeuroVISION was a prospective cohort study done in 12 academic centres in nine countries, in which we assessed patients aged 65 years or older who underwent inpatient, elective, non-cardiac surgery and had brain MRI after surgery. Two independent neuroradiology experts, masked to clinical data, assessed each MRI for acute brain infarction. Using multivariable regression, we explored the association between covert stroke and the primary outcome of cognitive decline, defined as a decrease of 2 points or more on the Montreal Cognitive Assessment from preoperative baseline to 1-year follow-up. Patients, health-care providers, and outcome adjudicators were masked to MRI results.

NeuroVISION是一项前瞻队列研究,在9个国家12个中心进行。我们对65岁以上接受择期非心脏手术且术后行头颅MRI检查的住院患者进行评估。2名不了解临床资料的神经影像学专家对每个MRI检查进行独立阅片,判断是否发生急性脑梗塞。我们采用多因素回归模型验证隐匿型卒中与主要预后指标即认知功能下降(定义为从术前基线情况到1年随访时蒙特利尔认知量表降低2分或更多)的相关性。MRI结果对患者、医务人员及预后评估人员隐藏。

Findings 结果

Between March 24, 2014, and July 21, 2017, of 1114 participants recruited to the study, 78 (7%; 95% CI 6–9) had a perioperative covert stroke. Among the patients who completed the 1-year follow-up, cognitive decline 1 year after surgery occurred in 29 (42%) of 69 participants who had a perioperative covert stroke and in 274 (29%) of 932 participants who did not have a perioperative covert stroke (adjusted odds ratio 1·98, 95% CI 1·22–3·20, absolute risk increase 13%; p=0·0055). Covert stroke was also associated with an increased risk of perioperative delirium (hazard ratio [HR] 2·24, 95% CI 1·06–4·73, absolute risk increase 6%; p=0·030) and overt stroke or transient ischaemic attack at 1-year follow-up (HR 4·13, 1·14–14·99, absolute risk increase 3%; p=0·019).

从2014年3月24日至2017年7月21日,研究共入选1114名患者,78名 (7%; 95% CI 6–9) 发生围手术期隐匿型卒中。在完成1年随访的患者中,69名围手术期隐匿型卒中患者中的29名(42%),以及932名没有发生围手术期隐匿型卒中患者中的 274 名 (29%) 出现认知功能下降(校正后比数比 1·98, 95% CI 1·22–3·20, 绝对风险增加 13%; p=0·0055)。隐匿型卒中还伴随围手术期谵妄(风险比 [HR] 2·24, 95% CI 1·06–4·73, 绝对风险增加 6%; p=0·030)及1年随访时隐匿型卒中或一过性脑缺血发作(HR 4·13, 1·14–14·99, 绝对风险增加 3%; p=0·019)风险增加。

Interpretation 结论

Perioperative covert stroke is associated with an increased risk of cognitive decline 1 year after non-cardiac surgery, and perioperative covert stroke occurred in one in 14 patients aged 65 years and older undergoing non-cardiac surgery. Research is needed to establish prevention and management strategies for perioperative covert stroke.

每14例接受非心脏手术的65岁以上患者中,就有1名发生围手术期隐匿型卒中,且伴随1年后认知功能下降风险增加。需要进行有关围手术期隐匿型卒中预防和治疗策略的研究。

Funding 资助

Canadian Institutes of Health Research; The Ontario Strategy for Patient Oriented Research support unit; The Ontario Ministry of Health and Long-Term Care; Health and Medical Research Fund, Government of the Hong Kong Special Administrative Region, China; and The Neurological Foundation of New Zealand.

评论[仅代表个人意见]

  • 有一些科学问题只能通过队列研究而非随机对照试验阐明。然而,队列研究为何能够发表在有影响的杂志上?
  • 这篇研究告诉我们,困难可能不在于方法学,而在于问题的普遍性和未知性
  • 简述本研究的方法学:非心脏手术后患者术前接受多项认知功能评估(这个有一定困难),术后行头颅MRI检查且临床没有明显的脑梗塞表现,随访一年时再次进行认知功能评估(这个也存在一定困难)
  • 由于术前没有进行MRI检查(几乎不可能),因此无法评估术前隐匿型脑梗塞的比例
  • 12个中心历时40个月入选1114名患者,平均每个中心每个月2.3例

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