加拿大麦克马斯特大学P.J. Devereaux研究组对非心脏手术患者围手术期隐性卒中进行了一项前瞻性队列研究。该项研究成果发表在2019年9月21日出版的《柳叶刀》上。

这项研究在9个国家的12个学术中心完成。参与者年龄为65岁及以上，均住院择期行非心脏手术，术后行脑MRI，由两位神经放射学专家独立评估是否有隐形卒中。

2014年3月24日至2017年7月21日，1114名参与者中有78人（7%）发生围手术期隐性卒中。69名有围手术期隐性卒中的患者中有29名（42%）在术后1年内出现认知功能下降，而在932名无围手术期隐性卒中的患者中有274名（29%）认知下降，校正风险比为1.98。隐性卒中与围手术期谵妄的风险增加有关，风险比为2.24，还与1年内显性卒中或短暂性缺血发作相关，风险比为4.13。

总之，围手术期隐性卒中与非心脏手术1年后认知功能下降呈正相关，在接受非心脏手术的65岁及以上患者中，每14名患者里就有1名发生围手术期隐性卒中。

据悉，在非手术治疗中，隐性卒中比显性卒中更常见，且与认知功能下降相关。虽然在非心脏手术后不到1％的成人发生显性卒中，且病情严重，但大家对围手术期隐性卒中知之甚少。

附：英文原文

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

Author: Marko Mrkobrada, Matthew T.V. Chan, David Cowan, Douglas Campbell, Chew Yin Wang, David Torres, German Malaga, Robert D. Sanders, Manas Sharma, Carl Brown, Alben Sigamani, Wojciech Szczeklik, Mukul Sharma, Gordon Guyatt, Eric E. Smith, Ronit Agid, Adam A. Dmytriw, Jessica Spence, Nikesh R. Adunuri, Flavia K. Borges, Timothy G. Short, Michael D. Hill, Feryal Saad, Ingrid Copland, Shirley Pettit, Quazi Ibrahim, Shrikant I. Bangdiwala, Salim Yusuf, Scott Tsai, Demetrios J Sahlas, Arun Mensinkai, Luciano A Sposato, Sara Hussain, Steven Yang, Deborah Siegal, Alexander Khaw, Jennifer Mandzia, Sara Simpson, Manoj Raval, Ahmer Karimuddin, PT Phang, Vincent CT Mok, William KK Wu, Simon CH Yu, Tony Gin, Pui San Loh, Mun Thing Liew, Norlisah Ramli, Yee Lein Siow, Maite Fuentes, Victor Ortiz-Soriano, Ellen Waymouth, Jonathan Kumar, Divya Sadana, Lenimol Thomas, Bogusz Kaczmarek, Heidi Lindroth, Daniel Sessler, Sarah Apolcer, Amelia Trombetta, Stephanie Handsor, Monidipa Dasgupta, John M Murkin, Shun Fu Lee, P.J. Devereaux

Issue&Volume: Volume 394 Number 10203

Summary: 

Background

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.

Methods

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.

Findings

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).

Interpretation

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.

Funding

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.

DOI: 10.1016/S0140-6736(19)31795-7

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31795-7/fulltext