老年开颅肿瘤切除患者围手术期同时并发缺血性卒中及脑出血报道

doi:10.3969/j.issn.1673-5765.2024.07.010

摘要/Abstract

摘要：

目的观察老年开颅肿瘤切除术围手术期合并缺血性卒中及脑出血患者的临床特点，为老年开颅肿瘤切除术患者围手术期的麻醉管理提供参考。

方法连续回顾首都医科大学附属北京天坛医院2018年1月—2020年10月收治的年龄65岁以上，择期进行了开颅肿瘤切除术的患者资料，对围手术期同时并发缺血性卒中及脑出血患者的一般资料、临床资料和影像学特征进行总结。

结果研究期间共6例老年患者围手术期同时合并缺血性卒中及脑出血，年龄65～72岁，男性、女性各3例（50%）。其中5例（83%）患者为恶性肿瘤，4例（67%）为胶质母细胞瘤；5例（83%）患者肿瘤最大径≥40 mm；5例（83%）患者合并高血压，其中2例（33%）既往有缺血性脑血管病；2例（33%）合并糖尿病。术中有2例（33%）患者发生低血压。6例（100%）患者术后首次发现的缺血性卒中为隐匿性卒中，2例（33%）患者缺血性卒中发生于脑出血前，3例（50%）患者脑出血发生在术后48 h内，1例（17%）患者在血肿清除术后再次发生缺血性卒中，且为大面积脑梗死。1例（17%）患者自动出院，NIHSS评分为25分，深昏迷状态；其他患者出院时有2例（33%）NIHSS评分为1分，其余3例（50%）NIHSS评分为0分。

结论老年开颅肿瘤切除术患者围手术期合并缺血性卒中和脑出血预后欠佳，多合并高血压病史。本研究中发现的缺血性卒中多为隐匿性，提示对老年患者需注意围手术期卒中轻微或可疑症状的观察，及时诊疗。

文章导读：

临床上，外科手术患者围手术期同时并发出血性和缺血性卒中的情况虽然少见，但此类患者，特别是老年患者的预后往往欠佳，本文对这类少见情况进行了临床病例总结，为临床诊疗提供了一定的借鉴。

关键词: 老年; 脑肿瘤; 围手术期; 缺血性卒中; 脑出血

Abstract:

Objective To observe the clinical characteristics of geriatric patients who underwent craniotomy for tumor resections and simultaneously complicated with ischemic stroke and intracerebral hemorrhage during the perioperative period, and to provide a reference on perioperative anesthesia management of geriatric patients who underwent craniotomy for tumor resections.

Methods The data of patients over 65 years old who underwent craniotomy for tumor resections were continuously collected in Beijing Tiantan Hospital, Capital Medical University from January 2018 to October 2020, and the general data, clinical data, and imaging characteristics of patients simultaneously complicated with perioperative ischemic stroke and intracerebral hemorrhage were summarized.

Results A total of 6 geriatric patients had perioperative ischemic stroke combined with intracerebral hemorrhage during the study period, aged from 65 to 72 years, 3 cases (50%) of males and 3 cases (50%) of females. Among them, 5 (83%) patients had malignant tumors, 4 (67%) had glioblastoma, and 5 (83%) patients had tumors with a maximum diameter of≥40 mm. Five (83%) patients had hypertension, 2 (33%) patients had ischemic cerebrovascular disease, and 2 (33%) patients had diabetes mellitus. Two (33%) patients occurred hypotension intraoperatively. All postoperative ischemic stroke detected was a cryptogenic stroke, 2 (33%) patients had an ischemic stroke before intracerebral hemorrhage, 3 (50%) patients had intracerebral hemorrhage within 48 h after surgery, and 1 (17%) patient had ischemic stroke again after hematoma removal, with a large cerebral infarction. One (17%) patient was discharged automatically with an NIHSS score of 25 and a deep coma. At the time of discharge, 2 (33%) patients had an NIHSS score of 1, and the remaining 3 (50%) patients had an NIHSS score of 0.

Conclusions Geriatric patients undergoing craniotomy for tumor resections complicated with ischemic stroke and intracerebral hemorrhage during the perioperative period have poor prognosis, and most of them have a history of hypertension. Most of the ischemic stroke found in this study was cryptogenic stroke, suggesting that geriatric patients should pay attention to the observation of mild or suspicious symptoms of perioperative stroke and timely diagnosis and treatment.

Key words: Geriatric; Brain tumor; Perioperative period; Ischemic stroke; Intracerebral hemorrhage

中图分类号:

赵岩, 姚婧鑫, 彭宇明.

老年开颅肿瘤切除患者围手术期同时并发缺血性卒中及脑出血报道 [J]. 中国卒中杂志, 2024, 19(7): 797-802.

ZHAO Yan, YAO Jingxin, PENG Yuming. A Report of Simultaneous Complications of Ischemic Stroke and Intracerebral Hemorrhage in Geriatric Patients Undergoing Craniotomy for Tumor Resections during the Perioperative Period [J]. Chinese Journal of Stroke, 2024, 19(7): 797-802.

参考文献

[1] BENESCH C，GLANCE L G，DERDEYN C P，et al. Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac，nonneurological surgery：a scientific statement from the American Heart Association/American Stroke Association[J/OL]. Circulation，2021，143（19）：e923-e946[2023-09-08]. https://doi.org/10.1161/cir.0000000000000968.

[2] AL-HADER R，AL-ROBAIDI K，JOVIN T，et al. The incidence of perioperative stroke：estimate using state and national databases and systematic review[J]. J Stroke，2019，21（3）：290-301.

[3] SANDERS R D，GROCOTT H P. Perioperative stroke：time to redefine the impact of age？[J]. Stroke，2012，43（1）：3-5.

[4] NeuroVISION Investigators. Perioperative covert stroke in patients undergoing non-cardiac surgery（NeuroVISION）：a prospective cohort study[J]. Lancet，2019，394（10203）：1022-1029.

[5] BOKURA H，KOBAYASHI S，YAMAGUCHI S，et al. Silent brain infarction and subcortical white matter lesions increase the risk of stroke and mortality：a prospective cohort study[J]. J Stroke Cerebrovasc Dis，2006，15（2）：57-63.

[6] WANG C H，NIU X D，REN Y M，et al. Risk factors for postoperative intracranial hemorrhage after resection of intracranial tumor in 2259 consecutive patients[J/OL]. World Neurosurg，2019，129：e663-e668[2023-09-08]. https://doi.org/10.1016/j.wneu.2019.05.239.

[7] SONG X W，ZENG C F，WANG M Z，et al. Clinical characteristics and risk factors of perioperative outcomes in elderly patients with intracranial tumors[J]. Neurosurg Rev，2021，44（1）：389-400.

[8] YU Q，QI J T，WANG Y W. Intraoperative hypotension and neurological outcomes[J]. Curr Opin Anaesthesiol，2020，33（5）：646-650.

[9] HSIEH J K，DALTON J E，YANG D，et al. The association between mild intraoperative hypotension and stroke in general surgery patients[J]. Anesth Analg，2016，123（4）：933-939.

[10] BIJKER J B，PERSOON S，PEELEN L M，et al. Intraoperative hypotension and perioperative ischemic stroke after general surgery：a nested case-control study[J]. Anesthesiology，2012，116（3）：658-664.

[11] DIETVORST S，DEPREITERE B，MEYFROIDT G. Beyond intracranial pressure：monitoring cerebral perfusion and autoregulation in severe traumatic brain injury[J]. Curr Opin Crit Care，2023，29（2）：85-88.

[12] NOMURA Y，FAEGLE R，HORI D，et al. Cerebral small vessel，but not large vessel disease，is associated with impaired cerebral autoregulation during cardiopulmonary bypass：a retrospective cohort study[J]. Anesth Analg，2018，127（6）：1314-1322.

[13] PESEK M，KIBLER K，EASLEY R B，et al. The upper limit of cerebral blood flow autoregulation is decreased with elevations in intracranial pressure[J]. Neurosurgery，2014，75（2）：163-170.

[14] 中华医学会麻醉学分会老年人麻醉与围术期管理学组，国家老年疾病临床医学研究中心，国家老年麻醉联盟. 中国老年患者围手术期麻醉管理指导意见（2020版）（二）[J]. 中华医学杂志，2020，100（33）：2565-2578.

Geriatric Anesthesia and Perioperative Medical Management Group，Chinese Association of Anesthesiology; National Clinical Research Center for Geriatric Diseases; National Alliance of Geriatric Anaesthesia. Guidelines on perioperative anaesthesia management for elderly patients in China（2020）[J]. Natl Med J China，2020，100（33）：2565-2578.

[15] GBD 2019 Stroke Collaborators. Global，regional，and national burden of stroke and its risk factors，1990—2019：a systematic analysis for the global burden of disease study 2019[J]. Lancet Neurol，2021，20（10）：795-820.

[16] LIU D C，NIE X M，PAN Y S，et al. Adverse outcomes associated with higher mean blood pressure and greater blood pressure variability immediately after successful embolectomy in those with acute ischemic stroke，and the influence of pretreatment collateral circulation status[J/OL]. J Am Heart Assoc，2021，10（5）：e019350[2023-09-08]. https://doi.org/10.1161/jaha.120.019350.

[17] ROBBA C，BERTUETTI R，RASULO F，et al. Coagulation management in patients undergoing neurosurgical procedures[J]. Curr Opin Anaesthesiol，2017，30（5）：527-533.

[18] SIMMONS J W，POWELL M F. Acute traumatic coagulopathy：pathophysiology and resuscitation[J/OL]. Br J Anaesth，2016，117（suppl 3）：iii31-iii43[2023-09-08]. https://doi.org/10.1093/bja/aew328.

[19] AL-SAMKARI H，CONNORS J M. Managing the competing risks of thrombosis，bleeding，and anticoagulation in patients with malignancy[J]. Blood Adv，2019，3（22）：3770-3779.

[20] KIRSCHEN M P，MAJMUDAR T，BEAULIEU F，et al. Deviations from NIRS-derived optimal blood pressure are associated with worse outcomes after pediatric cardiac arrest[J/OL]. Resuscitation，2021，168：110-118[2023-09-08]. https://doi.org/10.1016/j.resuscitation.2021.09.023.

[21] OLSEN M H，RIBERHOLT C G，MEHLSEN J，et al. Reliability and validity of the mean flow index（Mx）for assessing cerebral autoregulation in humans：a systematic review of the methodology[J]. J Cereb Blood Flow Metab，2022，42（1）：27-38.

[22] WANG K，WU M G，XU J，et al. Effects of dexmedetomidine on perioperative stress，inflammation，and immune function：systematic review and meta-analysis[J]. Br J Anaesth，2019，123（6）：777-794.