老年脊柱疾病应用颈动脉超声评估缺血性脑卒中风险的临床价值

doi:10.6040/j.issn.1671-7554.0.2019.006

摘要/Abstract

摘要： 目的回顾性分析老年脊柱疾病患者术前通过颈动脉彩色多普勒超声联合颅脑磁共振血管成像(MRA)评估术后发生缺血性脑卒中风险的临床价值。方法选取2014年1月至2017年12月因脊柱疾病接受全身麻醉手术患者269例,根据术前是否常规行颈动脉超声及颅脑MRA筛查,分为筛查组和未筛查组。筛查组131例,其中男61例,女70例,50~83岁,平均(62.16±7.64)岁,术前合并高血压112例,糖尿病19例,冠心病21例,脑血管疾病11例。根据年龄将患者分为50~55岁、56~65岁、>65岁3个年龄段。未筛查组138例,其中男66例,女72例,50~77岁,平均(61.33±5.93)岁,术前合并高血压108例,糖尿病13例,冠心病18例,脑血管疾病12例。筛查组采用颈动脉彩色多普勒超声检查颈内动脉血流流速、内-中膜(IMT)厚度、斑块厚度等指标并对颈动脉狭窄程度分级(轻、中、重度狭窄)。存在颈动脉狭窄者行颅脑MRA检查,脑血管异常者则由神经内科及麻醉科医师评估术后缺血性脑卒中风险,若患者存在手术禁忌则暂缓手术行保守治疗。对两组发生脑卒中例数及相关因素进行统计学分析。结果筛查组超声检查示存在颈动脉狭窄57例(43.5%,轻度狭窄44例,中度狭窄8例,重度狭窄5例),继而行颅脑MRA检查,其中53例［男24例,女29例,52~81岁,平均(65.51±7.45)岁］出现脑血管异常。经评估手术风险无绝对禁忌者32例,风险较高者11例,手术禁忌且最终未行手术者10例。术后筛查组无患者出现缺血性脑卒中,未筛查组6例出现缺血性脑卒中(4.35%),两组差异有统计学意义(P=0.045)。通过年龄分层比较发现,>65岁患者出现颈动脉狭窄、中度以上狭窄(狭窄>50%)的比例高于其他两个年龄段(P=0.001,P=0.006),未行手术者比例高于56~65岁年龄段(P=0.021)。颈动脉重度狭窄合并颅脑MRA异常者较轻-中度狭窄者具有更高的手术风险(P=0.007)。相较于稳定斑块,不稳定斑块更易出现中-重度颈动脉狭窄(P<0.001),并且出现不稳定斑块患者的HDL-C水平低于稳定斑块患者［(1.22±0.26)mmol/L vs(1.39±0.31)mmol/L,P=0.036］,而LDL-C水平则高于稳定斑块患者［(3.02±0.88)mmol/L vs(2.59±0.64 )mmol/L,P=0.038］,两者手术禁忌患者比例差异无统计学意义(P=0.879)。通过多因素Logistic回归分析发现,年龄增长和脑血管病病史是出现颈动脉狭窄的相关危险因素。结论颈动脉超声筛查可常规作为老年脊柱患者术前评估缺血性脑卒中风险的评估手段,联合颅脑MRA检查可有效提高术后脑卒中风险评估准确性,有利于提高手术安全性并提示临床医生及时采取针对性干预手段预防缺血性脑卒中的发生。

关键词: 老年脊柱疾病, 术前筛查, 颈动脉超声, 颅脑MRA, 脑卒中风险

Abstract: Objective To analyze the clinical value of preoperative carotid Doppler ultrasound with magnetic resonance angiography(MRA)to assess the risk of postoperative ischemic stroke in elderly patients with spinal diseases. Methods 山东大学学报 (医学版)57卷5期 -陈希,等.老年脊柱疾病应用颈动脉超声评估缺血性脑卒中风险的临床价值 \=-During Jan. 2014 and Dec. 2017, 269 patients who received general anesthesia due to spinal diseases were divided into the screening and non-screening groups. The screening group(n=131)included 61 male and 70 female, aged 50-83 years, average(62.16±7.64)years. Hypertension was found in 112 cases, diabetes in 19 cases, coronary heart disease in 21 cases and cerebrovascular diseases in 11 cases. The screening group was then subdivided into three age groups: 50-55, 56-65 and >65 years. The non-screening group(n=138)included 66 male and 72 female, aged 50-77 years, average(61.33±5.93)years. Hypertension was found in 108 cases, diabetes in 13 cases, coronary heart disease in 18 cases, and cerebrovascular diseases in 12 cases. For the screening group, the blood flow velocity of internal carotid artery, thickness of intima-media thickness(IMT), thickness of plaques, and the degrees of carotid artery stenosis(mild, moderate and severe)were measured. Patients with carotid artery stenosis underwent craniocerebral MRA, and the risk of postoperative ischemic stroke was evaluated by neurologists and anesthesiologists. Conservative treatment was recommended to those who had surgical contraindications. The incidence of postoperative stroke and relevant factors were evaluated. Results In the screening group, 57 cases(43.5%)showed carotid stenosis(mild stenosis in 44 cases, moderate stenosis in 8 cases, severe stenosis in 5 cases), and craniocerebral MRA showed 53 cases had cerebral abnormalities ［24 male, 29 female, aged 52-81 years, average(65.5±7.45)years］. There were 32 cases with no absolute contraindications, 11 cases with high surgical risks, and 10 of which turned to conservative treatment. After operation, ischemic stroke occurred in 6 cases in the non-screening group but in no case in the screening group(P=0.045). According to the age stratification, patients aged ≥65 years had higher risk of moderate and severe carotid stenosis than the other two age groups (P=0.001, P=0.006), and had a higher rate of contraindications than the 56-65 years group (P=0.021). Patients with severe carotid artery stenosis and abnormal brain MRA had higher operative risk than those with mild-mederate stenosis (P=0.007). Compared with patients with stable plaques, those with unstable plaques had higher risk of moderate or severe carotid stenosis (P<0.001), lower level of HDL-C ［(1.22±0.26)mmol/L vs(1.39±0.31)mmol/L, P=0.036), higher level of LDL-C ［(3.02±0.88)mmol/L vs(2.59±0.64), P=0.038］, but there was no difference in the rate of surgical contraindications(P=0.879). Multivariate logistic analysis showed that old age and history of cerebrovascular diseases were risk factors of carotid artery stenosis. Conclusion Carotid Doppler ultrasound screening can be used as a tool for preoperative assessment of ischemic stroke risk in elderly patients with spinal diseases. Combined craniocerebral MRA screening can effectively improve the accuracy of assessment and promote the safety of surgery.

Key words: Elderly spinal diseases, Preoperative assessment, Carotid Doppler ultrasound, Craniocerebral magnetic resonance angiography, Ischemic stroke

中图分类号:

R574

陈希,刘新宇,范立霞,田永昊,原所茂. 老年脊柱疾病应用颈动脉超声评估缺血性脑卒中风险的临床价值[J]. 山东大学学报 (医学版), 2019, 57(5): 48-55.

CHEN Xi, LIU Xinyu, FAN Lixia, TIAN Yonghao, YUAN Suomao. Clinical value of carotid ultrasound in evaluating ischemic stroke risk in elderly patients with spinal diseases[J]. Journal of Shandong University (Health Sciences), 2019, 57(5): 48-55.

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