术前血压变异性对颈动脉狭窄患者颈动脉内膜剥脱术后脑灌注改变的影响

Influence of blood pressure variability before carotid endarterectomy in postoperative cerebral perfusion changes in patients with carotid artery stenosis

目的探讨术前血压变异性(BPV)是否与颈动脉狭窄患者颈动脉内膜剥脱术(CEA)后脑灌注改变相关。方法前瞻性纳入南方医科大学广东省人民医院神经外科自2019年1月至2022年12月收治并行CEA治疗的47例颈动脉狭窄患者为研究对象,于术前3 d起严密监测患者血压(4次/d)以获得其术前BPV(BPV以观察时间段内连续测量的收缩压或舒张压之间的最大绝对差值即最大△为标准),同时监测术后3 d内出现的脑灌注变化(脑高灌注标准为手术麻醉复苏后新出现谵妄、亢奋表现或经影像学检查发现存在颅内出血等,脑低灌注标准为手术麻醉复苏后新出现言语、运动等神经功能缺损或原有脑缺血症状加重,或影像学检查发现新发脑梗死等),应用受试者工作特征(ROC)曲线评价术前BPV对患者CEA术后脑灌注改变的预测效能。结果47例患者中9例(19.1%)术后脑灌注发生改变(5例脑高灌注、4例脑低灌注),其中2例患者因术后发生脑梗死遗留神经功能缺损,余7例患者均为术后短期的谵妄(5例)或局灶性神经功能缺损(2例)表现,经适当调整血压后均恢复正常。ROC曲线分析显示,术前BPV预测患者CEA术后脑灌注改变的ROC曲线下面积(AUC)为0.876(P=0.001,95%CI:0.775~0.977);进一步根据最佳指标阈值(27.00)将47例患者分为高BPV组(n=16)与低BPV组(n=31)后统计显示,2组患者间CEA术后脑灌注改变发生率的差异有统计学意义(P<0.05),其中高BPV组患者发生术后脑灌注改变的风险是低BPV组的15.5倍(RR=15.500,P<0.001,95%CI:2.120~113.320)。结论术前BPV可能有助于预测颈动脉狭窄患者CEA术后脑灌注改变的发生。

Objective To investigate whether the fluctuation of blood pressure variability(BPV)before carotid endarterectomy(CEA)is related to postoperative cerebral perfusion changes in patients with carotid artery stenosis.Methods A prospective observational cohort study was performed.Forty-seven patients with carotid artery stenosis accepted CEA in Department of Neurosurgery,Guangdong Provincial People's Hospital Affiliated to Southern Medical University from January 2019 to December 2022 were chosen.Patients'blood pressure was closely monitored 3 d before surgery(4 times/d)to obtain their BPV(the maximum△,based on the maximum absolute differences between systolic or diastolic blood pressures measured continuously during the observation period).At the same time,the changes of cerebral perfusion 3 d after surgery were monitored(criteria of cerebral hyperperfusion:newly-appeared delirium and hyperactivity after anesthesia resuscitation or intracranial hemorrhage found by imaging examination;criteria of cerebral hypoperfusion:newly-appeared speech and motor function deficits or aggravation of original cerebral ischemia symptoms after anesthesia resuscitation,or new-found cerebral infarction by imaging examination).Receiver operating characteristic(ROC)curve was used to evaluate the predictive efficacy of BPV before CEA in postoperative cerebral perfusion changes.Results In these 47 patients,9 patients(19.1%)had postoperative cerebral perfusion changes:2 had neurological deficits due to postoperative cerebral infarction,and the other 7 had short-term postoperative delirium or focal neurological deficits(returned to normal after appropriate adjustment of blood pressure).Area under the ROC curve(AUC)of BPV before CEA in predicting postoperative cerebral perfusion changes was 0.876(P=0.001,95%CI:0.775-0.977).These 47 patients were divided into high BPV group(n=16)and low BPV group(n=31)according to the optimal index threshold(27.00),and the statistics showed that significant difference in incidence of cerebral perfusion changes after CEA was noted between the 2 groups(P<0.05);incidence of postoperative cerebral perfusion changes in the high BPV group was 15.5 times higher than that in the low BPV group(RR=15.500,P<0.001,95%CI:2.120-113.320).Conclusion BPV before CEA in patients with carotid artery stenosis can well predict the occurrence of postoperative cerebral perfusion changes.