术前CTA预测急性A型主动脉夹层术后脑并发症的危险因素
|
摘要
目的研究急性Standford A型主动脉夹层术后脑神经系统并发症(Neurological Dysfunction,ND)的CTA征象的危险因素。方法回顾2014年1月至2016年6月255例经急诊外科手术治疗的急性Standford A型主动脉夹层患者的临床及影像资料。对术后脑神经系统并发症:永久性神经系统功能不全(Permanent Neurological Dysfunction,PND)及短暂性神经系统功能不全(Temporary Neurological Dysfunction,TND)的影响因素分别进行单因素分析,将单因素分析中具有统计学差异的变量进行logistic回归多因素分析。影响因素包括临床基线资料、术中资料,及术前CTA影像特征。结果 255例患者中出现术后脑神经系统并发症共56例(21.96%),其中PND 18例(7.06%),TND 38例(14.90%)。Logistic回归多因素分析显示:主动脉弓部破口(OR=21.325,P=0.008)、颈总动脉撕裂(OR=14.441,P=0.022)及一侧颈内动脉密度减低(OR=9.141,P=0.024)是术后TND的危险因素;主动脉逆行撕裂(OR=5.622,P=0.003)、主动脉弓部破口(OR=6.742,P=0.006)是术后PND的危险因素。结论主动脉弓部破口、颈总动脉撕裂及一侧颈内动脉密度减低,是术后TND独立危险因素;而弓部破口及主动脉逆行撕裂是PND独立危险因素。术前CTA提供的高风险征象是早期预防、干预脑神经系统并发症发生的有利证据。
Objective To analyze risk factors for cerebral neurological injury after operation of acute Stanford type A aortic dissection to CTA morphological study. Methods From January 2015 to June 2016, 110 cases of acute Stanford type A aortic dissection patients underwent aortic arch replacement were retrospectively analyzed. Univariate and multivariate analysis(multiple logistic regression) were used to identify the risk factors for postoperative cerebral neurological injury including permanent neurological dysfunction(PND) and temporary neurological dysfunction(TND). Results Cerebral neurological injury occurred in 18 cases(18%), PND 4 cases(4%) and TND 14 cases(14%). Preoperative imaging features of CTA of 18 patients with postoperative ND: arotic arch intimal tear 17 cases(94.4%), common carotid artery dissection 15 cases(83.3%) dissection involving right ICA 13 cases(72.2%), and low attenuation in unilateral ICA 8 cases(44.4%). Multiple logistic regression showed that arotic arch intimal tear(OR=21.325, P=0.008), common carotid artery dissection(OR=14.441, P=0.022) and low attenuation in unilateral ICA(OR=9.141, P=0.024) were independent risk factors for ND. Conclusion Preoperative CTA image characteristics(arotic arch intimal tear, common carotid artery dissection, low attenuation in unilateral ICA) indicate the occurrence of ND. These signs can indicate intracranial ischemia, provide clinical evidence for early intervention to reduce the happening of the ND.
Objective To analyze risk factors for cerebral neurological injury after operation of acute Stanford type A aortic dissection to CTA morphological study. Methods From January 2015 to June 2016, 110 cases of acute Stanford type A aortic dissection patients underwent aortic arch replacement were retrospectively analyzed. Univariate and multivariate analysis(multiple logistic regression) were used to identify the risk factors for postoperative cerebral neurological injury including permanent neurological dysfunction(PND) and temporary neurological dysfunction(TND). Results Cerebral neurological injury occurred in 18 cases(18%), PND 4 cases(4%) and TND 14 cases(14%). Preoperative imaging features of CTA of 18 patients with postoperative ND: arotic arch intimal tear 17 cases(94.4%), common carotid artery dissection 15 cases(83.3%) dissection involving right ICA 13 cases(72.2%), and low attenuation in unilateral ICA 8 cases(44.4%). Multiple logistic regression showed that arotic arch intimal tear(OR=21.325, P=0.008), common carotid artery dissection(OR=14.441, P=0.022) and low attenuation in unilateral ICA(OR=9.141, P=0.024) were independent risk factors for ND. Conclusion Preoperative CTA image characteristics(arotic arch intimal tear, common carotid artery dissection, low attenuation in unilateral ICA) indicate the occurrence of ND. These signs can indicate intracranial ischemia, provide clinical evidence for early intervention to reduce the happening of the ND.
引文
[1]Dumfarth J,Kofler M,Stastny L,et al.Stroke after emergent surgery for acute type A aortic dissection:predictors,outcome and neurological recovery?[J].Eur J Cardio-Thoracic,2018,(53):1013-1020.
[2]罗海燕,胡克俭,刘祖赟,等.A型主动脉夹层术后脑部并发症危险因素分析[J].中华胸心血管外科杂志,2009,25(3):148-150.
[3]赵宏亮,郑敏文,段维勋,等.低剂量双源CT头颈主动脉联合扫描的可行性及在A型主动脉夹层的临床应用价值[J].中国医疗设备,2017,32(11):8-11.
[4]刘红,常谦,张海涛,等.急性Stanford A型主动脉夹层术后脑神经系统并发症的危险因素[J].中华胸心血管外科杂志,2014,30(6):342-345.
[5]Conzelmann LO,Hoffmann I,Blettner M,et al.Analysis of risk factors for neurological dysfunction in patients with acute aortic dissection type A:data from the German Registry for Acute Aortic Dissection type A(GERAADA)[J].Eur J Cardiothorac Surg,2012,42(3):557-565.
[6]Bossone E,Corteville DC,Harris KM,et al.Stroke and outcomes in patients with acute type A aortic dissection[J].Circulation,2013,128(S1):175-179.
[7]赵宏亮,王晋,郑敏文,等.CTA对急性A型主动脉夹层术前头颈血管评估应用价值研究[J].医疗卫生装备,2018,61-64.
[8]Krüger T,Weigang E,Hoffmann I,et al.Cerebral protection during surgery for acute aortic dissection type A:results of the German registry for acute aortic dissection type A(GERAADA)[J].Circulation,2011,124(4):434-443.
[9]Khaladj N,Shrestha M,Meck S,et al.Hypothermic circulatory arrest with selective antegrade cerebral perfusion in ascending aortic and aortic arch surgery:a risk factor analysis for adverse outcome in501 patients[J].J Thoracic Cardiovasc Surg,2008,135(4):908-914.
[10]Haldenwang PL,Wahlers T,Himmels A,et al.Evaluation of risk factors for transient neurological dysfunction and adverse outcome after repair of acute type A aortic dissection in 122 consecutive patients[J].Eur Cardiothorac Thorac,2012,42(5):115-120.
[11]Buonocore M,Amarelli C,Scardone M,et al.Cerebral perfusion issues in acute type A aortic dissection without preoperative malperfusion:how do surgical factors affect outcomes[J].Eur JCardiothorac Surg,2016,50:652-659.
[12]马贵洲,徐荣和,余丹青,等.主动脉夹层神经系统并发症的研究进展[J].心血管病学进展,2010,31(3):422-426.
[13]Wen D,Zhao H,Duan W,et al.Combined CT angiography of the aorta and craniocervical artery:a new imaging protocol for assessment of acute type A aortic dissection[J].J Thorac Dis,2017,9(11):4733.
[14]Gaul C,Dietrich W,Friedrich I,et al.Neurological symptoms in type A aortic dissections[J].Stroke,2007,38(2):292-297.
[15]Liu H,Chang Q,Zhang HT,et al.Predictors of adverse outcome and transient neurological dysfunction following aortic arch replacement in 626 consecutive patients in China[J].Heart Lung Circul,2016:S1443950616300026.
[16]Matsubara S,Koga M,Ohara T,et al.Cerebrovascular imaging of cerebral ischemia in acute type A aortic dissection[J].J Neurol Sci,2018,388:23-27.
[2]罗海燕,胡克俭,刘祖赟,等.A型主动脉夹层术后脑部并发症危险因素分析[J].中华胸心血管外科杂志,2009,25(3):148-150.
[3]赵宏亮,郑敏文,段维勋,等.低剂量双源CT头颈主动脉联合扫描的可行性及在A型主动脉夹层的临床应用价值[J].中国医疗设备,2017,32(11):8-11.
[4]刘红,常谦,张海涛,等.急性Stanford A型主动脉夹层术后脑神经系统并发症的危险因素[J].中华胸心血管外科杂志,2014,30(6):342-345.
[5]Conzelmann LO,Hoffmann I,Blettner M,et al.Analysis of risk factors for neurological dysfunction in patients with acute aortic dissection type A:data from the German Registry for Acute Aortic Dissection type A(GERAADA)[J].Eur J Cardiothorac Surg,2012,42(3):557-565.
[6]Bossone E,Corteville DC,Harris KM,et al.Stroke and outcomes in patients with acute type A aortic dissection[J].Circulation,2013,128(S1):175-179.
[7]赵宏亮,王晋,郑敏文,等.CTA对急性A型主动脉夹层术前头颈血管评估应用价值研究[J].医疗卫生装备,2018,61-64.
[8]Krüger T,Weigang E,Hoffmann I,et al.Cerebral protection during surgery for acute aortic dissection type A:results of the German registry for acute aortic dissection type A(GERAADA)[J].Circulation,2011,124(4):434-443.
[9]Khaladj N,Shrestha M,Meck S,et al.Hypothermic circulatory arrest with selective antegrade cerebral perfusion in ascending aortic and aortic arch surgery:a risk factor analysis for adverse outcome in501 patients[J].J Thoracic Cardiovasc Surg,2008,135(4):908-914.
[10]Haldenwang PL,Wahlers T,Himmels A,et al.Evaluation of risk factors for transient neurological dysfunction and adverse outcome after repair of acute type A aortic dissection in 122 consecutive patients[J].Eur Cardiothorac Thorac,2012,42(5):115-120.
[11]Buonocore M,Amarelli C,Scardone M,et al.Cerebral perfusion issues in acute type A aortic dissection without preoperative malperfusion:how do surgical factors affect outcomes[J].Eur JCardiothorac Surg,2016,50:652-659.
[12]马贵洲,徐荣和,余丹青,等.主动脉夹层神经系统并发症的研究进展[J].心血管病学进展,2010,31(3):422-426.
[13]Wen D,Zhao H,Duan W,et al.Combined CT angiography of the aorta and craniocervical artery:a new imaging protocol for assessment of acute type A aortic dissection[J].J Thorac Dis,2017,9(11):4733.
[14]Gaul C,Dietrich W,Friedrich I,et al.Neurological symptoms in type A aortic dissections[J].Stroke,2007,38(2):292-297.
[15]Liu H,Chang Q,Zhang HT,et al.Predictors of adverse outcome and transient neurological dysfunction following aortic arch replacement in 626 consecutive patients in China[J].Heart Lung Circul,2016:S1443950616300026.
[16]Matsubara S,Koga M,Ohara T,et al.Cerebrovascular imaging of cerebral ischemia in acute type A aortic dissection[J].J Neurol Sci,2018,388:23-27.