Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,编辑版ppt,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,编辑版ppt,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,编辑版ppt,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,编辑版ppt,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,编辑版ppt,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,编辑版ppt,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,编辑版ppt,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,编辑版ppt,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,编辑版ppt,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,编辑版ppt,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,编辑版ppt,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,编辑版ppt,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,编辑版ppt,*,Perioperative StrokeRisks&Prevention,Chuanyao Tong,MD,Professor,Wake Forest School of Medicine,Winston-Salem,North Carolina,9/24/2016,11/17/2024,1,编辑版ppt,案例,70,岁的老年女性择期行经皮肾镜下碎石取石术,其他问题,:,国籍埃及，不会说英语,并存症,:,高血压,冠心病,糖尿病,慢性肾功能衰竭,(Cr 2.4),严重腰椎病变,右肾萎缩,(,不明原因,),BMI,指数,42(137 kg),术前用药,:,别嘌呤醇,Vit B12,硝酸异山梨酯片,60 mg,氢可酮,布洛芬,阿司匹林,(,已停药,5,天,),生命体征,:T 37,BP 180-120/74-57,HR 64-73,实验室检查,:Hgb 13,Hct 41,Plt 415;Na 138,K 5,Cl 109,CO2 21,BUN 28,Cr 2.11,Glu 91;,术前晚上由住院访视评估患者为,ASA2,级，并决定翌日行择期手术。,11/17/2024,2,编辑版ppt,术前与患者及家属谈话,患者女儿的状况：活动后容易气促，反复心悸，久坐的生活习惯因而也得了严重的腰痛。,超声心动图,:EF45%,左房与左室,室间隔与下壁收缩功能减弱。,心电图,:,心室率,94,1,房室传导阻滞,胸导联低电压。,特别交待患者及其家属以下情况：,“,患者本身极可能并存有心脏的器质性病变，术后住院期间可能需要请我院心内科医师会诊。,”,与泌尿外科医师协商：即使患者目前状态稳定仍需要实施,24,小时遥测心电监护。,11/17/2024,3,编辑版ppt,Anesthesia,麻醉诱导以及插管过程顺利。,麻醉过程中出现短暂的心动过速和低血压,予美托洛尔和去氧肾上腺素处理。,术后于手术室内拔管，苏醒及反射良好。,带,24,小时遥测心电监护离开,PACU,返回病房。,11/17/2024,4,编辑版ppt,术后病程记录,泌尿外住院医师,:“,患者整夜出现恶心呕吐，辗转难眠，必须给予对症治疗,”,9:00 am,心电监护提示一次长达,9,秒的窦性停搏,无伴意识丧失。但过了一会儿,就出现进行性的意识加深,说话含糊不清,复视,(,右眼斜视,),步伐不稳。,神经内科医师会诊后决定立即送往神经内科,ICU,治疗。,MRI/MRA:,右侧小脑梗死，可疑基底节腔隙性脑梗塞。,11/17/2024,5,编辑版ppt,MRI,(,急性小脑梗死及其他脑区明显陈旧性梗死灶,),后颅窝散在性的急性,/,亚急性缺血梗死灶,(,包括双侧小脑半球,左侧桥脑和右侧小脑脚。,局灶性左后颞叶,左枕部,后顶叶可见,老年性微血管缺血性改变。,MRA,(,大脑后动脉右优势型,，且基底节血栓形成可能,),大脑前循环,:,正常,.,无证据显示有动脉瘤,动脉狭窄或堵塞。,椎,-,基底动脉,:,远端基底动脉及大脑后左动脉流动信号中断。,病人为大脑后动脉右优势型,.,大脑后动脉有一起始于远端左颈内动脉的短小圆锥部分即可能为大脑后动脉左优势型。,(series one,images 69 through 72)versus an aneurysm or infundibulum.Diminutive flow related signal within the superior cerebellar arteries bilaterally.The distal left vertebral artery is diminutive relative to the right which may reflect its congenitally small size versus atherosclerosis.,11/17/2024,6,编辑版ppt,Cerebellum,infarction,Brainstem,小脑以及脑干新鲜梗死灶。,皮层及其他区域散在性陈旧性梗死灶。,11/17/2024,7,编辑版ppt,Fetal Type PCA,11/17/2024,8,编辑版ppt,The teams responses,神经科会诊,:,已经错过介入治疗以及血栓取出术的窗口期，,建议用阿司匹林和美托洛尔。,心内科会诊,:,窦性心律不齐,脑卒中风险高,不建议行起搏器植入,建议服用阿司匹林和美托洛尔缓释片。,神经外科会诊,:,没有手术指征，我科随诊。,患者家属,:,原定于,7,天内回国的计划泡汤，所以显得非常焦急。,麻醉,:,到底哪里出错？什么原因导致这样？有什么办法可以预防。,9,编辑版ppt,术后访视,48,小时后,意识状态无明显好转,但表情自如,自主呼吸,生命体征平稳,(,依然未行抗凝治疗,),72,小时后,患者开始苏醒,定向功能恢复,可以认出我是她的麻醉医生,再次提问,有什么办法能预防此事发生？,11/17/2024,10,编辑版ppt,定义,脑梗塞,局部或者广泛的脑血管源性缺氧缺氧，症状持续,24,小时或者,24,小时内死亡的。,TIA,局部或者广泛的脑血管源性缺血缺氧，症状出现迅速但持续少于,24,小时的。,腔隙性脑梗,(,更常见,),往往只能通过高端影像学检查（例如头颅,MRI,）才能发现的无症状性脑缺血事件,主要影响患者的认知功能和生活质量。,11,编辑版ppt,Incidence of Stroke after Surgery,N Engl J Med 2007;356:706-13,11/17/2024,12,编辑版ppt,N Engl J Med 2007;356:706-13,Anesthesiology 2011;115:879-90,Arch Surg 1990;125:986 9,普外手术的围术期发生脑卒中后的死亡率为,26%,，如患者本身术前已合并脑卒中，那么死亡率将升高至,86%,。,Incidence of Stroke from various surgery,普外,0.08-0.7,外周血管手术,0.8-3.0,头颈部肿瘤切除术,4.8,颈动脉内膜剥离术,5.5-6.1,单纯冠脉搭桥术,1.4-3.8,冠脉搭桥术,+,心脏瓣膜置换术,7.4,单纯心脏瓣膜置换术,4.8-8.8,两组或三组心脏瓣膜置换,9.7,大动脉修补术,8.7,13,编辑版ppt,围术期危险因素,年龄,70,岁,(,年纪越小,and,coexisting dz),女性,并存疾病,:,高血压,糖尿病,慢性肾病,(Cr2 mg/dl),吸烟,COPD,肺源性心脏病,冠心病,心律失常,慢性心力衰竭,(EF 40%),病史：,脑卒中或者,TIA,发生,75,）,1,D,糖尿病,（,DM,）,1,S2,脑卒中或,TIA,（,Stroke or TIA,）,2,风险因子,分数,C,慢性心力衰竭,/,左心功能衰竭,1,H,高血压,1,A,年龄,75,1,D,糖尿病,1,S2,脑卒中或,TIA,2,V,血管疾病,-CAD,MI,PCD,aortic plaque,1,A,年龄,65-74,1,Sc,女性,1,JAMA.2001.285(22):286470,Thromb Haemost.2010.5;104(1):45-8,17,编辑版ppt,得分,平均发生脑卒中的概率,0,1.9%,1,2.8%,2,4.0%,3,5.9%,4,8.5%,5,12.5%,6,18.2%,得分,风险,推荐处理措施,0,低,阿司匹林,(81-325 mg/,d,),1,中,阿司匹林,(81-321/d)or,华法林,(INR2-3),据症状调整,2,或者更高,高,华法林,(INR 2-3),除非有禁忌症否则一律华法林,18,编辑版ppt,抗凝剂,小手术或者没什么可能出现大出血的手术不应停用抗凝药,高风险的手术应停用抗凝药并开展桥接疗法,术后继续应用,ASAP,。,(SNACC 2014),患有房颤并服用华法林的患者择期手术前停用华法林,5,天发现,:1),在动脉血栓栓塞发