| 摘要: | 背景與目的：中風是影響發病率及死亡率之一重要因素，並且耗用龐大醫療資源。美國心臟協會2010年報告顯示，每年約795,000人在美國發生初次或復發性中風。復發性中風佔所有的中風約25~30%。儘管諸多中風預防之努力，中風復發仍普遍。中風病史或腦血管功能不全症狀是預測手術圍期中發生中風之顯著因子，因此如果中風或短暫性神經功能障礙尚未得到充分評估或近期才剛發生，擇期手術應考慮延後。現有文獻雖顯示手術圍期與再次中風(Recurrent Stroke)有關，惟系統化探討初次中風與之後手術之間隔對再次中風風險之研究闕如。本研究欲探討此期間長短與再次中風之相關，以作為未來臨床指引參考依據。
方法：利用2002~2009年國家衛生研究院全民健康保險資料庫之承保抽樣歸人檔，獲取初次中風樣本9,414人，進行次級資料分析。研究設計為回溯性世代研究(Retrospective cohort study)。以SAS 9.1進行描述性統計、卡方檢定及羅吉斯迴歸分析中風後接受手術之間隔及其他因素對再次中風之影響。
結果：有關初次中風病患接受擇期手術後再次中風之相對機率，女性低於男性（OR=0.744; 95% CI=0.627-0.881; p=0.0006）；高血壓 （OR=1.584; 95% CI=1.253-2.001; p=0.0001）、心房顫動（OR=2.648; 95% CI=1.789-3.920; p<0.0001）、高血脂（OR=3.398; 95% CI=2.497-4.622; p<0.0001）皆為再次中風之風險因子。卡方檢定與羅吉斯迴歸結果皆顯示，中風-手術間隔期間越長，再次中風機率越低。中風-手術間隔在10-12 個月（OR=0.625; 95% CI=0.425-0.919; p=0.0170）及≧12個月（OR=0.645; 95% CI=0.501-0.830; p=0.0007）皆顯示較低之再次中風機率。
結論與建議：病患罹患中風後，欲接受擇期手術者，在充分評估腦血管功能後，在中風後≧10個月後進行手術方可降低再次中風之機率。時值預防醫學甚受重視，中風手術間隔宜列臨床實務考量。
Background and Purpose: As one of the most costly diseases, stroke is also a major cause of morbidity and mortality in the general population. American Heart Association reported in 2010 that approximately 795,000 people in US suffered from new or recurrent stroke yearly. Recurrent stroke accounted for 25~30% of all strokes, and therefore, prevention of stroke recurrence is important to both individual and public health. History of stroke and symptoms of cerebrovascular insufficiency are the significant predictors of perioperative stroke. Elective surgery should be considered pending if a stroke or transient neurologic deficit has occurred recently. However, data are lacking on the safe time interval between previous stroke and the following surgical procedure (stroke-to-surgery time interval). This research sought to investigate a reasonable time interval between the previous stroke and the following surgical intervention that is considered safe among patients with history of stroke.
Methods: Data source is the longitudinal National Health Insurance Research Database (NHIRD) 2002~2009 with original claims data for 1,000,000 randomly sampled beneficiaries. In the design of retrospective cohort study, a total of 9,414 first-time stroke patients (ICD-9-CM codes 430-438) who subsequently underwent any surgical procedures one months later were included in the sample. Emergent surgeries, cardio-vascular and any related neurosurgical surgeries were excluded. SAS 9.1 was used to perform descriptive and inferential statistics, including Chi-square, bivariate and multivariate logistic regressions to generalize the effects of time-interval and related factors on perioperative recurrent stroke.
Result: Of all the sample, 626 (6.65%) experienced stroke recurrence. Female (OR=0.744; 95% CI=0.627-0.881; p=0.0006) showed lower odds of perioperative stroke recurrence, while hypertension (OR=1.584; 95% CI=1.253-2.001; p=0.0001), atrial fibrillation (OR=2.648; 95% CI=1.789-3.920; p<0.0001), and hypercholesterolemia (OR=3.398; 95% CI=2.497-4.622; p<0.0001) exhibited higher, among first-time stroke patients receiving elective surgeries. Chi-square and logistic regression results both proved that longer stroke-to-surgery time interval was significantly associated with lower odds of perioperative stroke recurrence. Stroke-to-surgery time interval at 10-12 months (OR=0.625; 95% CI=0.425-0.919; p=0.0170) and ≧12 months (OR=0.645; 95% CI=0.501-0.830; p=0.0007) showed evidence of lower perioperative stroke recurrence.
Conclusion: A safe ≧10 months of stroke-to-surgery time interval significantly lowered the likelihood of perioperative stroke recurrence. Therefore, elective surgeries with no urgency should not be performed until 10 months of stroke-to-surgery time interval is reached. We also suggest that the implication of stroke-to-surgery time interval on preventive medicine merits more attention among stroke practitioners. |
