Risco de acidente vascular cerebral perioperatório e monitoramento de autorregulação cerebral: uma revisão sistemática

Santos, Daniel Paes de Almeida dos; Thirumala, Parthasarathy Deenadayalan; Reddy, Gautama; Barros, Daniel Ferreira de; Faria, Vinicius Naves Rezende; Shandal, Varun; Kurtz, Pedro

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Sumário

Original Article • Arq. Neuro-Psiquiatr. 80 (12) • 2022 • https://doi.org/10.1055/s-0042-1758648 copiar

Risco de acidente vascular cerebral perioperatório e monitoramento de autorregulação cerebral: uma revisão sistemática

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo

Antecedentes

Acidente vascular cerebral (AVC) perioperatório, delírio e comprometimento cognitivo podem estar relacionados ao manejo e à variações no controle da pressão arterial, à hipoperfusão cerebral, e ao aumento do volume sanguíneo. A autorregulação cerebral (ARC) é um mecanismo para manter a perfusão cerebral por meio do controle do tônus vascular e das reações hemodinâmicas na circulação.

Objetivo

Este trabalho aborda sistematicamente a determinação da relação entre a falha da ARC e o AVC perioperatório, com uma avaliação da taxa de complicações neurológicas pós-cirúrgicas em estudos em que a ARC perioperatória foi monitorada.

Métodos

Esta revisão sistemática incluiu ensaios clínicos randomizados e estudos observacionais prospectivos. Todos os estudos ajustaram o risco relativo, a razão de risco ou os valores de intervalo de confiança de 95% (IC95%). Esses efeitos de estimativas foram testados usando modelos de efeitos aleatórios. A heterogeneidade entre os diferentes estudos foi avaliada por meio das estatísticas de Higgins e Thompson I².

Resultados

As bases de dados eletrônicas Web of Science, PubMed e Embase foram pesquisadas para selecionar os artigos. Um total de 4.476 estudos publicados entre 1983 e 2019 foram analisados, mas apenas 5 se qualificavam para a extração de dados e foram incluídos na análise final. A coorte combinada do estudo foi composta por 941 pacientes. Todos os estudos forneceram informações sobre AVC perioperatório, o que equivaleu a 16% (158 de 941) da população geral de pacientes.

Conclusão

Esta meta-análise mostrou evidências do impacto do prejuízo da ARC no risco de AVC perioperatório. Na análise conjunta, as flutuações sanguíneas ou outros insultos cerebrais grandes o suficiente para comprometer a ARC foram associados ao resultado do AVC (razão de probabilidades [RP]: 2,26; IC95%: 1,54–2,98;p < 0,0001).

Palavras-chave
Ultrassonografia Doppler Transcraniana; Derivação Cardíaca Direita; Espectroscopia de Luz Próxima ao Infravermelho; Circulação Cerebrovascular

		Combined sample (n = 941)
Mean age (years)		65 (±1)
Sex: n (%)	Male	718 (76%)
Sex: n (%)	Female	221 (24%)
Medical history: n (%)	Hypertension	722 (76.7%)
	Diabetes	341 (36.2%)
	COPD	95 (10.1%)
Type of surgery: n (%)	CABG	560 (59.5%)
	CABG and valve	116 (12.3%)
	Valve	210 (22.3%)
	Thoracic aortic	3 (0.3%)
	CEA/CAS	35 (3.7%)
	Others	17 (1.8%)
Instrumentation: n (%)	TCD	396 (42.1%)
	NIRS	779 (82.8%)
	invasive BP	906 (96.3%)
	non-invasive BP	35 (3.16%)
	COx	671 (71.3%)
	TFA	35 (3.7%)
	Mx	361 (38.3%)
	MAP	906 (96.2%)
	CBF	234 (24.8%)
	ARI	108 (11.4%)
Outcomes: n (%)	Stroke	154 (16.37%)
Outcomes: n (%)	Mortality	16 (1.7%)

Papers	Modalities	Summary	Period
Joshi et al.²⁰20 Joshi B, Brady K, Lee J, et al. Impaired autoregulation of cerebral blood flow during rewarming from hypothermic cardiopulmonary bypass and its potential association with stroke. Anesth Analg 2010; 110(02):321–328. Doi: 10.1213/ANE.0b013e3181c6fd12 https://doi.org/10.1213/ANE.0b013e3181c6... (2010)	Monitoring through transcranial Doppler (TCD) of the blood flow velocity of the right and left middle cerebral arteries (MCAs)	Patients undergoing cardiopulmonary bypass (CPB) during cardiac surgery were submitted to TCD monitoring of the right and left MCAs. A continuous, moving Pearson correlation coefficient was calculated regarding the mean arterial blood pressure (MAP) and TCD blood flow velocities rendering the variable mean flow index (Mx)	Perioperative
Ono et al.²¹21 Ono M, Joshi B, Brady K, et al. Risks for impaired cerebral autoregulation during cardiopulmonary bypass and postoperative stroke. Br J Anaesth 2012;109(03):391–398. Doi: 10.1093/bja/aes148 https://doi.org/10.1093/bja/aes148... (2012)	Cerebral blood flow (CBF) by TCD velocity, and near-infrared spectroscopy (NIRS) data	All enrolled patients underwent coronary artery bypass graft (CABG) surgery, valvular surgery, or both, which required CPB. NIRS regional cerebral oxygen saturation (rSCO2) monitoring with an INVOS monitor and bilateral TCD monitoring of the middle cerebral arteries (MCAs). A continuous, moving Pearson correlation coefficient was calculated regarding MAP and CBF velocity to generate the Mx and cerebral oxygenation index (COx).	Perioperative
Ono et al.²²22 Ono M, Brady K, Easley RB, et al. Duration and magnitude of blood pressure below cerebral autoregulation threshold during cardiopulmonary bypass is associated with major morbidity and operative mortality. J Thorac Cardiovasc Surg 2014;147(01):483–489. Doi: 10.1016/j.jtcvs.2013.07.069 https://doi.org/10.1016/j.jtcvs.2013.07.... (2014)	rScO2 mesured through a NIRS monitor	Autoregulation was monitored during CPB, patients were connected to NIRS monitor. A continuous, moving Pearson correlation coefficient regarding the MAP and NIRS signals was then calculated to generate the variable COx	Perioperative
Semenyutin et al.²³23 Semenyutin VB, Asaturyan GA, Nikiforova AA, et al. Predictive Value of Dynamic Cerebral Autoregulation Assessment in Surgical Management of Patients with High-Grade Carotid Artery Stenosis. Front Physiol 2017;8:872. Doi: 10.3389/fphys.2017.00872 https://doi.org/10.3389/fphys.2017.00872... (2017)	Blood flow velocity (BFV) by TCD; ultrasound by Multidop TCD with 2 MHz transducers	Classified the patients with severe internal carotid artery stenosis according to preoperative state of cerebral autoregulation (CAR) and to assess its dynamics after surgery. The spectral amplitude of blood pressure (BP) and BFV derived from spectral power, phase shift (PS), and coherence coefficient were calculated in specifically selected range of systemic Mayer waves (M-waves) – transfer function analysis (TFA). This frequency band commonly reflects periodic BP fluctuations and is most informative for the assessment of the myogenic component of cerebrovascular response comparing with high-frequency oscillations	Preoperative and postoperative
Chan and Aneman²⁴24 Chan B, Aneman A. A prospective, observational study of cerebrovascular autoregulation and its association with delirium following cardiac surgery. Anaesthesia 2019;74(01):33–44. Doi: 10.1111/ anae.14457 https://doi.org/10.1111/anae.14457... (2019)	NIRS monitor	The FORESIGHT Elite NIRS monitor was used to continuously measure the oxygen saturation of the cerebral tissue. CAR was assessed by the Pearson correlation regarding NIRS-derived cerebral tissue oxygen saturation and mean arterial pressure to derive the tissue oxygenation index. The MAP corresponding to a tissue oxygenation index threshold of 0.30 was also calculated to represent the lower (LLA) and upper (ULA) limits of autoregulation, and to calculate the range of intact autoregulation (LLA-ULA). The parameters evaluated were: optimal MAP, optimal tissue oxygenation index, LLA, ULA and range (autoregulation index, ARI)	Postoperative

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[1] Address for correspondence Daniel P. A. Santos (e-mail: santosdpa@yahoo.com.br).