De Vleeschouwer S, Van Calenbergh F, van Loon J, Nuttin B, Goffin J, Plets C
Dept. of Neurosurgery, University Hospital Gasthuisberg, Leuven, Belgium.
Acta Chir Belg. 2005 May-Jun;105(3):268-74. doi: 10.1080/00015458.2005.11679715.
Intracranial haemorrhage (ICH) is a rare but potentially devastating complication of oral anticoagulants (OAC). This raises the difficult clinical choice between either permanent cessation of OAC, or continuing OAC and if so, when to restart. To make this choice, one needs to balance the thrombo-embolic risk after cessation of OAC against the risk of recurrent intracranial haemorrhage when OAC are restarted. There are few published data to base this difficult clinical decision on.
We present an observational study of a consecutive series of 108 patients, collected prospectively and admitted to our department, with an OAC-related intracranial haemorrhage, in whom we assessed the thrombotic event rate and the recurrent intracranial bleeding rate during follow-up.
In the 25 patients in whom OAC were reinstituted no new thrombo-embolic events occurred (0/506 unprotected patient-days). In the group of patients in whom OAC were not restarted (n = 81), the thrombo-embolic event rate was 8/11590 unprotected patient-days, of which only 2 were cerebrovascular thrombo-embolisms. The overall risk of a thrombo-embolic complication can be estimated to be 0.66 events/1000 patient-days at risk (95% exact confidence limits of 0.3 to 1.3 events/1000 patient-days at risk). In three patients the thrombo-embolic event was fatal. We saw recurrent intracranial bleeding in eight patients, 2 of which were fatal. Seven of these occurred before the restarting of the OAC.
In OAC-related intracranial haemorrhages, OAC can be stopped safely for a considerable period, with a very low overall thrombotic event rate. The recurrent bleeding risk after restarting OAC is low. Recurrent bleeding mostly occurred before restarting OAC and is probably caused by insufficient or unsustained correction of the initial coagulation deficit. Immediate reversal of anticoagulation provides the patient with the best possible treatment options including surgery. OAC-related intracranial haemorrhages can therefore be actively treated.
颅内出血（ICH）是口服抗凝剂（OAC）罕见但可能具有毁灭性的并发症。这引发了一个艰难的临床抉择，即要么永久停用OAC，要么继续使用OAC，如果继续使用，何时重新开始。为做出这一选择，需要权衡停用OAC后的血栓栓塞风险与重新启用OAC时颅内出血复发的风险。几乎没有已发表的数据可作为这一艰难临床决策的依据。
我们对连续108例患者进行了一项观察性研究，这些患者均前瞻性收集并入住我科，患有与OAC相关的颅内出血，我们评估了随访期间的血栓形成事件发生率和颅内出血复发率。
在重新启用OAC的25例患者中，未发生新的血栓栓塞事件（506个未受保护的患者日中0例）。在未重新启用OAC的患者组（n = 81）中，血栓栓塞事件发生率为11590个未受保护的患者日中8例，其中只有2例为脑血管血栓栓塞。血栓栓塞并发症的总体风险估计为每1000个有风险的患者日0.66例事件（95%精确置信区间为每1000个有风险的患者日0.3至1.3例事件）。3例患者的血栓栓塞事件是致命的。我们观察到8例患者出现颅内出血复发，其中2例致命。其中7例发生在重新启用OAC之前。
在与OAC相关的颅内出血中，OAC可以安全停用相当长一段时间，总体血栓形成事件发生率非常低。重新启用OAC后的出血复发风险较低。出血复发大多发生在重新启用OAC之前，可能是由于初始凝血缺陷的纠正不足或不持续所致。立即逆转抗凝可为患者提供包括手术在内的最佳治疗选择。因此，与OAC相关的颅内出血可以得到积极治疗。
