Stead Latha G, Jain Anunaya, Bellolio M Fernanda, Odufuye Adetolu O, Dhillon Ravneet K, Manivannan Veena, Gilmore Rachel M, Rabinstein Alejandro A, Chandra Raghav, Serrano Luis A, Yerragondu Neeraja, Palamari Balavani, Decker Wyatt W
Department of Emergency Medicine, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA.
Clin Neurol Neurosurg. 2010 May;112(4):275-81. doi: 10.1016/j.clineuro.2009.12.002. Epub 2009 Dec 29.
To assess the impact of anticoagulants and antiplatelet agents on the severity and outcome of spontaneous non-traumatic intra-cerebral hemorrhage (ICH). To evaluate associations between reversal of anticoagulation and mortality/morbidity in these patients.
Data was collected on a consecutive cohort of adults presenting with ICH to an academic Emergency Department over a 3-year period starting January 2006.
The final cohort of 245 patients consisted of 125 females (51.1%). The median age of the cohort was 73 years [inter-quartile (IQR) range of 59-82 years]. Antiplatelet (AP) use was seen in 32.6%, 18.4% were using anticoagulant (AC) and 8.9% patients were on both drugs (AC+AP). Patients on AC had significantly higher INR (median 2.3) and aPTT (median 31 s) when compared to patients not on AP/AC (median INR 1.0, median aPTT 24s; p<0.001). Similarly patients on AC+AP also had higher INR (median 1.9) and aPTT (median 30s) when compared to those not on AC/AP (p<0.001). Hemorrhage volumes were significantly higher for patients on AC alone (median 64.7 cm(3)) when compared to those not on either AC/AP (median 27.2 cm(3); p=0.05). The same was not found for patients using AP (median volume 20.5 cm(3); p=0.813), or both AC+AP (median volume 27.7 cm(3); p=0.619). Patients on AC were 1.43 times higher at risk to have intra-ventricular extension of hemorrhage (IVE) as compared to patients not on AC/AP (95% CI 1.04-1.98; p=0.035). There was no relationship between the use of AC/AP/AC+AP and functional outcome of patients. Patients on AC were 1.74 times more likely to die within 7 days (95% CI 1.0-3.03; p=0.05). No relationship was found between use of AP or AC+AP use and mortality. Of the 82 patients with INR>1.0, 52 patients were given reversal (minimum INR 1.4, median 2.3). Therapy was heterogeneous, with fresh frozen plasma (FFP) being the most commonly used agent (86.5% patients, median dose 4U). Vitamin K, activated factor VIIa and platelets were the other agents used. Post reversal, INR normalized within 24h (median 1.2, IQR 1.1-1.3). There was no association between reversal and volume of hemorrhage, IVE, early mortality (death<7 days) or functional outcome.
Anticoagulated patients were at 1.7 times higher risk of early mortality after ICH. Reversal of INR to normal did not influence mortality or functional outcome.
评估抗凝剂和抗血小板药物对自发性非创伤性脑出血（ICH）严重程度及预后的影响。评估这些患者抗凝逆转与死亡率/发病率之间的关联。
收集了从2006年1月开始的3年期间，连续入住一所学术性急诊科的成年ICH患者队列的数据。
最终队列的245例患者中，女性125例（51.1%）。队列的中位年龄为73岁[四分位间距（IQR）为59 - 82岁]。32.6%的患者使用抗血小板药物（AP），18.4%使用抗凝剂（AC），8.9%的患者同时使用两种药物（AC + AP）。与未使用AP/AC的患者相比，使用AC的患者国际标准化比值（INR）显著更高（中位值2.3），活化部分凝血活酶时间（aPTT）也显著更高（中位值31秒）（未使用AP/AC的患者中位INR为1.0，中位aPTT为24秒；p < 0.001）。同样，与未使用AC/AP的患者相比，使用AC + AP的患者INR（中位值1.9）和aPTT（中位值30秒）也更高（p < 0.001）。单独使用AC的患者出血体积（中位值64.7立方厘米）显著高于未使用AC/AP的患者（中位值27.2立方厘米；p = 0.05）。使用AP的患者（中位体积20.5立方厘米；p = 0.813）或同时使用AC + AP的患者（中位体积27.7立方厘米；p = 0.619）未发现同样情况。与未使用AC/AP的患者相比，使用AC的患者发生脑室内出血扩展（IVE）的风险高1.43倍（95%置信区间1.04 - 1.98；p = 0.035）。AC/AP/AC + AP的使用与患者的功能预后之间没有关系。使用AC的患者在7天内死亡的可能性高1.74倍（95%置信区间1.0 - 3.03；p = 0.05）。未发现AP或AC + AP的使用与死亡率之间的关系。在82例INR > 1.0的患者中，52例患者进行了逆转（最低INR为1.4，中位值为2.3）。治疗方法各异，新鲜冰冻血浆（FFP）是最常用的药物（86.5%的患者，中位剂量4单位）。维生素K、活化凝血因子VIIa和血小板是其他使用的药物。逆转后，INR在24小时内恢复正常（中位值1.2，IQR 1.1 - 1.3）。逆转与出血体积、IVE、早期死亡率（死亡<7天）或功能预后之间没有关联。
ICH后，抗凝患者的早期死亡风险高1.7倍。将INR逆转至正常水平不会影响死亡率或功能预后。
