Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy.
Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy.
Thromb Res. 2021 Apr;200:41-47. doi: 10.1016/j.thromres.2021.01.016. Epub 2021 Jan 26.
Venous thromboembolism (VTE) is a common complication after intracranial hemorrhage (ICH); the incidence has been reported to vary between 18% to 50% for deep vein thrombosis and between 0.5% to 5% for pulmonary embolism (PE). According to current clinical practice guidelines, patients with acute VTE should receive anticoagulant treatment for at least 3 months in the absence of contraindications. Anticoagulant treatment reduces mortality, prevents early recurrences and improves long-term outcome in patients with acute VTE. However, recent ICH is an absolute contraindication for anticoagulant treatment due to the potential increased risk of hematoma expansion or recurrent ICH. Hematoma expansion occurs in approximately a third of patients within 24 h following the diagnosis of a spontaneous ICH. The risk for recurrent ICH depends on patients' features as well as on the feature of index ICH. Limited evidence is available on the risks of therapeutic anticoagulation started shortly after ICH. Expert consensus around the introduction of therapeutic anticoagulation suggests delaying therapeutic anticoagulation for at least 2 weeks after spontaneous ICH, until the risk re-bleeding becomes acceptable. Vena cava filters should be inserted to reduce the risk for (non) fatal PE until therapeutic anticoagulation can be started; antithrombotic prophylaxis should be started as soon as possible to avoid recurrent VTE after vena cava filter insertion. For patients presenting PE with hemodynamic compromise, percutaneous embolectomy should be considered. Most patients will be able to receive anticoagulant treatment within 4 weeks following spontaneous ICH; direct oral anticoagulants are probably the treatment of choice for those ICH patients tolerating anticoagulant treatment.
静脉血栓栓塞症（VTE）是颅内出血（ICH）后的常见并发症；深静脉血栓形成的发生率为 18%至 50%，肺栓塞（PE）的发生率为 0.5%至 5%。根据当前的临床实践指南，在没有禁忌症的情况下，急性 VTE 患者应接受至少 3 个月的抗凝治疗。抗凝治疗可降低死亡率，预防早期复发，并改善急性 VTE 患者的长期预后。然而，最近的 ICH 是抗凝治疗的绝对禁忌症，因为血肿扩大或再次发生 ICH 的风险增加。自发性 ICH 诊断后约有三分之一的患者在 24 小时内发生血肿扩大。再次发生 ICH 的风险取决于患者的特征以及指数 ICH 的特征。关于 ICH 后不久开始治疗性抗凝的风险，目前只有有限的证据。关于引入治疗性抗凝的专家共识建议，自发性 ICH 后至少 2 周延迟开始治疗性抗凝，直到再次出血的风险可接受为止。应插入腔静脉滤器以降低（非）致命性 PE 的风险，直到可以开始治疗性抗凝；应尽快开始抗血栓预防，以避免腔静脉滤器插入后再次发生 VTE。对于出现血流动力学不稳定的 PE 患者，应考虑经皮血栓切除术。大多数患者在自发性 ICH 后 4 周内能够接受抗凝治疗；对于能够耐受抗凝治疗的 ICH 患者，直接口服抗凝剂可能是首选治疗方法。
