作者：潘柳华，赵珊珊

单位：

110000 辽宁省沈阳市，中国医科大学附属第一医院神经内科

Units：

Department of Neurology, First Affiliated Hospital of China Medical University, Shenyang 110000, China

关键词：

脑出血；抗凝治疗；华法林；新型口服抗凝剂；综述

Keywords：

Intracerebral hemorrhage; Anticoagulant therapy; Warfarin; New oral anticoagulant; Review

CLC：

R 743.34

DOI：

10.12114/j.issn.1008-5971.2022.00.048

Funds：

摘要：

　在人口老龄化进程不断加剧的背景下，口服抗凝剂（OAC）越来越多地用于临床实践，尤其是随着 新型口服抗凝剂（NOAC）的适应证不断扩大，以NOAC为代表的抗凝时代已经到来。口服抗凝剂相关脑出血（OACICH）是一种发生在抗凝治疗下的医源性效应，研究显示接受OAC治疗的患者脑出血（ICH）发生风险较未接受OAC 治疗的患者高7~10倍，且脑出血是抗凝治疗的严重不良事件，已引起临床医生的重视。笔者结合近年相关研究，就 OAC-ICH的发生风险、预后、潜在病因、继发脑损伤、临床表现与影像学特征、出血位置及预后预测因子等分析如 下：尽管OAC-ICH发生率并不高，但其发生意味着患者预后不良且需要承担更高的经济负担；OAC-ICH患者病死率较 高，功能预后不良；将影像学标志物（如脑微出血）纳入临床出血风险评估可能提高ICH的预测效能；ICH继发脑损伤 主要是脑实质结构的物理性破坏，且与华法林相关ICH相比，NOAC相关ICH具有较低的血肿扩大和死亡风险；OACICH的临床表现与其他原因相关的ICH相似，CT成像上的“液平”现象有望作为OAC-ICH的影像学标志物；OAC-ICH 和非OAC-ICH的出血位置存在差异；与OAC-ICH不良预后有关的预测因子主要包括入院时意识水平和脑出血量、血肿 扩大、血肿位置、脑室出血、医疗干预及共病等。

Abstract：

In the context of the aging population, oral anticoagulants (OACs) are increasingly used in clinical practice, especially with the continuous expansion of the indications of novel oral anticoagulants (NOACs) , the anticoagulation era represented by NOACs has come. Oral anticoagulant-associated intracerebral hemorrhage (OAC-ICH) is an iatrogenic effect that occurs with anticoagulant therapy. Studies have shown that the risk of cerebral hemorrhage in patients receiving OAC treatment is 7-10 times higher than that in patients not receiving OAC treatment, and cerebral hemorrhage is a serious adverse event of anticoagulation therapy, which has attracted the attention of clinicians. Based on the relevant research in recent years, the author analyzes the occurrence risk, prognosis, potential etiology, secondary brain injury, clinical manifestations and imaging features, bleeding location and prognosis predictors of OAC-ICH as follows: although the incidence of OAC-ICH is not high, its occurrence means that patients have a poor prognosis and need to bear a higher economic burden; OAC-ICH patients have high mortalityand poor functional prognosis; incorporating imaging markers (eg, cerebral microbleeds) into clinical bleeding risk assessment may improve the prediction efficiency of ICH; brain injury secondary to ICH is mainly physical destruction of brain parenchyma structure, and NOACs-related ICH has a lower risk of hematoma expansion and death compared with warfarin; the clinical manifestations of OAC-ICH are similar to other causes of cerebral hemorrhage, and the "fluid level" phenomenon on CT imaging is expected to be used as an imaging marker for OAC-ICH; there are differences in the location of bleeding between OACICH and non-OAC-ICH; the predictors related to the poor prognosis of OAC-ICH mainly include the level of consciousness on admission and the amount of cerebral hemorrhage, hematoma expansion, hematoma location, intraventricular hemorrhage, medical intervention and comorbidities.

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