蛛网膜下腔出血患者凝血及纤维蛋白溶解系统的变化

Coagulation and fibrinolytic functions in patients with subarachnoid hemorrhage

目的探讨蛛网膜下腔出血（SAH）患者血液凝固、纤维蛋白溶解（纤溶）功能的改变及其与脑血管痉挛（CVS）的关系。方法收集25例SAH患者外周静脉血,分别检测SAH后6、12 h和1、3、7、14、21 d凝血酶-AT复合物（TAT）、抗凝血酶（AT）、组织型纤溶酶原活化剂（t-PA）、纤溶酶原活化素抑制剂（PAI-1）含量变化．同时行经颅多谱勒超声检测患者的大脑中动脉平均血流速度。结果SAH后6 h,TAT急剧升高,达（5．6±1．1）μg/L,AT显著降低,为（101±1 7）mg/L（P＜0．01）;1 2 h至1 d仍维持这一状况于较高水平（P＜0．05）;第3天逐渐恢复（P＞0．05）;但在第7～14天,双呈现TAT明显升高、AT明显降低（P＜0．05）,21 d时逐渐恢复正常。SAH后t-PA呈现逐渐升高趋势,至第14 d达到最高峰（11．0±4．0）μg/L,21 d时基本恢复正常;而PAI-1在SAH后1d内活性显著低于对照组,随着时间延长逐渐上升,21 d时基本恢复正常。CVS组与非CVS组比较, TAT、AT分别在SAH后6、12 h和1、7、14 d差异有统计学意义（P＜0．05）;PAI-活性也在第7、14天升高显著（P＜O．05）,但丙组不同时点t-PA活性变化小明显（P＞0．05）。Fisher CT分级Ⅲ、Ⅳ级和Hunt分级Ⅲ、Ⅳ、Ⅴ级者,除第3、21天外,TAT、AT、t-PA、PAI-1各时点活性均明显高于Ⅰ、Ⅱ级者。结论SAH后凝血、纤溶状况的改变与病情发展、病情轻重、出血量及CVS发生有一定关系。

Objective To investigate the dynamical changes of coagulation and fibrinolytic system in patients with subarachnoid hemorrhage （SAH） and its relationship with cerebral vasospasm （CVS） Methods A total of 25 elderly patients aged over 60 years with subarachnoid hemorrhage were enrolled in the study, and devided into different severity groups according to the Hunt and Hess grading, the Fisher CT scale. Eighteen elderly healthy cases were recruited as control. The peripheral blood samples were collected at 6 h, 12 h, 1 d, 3 d, 7 d, 14 d and 21 d respectively, and thrombinantithrombin complexes （TAT）, AT, t PA activity, plasminogen activator inhibitor-1 （PAI-1） activity were measured. At the same time, transcranial doppler sonography （TCD） were used to measure the middle cerebral artery blood flow （ VMCA）. Results The level of TAT was significantly increased to （5.6± 1.1 ）μg/L and AT significantly decreased to 〈101± 17）mg/L at 6 h after SAH（all P〈0.01）. These changes maintained within 12 h-1 d after SAH（all P〈0.05） and restored to normal at 3d（P〉0.05）, but changed significantly again within 7 14 d（P〈0.05）, then restored to normal again at 21 d（P〉0.05）, t PA increased gradually after SAH and reached to the peak level at 14 d（（11.0±4.0）μg/lJ）, then decreased to normal at 21 d. PAI-1 level was significantly lower than control group within 1 d, then gradually increased, and restored to normal at 21 d. In CVS group, the level of TAT, AT were changed significantly compared with control group at 6 h, 12 h, 1 d, 7 d, 14 d after SAH. The level of PAI-1 was higher at 7 d, 14 d（P〈0. 05）, but the level of t-PA had no significant difference at different time points（all P〉0.05）. In groups of Fisher Ⅲ, Ⅳ and Hunt Ⅲ , Ⅳ, Ⅴ , the levels of TAT, AT, t-PA, PAI 1 were significantly higher than those in Fisher and Hunt Ⅰ , Ⅱ at 6 h, 12 h, 1 d, 7 d, 14 d after SAH, but not at 3, 21 d. Conclusions The changes of coagulation and fibrinolytic function in patients with SAH have correlation with the progress, severity, the loss of blood volume and CVS.