口服阿司匹林脑出血手术后再出血的风险评估

Risk assessment of rebleeding after cerebral hemorrhage surgery for oral administration of aspirin

目的 探讨口服阿司匹林脑出血手术后再出血的风险以及治疗决策的制定.方法 回顾性分析2009年1月至2014年12月首都医科大学附属北京朝阳医院神经外科306例有口服阿司匹林史的脑出血手术患者,采用病例对照研究对手术后再出血的影响因素进行分析.术前血栓弹力描记术（TEG）检查花生四烯酸（AA）途径诱导的血小板抑制率,以抑制率≥75％作为暂缓急诊手术的标准,比较不同治疗方案之间、不同术式之间术后再出血的风险差异.结果 抑制率≥75％组术后再出血率为26.9％,延期手术组为4.1％,OR=8.566,95％ CI=2.279 - 32.190,P=0.001,差异有统计学意义;抑制率＜75％组的再出血率为7.6％,OR=1.923,95％ CI=0.594 -6.224,P=0.275;抑制率≥75％组与＜75％组比较,OR=4.455,95％ CI=1.539 - 12.891,P=0.006,差异有统计学意义.急诊开颅手术组与延期手术组相比,再出血率为15.9％,OR =4.399,95％ CI=1.215 - 15.919,P=0.024,差异有统计学意义.结论 经AA途径诱导的血小板抑制率≥75％可做为口服阿司匹林脑出血患者手术后再出血高风险的预测指标,可根据术者自身经验及技术优势合理选择手术方法及治疗策略.

Objective To investigate the rebleeding risk after cerebral hemorrhage surgery for oral administration of aspirin and the development of treatment decision.Methods A total of 306 patients with intracerebral hemorrhage surgery with a history of oral administration of aspirin at the Department of Neurosurgery,Beijing Chaoyang Hospital,Capital Medical University from January 2009 to December 2014 were analyzed retrospectively.The influencing factors of postoperative rebleeding were analyzed by using a case-control study.Preoperative thrombelastography （TEG） was used to examine the arachidonic acid （AA） pathway induced platelet inhibition rate,and the inhibition rate ≥ 75% was used as the criterion of postponing emergency surgery.The postoperative rebleeding risk differences between the different treatment regimens and between the different surgical procedures were compared.Results The postoperative rebleeding rate of the inhibition rate ≥75% group was 26.9%,the delayed surgery group was 4.1% （OR,8.566,95% CI 2.279-32.190;P =0.001）.The rebleeding rate of the inhibition rate 〈 75% group was 7.6% （OR,1.923,95% CI 0.594-6.224;P =0.275）;the inhibition rate ≥75% group compared with the inhibition rate 〈75% group （OR,4.455,95% CI 1.539-12.891;P =0.006）.The emergency craniotomy group compared with the delayed surgery group,the rebleeding rate was 15.9% （OR,4.399,95% CI 1.215-15.919;P=0.024）.Conclusions The platelet inhibition rate ≥75% induced by AA pathway can be used as a predictor for the high risk of postoperative rebleeding in patients with cerebral hemorrhage for oral administration of aspirin.The surgical methods and treatment choice can be chosen reasonably according to the own experiences and technological advantages of surgeons