华法林相关脑出血的临床特点及手术疗效（附65例报告）

Clinical features and microsurgical treatment of warfarin-associated intracerebral hemorrhage （a report of 65 cases）

目的 探讨华法林相关脑出血（WICH）患者的临床特点及手术疗效.方法 回顾性分析2005年1月至2016年5月首都医科大学附属北京安贞医院神经外科行手术治疗的65例WICH患者的临床资料.其中50例行小骨窗颅内血肿清除术,8例行血肿清除＋去骨瓣减压术,7例行穿刺置管引流.结果 65例患者血肿平均体积为（46.8±13.7） ml,服用华法林为1.5 ～ 6.0 mg/d,平均（3.5 ±1.5）mg/d;服药时间为3～ 72个月,平均（27.8±3.4）个月.脑出血时,国际标准化比值（INR）为1.2～5.6,平均2.7±1.2;48例（73.8％）患者在抗凝推荐范围内（INR：2.0～3.0）发生了脑出血.65例患者均未发生手术相关的并发症;术后2周格拉斯哥预后评级（GOS）Ⅴ级28例（43.1％）,Ⅳ级15例（23.1％）,Ⅲ级8例（12.3％）,Ⅱ级5例（7.7％）,Ⅰ级9例（13.8％）;死亡9例（13.8％）患者中,因再出血死亡4例,多脏器功能衰竭5例.结论 恰当的手术时机和手术方式治疗WICH,可以防止血肿扩大,改善预后,降低病死率.

Objective To discuss the clinical features and surgical outcome of warfarin-associated intracerebral hemorrhage （WICH）.Methods Sixty-five consecutive patients with WICH were admitted to Department of Neurosurgery,Beijing Anzhen Hospital,Capital Medical University,from January 2005 to May 2016.Their clinical presentation,therapies and outcomes were retrospectively analyzed and discussed with reference to the relevant literatures.Among these patients,7 cases underwent drilling and drainage,intracranial hematomas were removed by small craniotomy in 50 cases,and both hematoma and bone were removed in the remaining 8 cases.Results The average volume of hematomas in 65 patients was （46.8 ± 13.7） ml.The mean dose of warfarin was 1.5-6.0 mg/d and the average dose was（3.5 ± 1.5） mg/d.The medication time was 3-72 with a mean of 27.8 ±-3.4 months.When the intracerebral hemorrhage occurred,the international normalized ratio （INR） was 1.2-5.6 （mean,2.7 ± 1.2）.WICH occurred in 48 （73.8%） patients within the recommended range of anticoagulation （INR：2.0-3.0）.There were no operative complications in the 65 patients.Based on the Glasgow coma scale （GOS）,28 cases （43.1%） were in grade Ⅴ,15 cases （23.1%） in grade Ⅳ,8 cases （12.3%） in grade Ⅲ,5 cases （7.7%） in grade Ⅱ,and 9 cases （13.8%） in grade Ⅰ （13.8%）.Nine cases （13.8%） died,among which 4 cases died due to rebleeding and multiple systemic organ failure occurred in the remaining 5 cases.Conclusion Appropriate surgical timing and surgical treatment of WICH could help prevent the enlargement of hemotomas,improve the prognosis and reduce its mortality.