脑静脉窦血栓形成患者的抗凝治疗延迟:影响因素及对转归的影响

Delay in anticoagulation in patients with cerebral venous sinus thrombosis: influencing factors and its effect on outcome

目的探讨脑静脉窦血栓形成(cerebral venous sinus thrombosis, CVST)患者抗凝治疗延迟的影响因素及对转归的影响。方法回顾性纳入2010年1月至2021年8月期间海军军医大学第一附属医院收治的CVST患者, 按首发症状到启动抗凝治疗时间间隔的中位数分为早期抗凝组和晚期抗凝组。在发病后90 d时应用改良Rankin量表进行转归评价, 0~2分定义为转归良好, 3~6分定义为转归不良。对早期抗凝组与晚期抗凝组以及转归良好组与转归不良组人口统计学和临床资料进行比较。采用多变量logistic回归分析确定抗凝治疗延迟的独立影响因素以及抗凝治疗延迟与转归不良的相关性。结果共纳入131例患者, 年龄(40.07±15.11)岁, 男性68例(51.91%)。其中, 早期抗凝组65例(49.62%), 转归不良组14例(10.69%)。与晚期抗凝组相比, 早期抗凝组癫痫发作和脑实质损伤的患者比例以及入院时D-二聚体水平显著较高, 而视力障碍/视盘水肿的患者比例显著更低(P均<0.05)。与转归良好组相比, 转归不良组癫痫发作、运动障碍、意识障碍、低格拉斯哥昏迷量表评分和脑实质损伤的患者比例以及D-二聚体、总胆固醇和低密度脂蛋白胆固醇水平显著更高, 血栓累及部位更多见于上矢状窦和直窦, 而头痛患者的比例和入院时白蛋白水平显著更低(P均<0.05)。多变量logistic回归分析显示, 视力障碍/视盘水肿[优势比(odds ratio,OR)0.119, 95%置信区间(confidence interval,CI)0.030~0.473;P=0.002]和脑实质损伤(OR 1.341, 95%CI 1.042~1.727;P=0.023)与抗凝治疗延迟独立相关, 抗凝治疗延迟(OR 6.102;95%CI 1.185~30.504;P=0.030)和入院时D-二聚体水平(OR 1.299, 95%CI 1.141~1.480;P<0.001)是CVST患者转归不良的独立影响因素。结论视力障碍/视盘水肿和头颅影像未见脑实质损伤是CVST患者抗凝治疗延迟的独立危险因素, 抗凝治疗延迟与CVST患者转归不良密切相关。

Objective To investigate the factors associated with delay in anticoagulant therapy in patients with cerebral venous sinus thrombosis(CVST)and its effect on outcome.Methods Patients with CVST admitted to Changhai Hospital,Naval Medical University from January 2010 to August 2021 were retrospectively enrolled.Patients were divided into early anticoagulation group and late anticoagulation group by the median time interval from first symptom to initiation of anticoagulation.The modified Rankin Scale was used for outcome assessment at 90 d after onset.0-2 scores were defined as good outcome and 3-6 were defined as poor outcome.Demographic and clinical data were compared for the early versus late anticoagulation group and for the good versus poor outcome groups.Multivariable logistic regression was used to identify independent influencing factors of delay in anticoagulation and the correlation of delay in anticoagulation with poor outcome.Results A total of 131 patients were included,their age was 40.07±15.11 years old,and 68(51.91%)were male.Of these,65 patients(49.62%)were in the early anticoagulation group and 14(10.69%)were in the poor outcome group.Compared with the late anticoagulation group,the early anticoagulation group had a significantly higher proportion of patients with seizures and brain parenchymal damage as well as higher D-dimer levels on admission,while the proportion of patients with visual impairment/papilloedema was significantly lower(all P<0.05).Compared with the good outcome group,the poor outcome group had significantly higher proportions of patients with seizures,dyskinesia,impaired consciousness,low Glasgow Coma Scale score,and brain parenchymal damage as well as higher D-dimer,total cholesterol and low density lipoprotein cholesterol levels,sites of thrombus involvement were more common in the superior sagittal and straight sinuses,and significantly lower proportions of patients with headache and lower albumin levels on admission(all P<0.05).Multivariate logistic regression analysis showed that visual impairment/papilloedema(odds ratio[OR]0.119,95%confidence interval[CI]0.030-0.473;P=0.002)and brain parenchymal damage(OR 1.341,95%CI 1.042-1.727;P=0.023)were independently associated with a delay in anticoagulation treatment,and a delay in anticoagulation treatment(OR 6.102,95%CI 1.185-30.504;P=0.030)and D-dimer level on admission(OR 1.299,95%CI 1.141-1.480;P<0.001)were the independent predictors of poor outcome in patients with CVST.Conclusions Visual impairment/papilloedema and absence of brain parenchymal damage on cranial imaging are the independent risk factors for delay in anticoagulation in patients with CVST.The delay in anticoagulation is strongly associated with the poor outcome in patients with CVST.