诊断学理论与实践 ›› 2020, Vol. 19 ›› Issue (05): 534-539.doi: 10.16150/j.1671-2870.2020.05.018
武冬冬, 胡夏生, 刘银红(
), 蒋景文
收稿日期:2019-11-28
出版日期:2020-10-25
发布日期:2022-07-14
通讯作者:
刘银红
E-mail:liuyh302@126.com
Received:2019-11-28
Online:2020-10-25
Published:2022-07-14
中图分类号:
武冬冬, 胡夏生, 刘银红, 蒋景文. 脑微出血的临床意义及其伴心房颤动时的抗凝治疗决策进展[J]. 诊断学理论与实践, 2020, 19(05): 534-539.
表1
CMB的分类和可能的机制
| 分类 | 机制 |
|---|---|
| 原发性CMB | 动脉和（或）小动脉破裂, 血脑屏障破坏和（或） 毛细血管中断 |
| 继发性CMB | 出血性梗死, 出血性微梗死 |
| 假性CMB | 缺血诱导的少突胶质细胞内贮存铁的释放, 血管自噬a) |
图1
不同AF人群的抗凝治疗决策流程图 ICH：脑出血（intracerebral hemorrhage）;LAA：左心耳（left atrial appendage）;CMB：脑微出血（cerebral microbleed）;CAA：脑淀粉样血管病（cerebral amyloid angiopathy）
图2
房颤患者抗凝治疗前行MRI筛查的流程图 AF：房颤（atrial fibrillation）;CMB：脑微出血（cerebral microbleed）;NOAC：新型口服抗凝药（novel oral anticoagulant）
| [1] |
Offenbacher H, Fazekas F, Schmidt R, et al. MR of cerebral abnormalities concomitant with primary intracerebral hematomas[J]. Am J Neuroradiol, 1996, 17(3):573-578.
pmid: 8881257 |
| [2] |
Fazekas F, Kleinert R, Roob G, et al. Histopathologic analysis of foci of signal loss on gradient-echo T2*-weighted MR images in patients with spontaneous intra-cerebral hemorrhage: evidence of microangiopathy-related microbleeds[J]. Am J Neuroradiol, 1999, 20(4):637-642.
pmid: 10319975 |
| [3] | Poels MM, Vernooij MW, Ikram MA, et al. Prevalence and risk factors of cerebral microbleeds: an update of the Rotterdam scan study[J]. Stroke, 2010, 41(10 Suppl):S103-S106. |
| [4] |
Cordonnier C, Al-Shahi Salman R, Wardlaw J. Spontaneous brain microbleeds: systematic review, subgroup analyses and standards for study design and reporting[J]. Brain, 2007, 130(Pt 8):1988-2003.
doi: 10.1093/brain/awl387 pmid: 17322562 |
| [5] |
Fisher M. Cerebral microbleeds: where are we now?[J]. Neurology, 2014, 83(15):1304-1305.
doi: 10.1212/WNL.0000000000000871 pmid: 25186856 |
| [6] |
Cheng AL, Batool S, McCreary CR, et al. Susceptibility-weighted imaging is more reliable than T2*-weighted gradient-recalled echo MRI for detecting microbleeds[J]. Stroke, 2013, 44(10):2782-2786.
doi: 10.1161/STROKEAHA.113.002267 URL |
| [7] |
Rockson SG, Albers GW. Comparing the guidelines: anticoagulation therapy to optimize stroke prevention in patients with atrial fibrillation[J]. J Am Coll Cardiol, 2004, 43(6):929-935.
doi: 10.1016/j.jacc.2003.11.028 URL |
| [8] |
Saito T, Kawamura Y, Tanabe Y, et al. Cerebral microbleeds and asymptomatic cerebral infarctions in patients with atrial fibrillation[J]. J Stroke Cerebrovasc Dis, 2014, 23(6):1616-1622.
doi: 10.1016/j.jstrokecerebrovasdis.2014.01.005 URL |
| [9] |
European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery, Camm AJ, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology(ESC)[J]. Eur Heart J, 2010, 31(19):2369-2429.
doi: 10.1093/eurheartj/ehq278 URL |
| [10] |
Dowlatshahi D, Butcher KS, Asdaghi N, et al. Poor prognosis in warfarin-associated intracranial hemorrhage despite anticoagulation reversal[J]. Stroke, 2012, 43(7):1812-1817.
doi: 10.1161/STROKEAHA.112.652065 pmid: 22556194 |
| [11] |
Greenberg SM, Vernooij MW, Cordonnier C, et al. Cerebral microbleeds: a guide to detection and interpretation[J]. Lancet Neurol, 2009, 8(2):165-174.
doi: 10.1016/S1474-4422(09)70013-4 pmid: 19161908 |
| [12] |
Lovelock CE, Cordonnier C, Naka H, et al. Antithrombotic drug use, cerebral microbleeds, and intracerebral hemorrhage: a systematic review of published and unpublished studies[J]. Stroke, 2010, 41(6):1222-1228.
doi: 10.1161/STROKEAHA.109.572594 URL |
| [13] |
Jeon SB, Kang DW, Cho AH, et al. Initial microbleeds at MR imaging can predict recurrent intracerebral hemorrhage[J]. J Neurol, 2007, 254(4):508-512.
doi: 10.1007/s00415-006-0406-6 URL |
| [14] |
Imaizumi T, Inamura S, Nomura T. Contribution of deep microbleeds to stroke recurrence: differences between patients with past deep intracerebral hemorrhages and lacunar infarctions[J]. J Stroke Cerebrovasc Dis, 2015, 24(8):1855-1864.
doi: 10.1016/j.jstrokecerebrovasdis.2015.04.027 pmid: 25980343 |
| [15] |
Vermeer SE, Algra A, Franke CL, et al. Long-term prognosis after recovery from primary intracerebral hemorrhage[J]. Neurology, 2002, 59(2):205-209.
pmid: 12136058 |
| [16] |
Charidimou A, Kakar P, Fox Z, et al. Cerebral micro-bleeds and recurrent stroke risk: systematic review and meta-analysis of prospective ischemic stroke and transient ischemic attack cohorts[J]. Stroke, 2013, 44(4):995-1001.
doi: 10.1161/STROKEAHA.111.000038 pmid: 23493732 |
| [17] |
Wilson D, Charidimou A, Ambler G, et al. Recurrent stroke risk and cerebral microbleed burden in ischemic stroke and TIA: a meta-analysis[J]. Neurology, 2016, 87(14):1501-1510.
doi: 10.1212/WNL.0000000000003183 URL |
| [18] |
Akoudad S, Portegies ML, Koudstaal PJ, et al. Cerebral microbleeds are associated with an increased risk of stroke: the rotterdam study[J]. Circulation, 2015, 132(6):509-516.
doi: 10.1161/CIRCULATIONAHA.115.016261 pmid: 26137955 |
| [19] |
Charidimou A, Karayiannis C, Song TJ, et al. Brain microbleeds, anticoagulation, and hemorrhage risk: meta-analysis in stroke patients with AF[J]. Neurology, 2017, 89(23):2317-2326.
doi: 10.1212/WNL.0000000000004704 pmid: 29117953 |
| [20] |
Song TJ, Kim J, Song D, et al. Association of cerebral microbleeds with mortality in stroke patients having atrial fibrillation[J]. Neurology, 2014, 83(15):1308-1315.
doi: 10.1212/WNL.0000000000000862 URL |
| [21] |
Eckman MH, Wong LK, Soo YO, et al. Patient-specific decision-making for warfarin therapy in nonvalvular atrial fibrillation: how will screening with genetics and imaging help?[J]. Stroke, 2008, 39(12):3308-3315.
doi: 10.1161/STROKEAHA.108.523159 pmid: 18845797 |
| [22] |
Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation[J]. N Engl J Med, 2009, 361(12):1139-1151.
doi: 10.1056/NEJMoa0905561 URL |
| [23] |
Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation[J]. N Engl J Med, 2011, 365(11):981-992.
doi: 10.1056/NEJMoa1107039 URL |
| [24] |
Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation[J]. N Engl J Med, 2011, 365(10):883-891.
doi: 10.1056/NEJMoa1009638 URL |
| [25] |
Cervera A, Amaro S, Chamorro A. Oral anticoagulant-associated intracerebral hemorrhage[J]. J Neurol, 2012, 259(2):212-224.
doi: 10.1007/s00415-011-6153-3 pmid: 21748282 |
| [26] |
Eckman MH, Rosand J, Knudsen KA, et al. Can patients be anticoagulated after intracerebral hemorrhage? A decision analysis[J]. Stroke, 2003, 34(7):1710-1716.
pmid: 12805495 |
| [27] |
Greenberg SM, Eng JA, Ning M, et al. Hemorrhage burden predicts recurrent intracerebral hemorrhage after lobar hemorrhage[J]. Stroke, 2004, 35(6):1415-1420.
pmid: 15073385 |
| [28] |
Kuramatsu JB, Gerner ST, Schellinger PD, et al. Anticoa-gulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intra-cerebral hemorrhage[J]. JAMA, 2015, 313(8):824-836.
doi: 10.1001/jama.2015.0846 pmid: 25710659 |
| [29] |
Passero S, Burgalassi L, D'Andrea P, et al. Recurrence of bleeding in patients with primary intracerebral hemorrhage[J]. Stroke, 1995, 26(7):1189-1192.
pmid: 7604411 |
| [30] |
Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke, 2015, 46(7):2032-2060.
doi: 10.1161/STR.0000000000000069 pmid: 26022637 |
| [31] |
Wilson D, Jäger HR, Werring DJ. Anticoagulation for atrial fibrillation in patients with cerebral microbleeds[J]. Curr Atheroscler Rep, 2015, 17(8):47.
doi: 10.1007/s11883-015-0524-7 URL |
| [32] |
Stroke Risk in Atrial Fibrillation Working Group. Independent predictors of stroke in patients with atrial fibrillation: a systematic review[J]. Neurology, 2007, 69(6):546-554.
doi: 10.1212/01.wnl.0000267275.68538.8d URL |
| [33] |
Hart RG, Tonarelli SB, Pearce LA. Avoiding central nervous system bleeding during antithrombotic therapy: recent data and ideas[J]. Stroke, 2005, 36(7):1588-1593.
doi: 10.1161/01.STR.0000170642.39876.f2 URL |
| [34] |
Song TJ, Kim J, Lee HS, et al. The frequency of cerebral microbleeds increases with CHADS(2) scores in stroke patients with non-valvular atrial fibrillation[J]. Eur J Neurol, 2013, 20(3):502-508.
doi: 10.1111/ene.12003 pmid: 23057579 |
| [35] |
Wilson D, Ambler G, Shakeshaft C, et al. Cerebral microbleeds and intracranial haemorrhage risk in patients anticoagulated for atrial fibrillation after acute ischaemic stroke or transient ischaemic attack (CROMIS-2): a multicentre observational cohort study[J]. Lancet Neurol, 2018, 17(6):539-547.
doi: 10.1016/S1474-4422(18)30145-5 URL |
| [36] |
Soo Y, Abrigo JM, Leung KT, et al. Risk of intracerebral whaemorrhage in Chinese patients with atrial fibrillation on warfarin with cerebral microbleeds: the IPAAC-warfarin study[J]. J Neurol Neurosurg Psychiatry, 2019, 90(4):428-435.
doi: 10.1136/jnnp-2018-319104 URL |
| [37] |
Wilson D, Charidimou A, Ambler G, et al. Recurrent stroke risk and cerebral microbleed burden in ischemic stroke and TIA: a meta-analysis[J]. Neurology, 2016, 87(14):1501-1510.
doi: 10.1212/WNL.0000000000003183 URL |
| [38] |
Selim M, Diener HC. Atrial fibrillation and microbleeds[J]. Stroke, 2017, 48(10):2660-2664.
doi: 10.1161/STROKEAHA.117.017085 URL |
| [39] |
Lip GY, Andreotti F, Fauchier L, et al. Bleeding risk assessment and management in atrial fibrillation patients: a position document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis[J]. Europace, 2011, 13(5):723-746.
doi: 10.1093/europace/eur126 URL |
| [40] |
Hylek EM, Evans-Molina C, Shea C, et al. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation[J]. Circulation, 2007, 115(21):2689-2696.
doi: 10.1161/CIRCULATIONAHA.106.653048 URL |
| [41] |
Pisters R, Lane DA, Nieuwlaat R, et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey[J]. Chest, 2010, 138(5):1093-1100.
doi: 10.1378/chest.10-0134 pmid: 20299623 |
| [42] |
Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials[J]. Lancet, 2014, 383(9921):955-962.
doi: 10.1016/S0140-6736(13)62343-0 URL |
| [43] |
Lee SH, Ryu WS, Roh JK. Cerebral microbleeds are a risk factor for warfarin-related intracerebral hemorrhage[J]. Neurology, 2009, 72(2):171-176.
doi: 10.1212/01.wnl.0000339060.11702.dd URL |
| [44] |
Saito T, Kawamura Y, Sato N, et al. Non-vitamin K anta-gonist oral anticoagulants do not increase cerebral micro-bleeds[J]. J Stroke Cerebrovasc Dis, 2015, 24(6):1373-1377.
doi: 10.1016/j.jstrokecerebrovasdis.2015.02.018 URL |
| [45] |
Fisher M. MRI screening for chronic anticoagulation in atrial fibrillation[J]. Front Neurol, 2013, 4:137.
doi: 10.3389/fneur.2013.00137 pmid: 24109470 |
| [46] |
Wang Z, Soo YO, Mok VC. Cerebral microbleeds: is antithrombotic therapy safe to administer?[J]. Stroke, 2014, 45(9):2811-2817.
doi: 10.1161/STROKEAHA.114.004286 URL |
| [47] | Smith EE, Saposnik G, Biessels GJ, et al. Prevention of stroke in patients with silent cerebrovascular disease: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke, 2017, 48:e44-e71. |
| [48] |
Microbleeds International Collaborative Network. Worldwide collaboration in the Microbleeds International Collaborative Network[J]. Lancet Neurol, 2016, 15(11):1113-1114.
doi: 10.1016/S1474-4422(16)30213-7 URL |
| [49] |
Charidimou A, Soo Y, Heo JH, et al. A call for researchers to join the META-MICROBLEEDS Consortium[J]. Lancet Neurol, 2016, 15(9):900.
doi: S1474-4422(16)30124-7 pmid: 27478945 |
| [1] | 罗晓颖, 许燕, 张凤如, 吴立群, 戚文航. P波离散度和N端脑钠肽前体预测房颤冷冻球囊导管消融术后复发的价值[J]. 诊断学理论与实践, 2020, 19(1): 32-36. |
| [2] | 刘彤, 王鑫. 心房颤动预后不良风险的评估策略[J]. 诊断学理论与实践, 2020, 19(06): 555-558. |
| [3] | 罗晓颖, 许燕, 张建盛, 吴立群, 戚文航. N端脑钠肽前体预测首次急性心肌梗死后新发心房颤动的价值研究[J]. 诊断学理论与实践, 2020, 19(03): 303-307. |
| [4] | 王晨琛, 杨文波, 华玮, 陈晔芬, 苏秀秀, 龚俊世, 方跃华. 左心耳解剖形态、功能与非瓣膜性心房颤动患者脑卒中发生风险的相关性研究[J]. 诊断学理论与实践, 2020, 19(02): 151-156. |
| [5] | 毛毅敏, 黄伸伸, 和雪改. 围手术期静脉血栓栓塞症形成风险评估及抗凝药物管理[J]. 诊断学理论与实践, 2019, 18(1): 16-20. |
| [6] | 胡荣郭, 庞德芳, 黄澍, 沈振坤, 陈玮, 杨育伟, 来小音, 朱玮, 吴菲菲, 计海峰, 吴大玉, 江梅, 孙家兰, 李龙宣. 急性缺血性卒中早期血浆miRNAs水平与房颤发生间的关系[J]. 诊断学理论与实践, 2017, 16(01): 98-103. |
| [7] | 黄红漫, 查爽英, 刘新兵, 柏晓松, 冯六六. 超高龄心房颤动患者华法林抗凝过程中心血管不良事件的观察[J]. 诊断学理论与实践, 2016, 15(05): 513-516. |
| [8] | 刘兴鹏, 廖文凯,. 心房颤动的驱动机制认识[J]. 诊断学理论与实践, 2015, 14(03): 197-200. |
| [9] | 吴立群,. 心房颤动的现代诊断及导管消融治疗进展认识[J]. 诊断学理论与实践, 2015, 14(03): 201-203. |
| [10] | 陈松文, 刘少稳,. 心房颤动患者应用新型口服抗凝药物的指南解读[J]. 诊断学理论与实践, 2015, 14(03): 204-207. |
| [11] | 吴杰,. 自主神经异常与心房颤动[J]. 诊断学理论与实践, 2015, 14(03): 208-210. |
| [12] | 徐亚伟, 唐恺,. 左心耳封堵预防房颤卒中的原理及临床价值[J]. 诊断学理论与实践, 2015, 14(03): 211-214. |
| [13] | 罗晓颖, 权薇薇, 许燕, 张风如, 吴立群, 戚文航,. C反应蛋白与房颤冷冻球囊导管消融术后房颤复发的相关性研究[J]. 诊断学理论与实践, 2015, 14(03): 219-222. |
| [14] | . 互刊信息[J]. 诊断学理论与实践, 2008, 7(04): 442-. |
| [15] | 金奇, 吴立群,. 心肌连接蛋白在心房颤动发生机制中的作用[J]. 诊断学理论与实践, 2007, 6(03): 266-268. |
| 阅读次数 | ||||||
|
全文 |
|
|||||
|
摘要 |
|
|||||
