切换至 "中华医学电子期刊资源库"

中华脑血管病杂志(电子版) ›› 2022, Vol. 16 ›› Issue (01) : 12 -16. doi: 10.11817/j.issn.1673-9248.2022.01.003

专家论坛

伴脑微出血的心房颤动患者抗栓策略的研究进展
于垚1, 李华军1, 李永杰1,()   
  1. 1. 100044 北京大学人民医院神经内科
  • 收稿日期:2022-01-04 出版日期:2022-02-01
  • 通信作者: 李永杰
  • 基金资助:
    北京大学人民医院研究与发展基金(RDY2019-25)

Progress in antithrombotic strategy for atrial fibrillation in patients with cerebral microbleeds

Yao Yu1, Huajun Li1, Yongjie Li1,()   

  1. 1. Department of Neurology, Peking University People's Hospital, Beijing 100044, China
  • Received:2022-01-04 Published:2022-02-01
  • Corresponding author: Yongjie Li
引用本文:

于垚, 李华军, 李永杰. 伴脑微出血的心房颤动患者抗栓策略的研究进展[J/OL]. 中华脑血管病杂志(电子版), 2022, 16(01): 12-16.

Yao Yu, Huajun Li, Yongjie Li. Progress in antithrombotic strategy for atrial fibrillation in patients with cerebral microbleeds[J/OL]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2022, 16(01): 12-16.

脑微出血系脑小血管病变所致,人群患病率高。越来越多的研究证据表明,脑微出血是缺血性卒中后发生出血转化和原发性颅内出血的独立危险因素,而出血正是抗栓治疗的最大顾虑所在。因此,伴脑微出血的心房颤动患者的抗栓治疗面临更大的挑战。然而,迄今为止,仍缺乏高质量的临床随机对照试验对脑微出血伴心房颤动患者抗栓治疗的获益和风险进行评价。本文对相关研究进行综述,为临床医师制定个体化的抗栓方案提供参考,使患者最大程度获益。

Cerebral microbleeds (CMBs) are caused by cerebral small vessel diseases with high prevalence. Emerging evidence shows that CMBs are an independent risk factor of intracranial hemorrhage and hemorrhagic transformation after ischemic stroke. Hemorrhage is the biggest concern of antithrombotic therapy. Therefore, antithrombotic therapy is one of the major challenges for atrial fibrillation in patients with CMBs. However, so far there is no high-quality clinical randomized controlled trial to evaluate the benefits and risks of the patients taking antithrombotic therapy. This article reviews the relevant studies to provide evidence for clinicians to antithrombotic strategy according to the clinical characteristics of patients, so as to maximize the benefits of patients.

1
DeSimone CV, Graff-Radford J, El-Harasis MA, et al. Cerebral amyloid angiopathy and implications for atrial fibrillation management [J]. Lancet, 2017, 390(10089): 9-11.
2
Ntaios G, Perlepe K, Lambrou D, et al. Identification of patients with embolic stroke of undetermined source and low risk of new incident atrial fibrillation: the AF-ESUS score [J]. Int J Stroke, 2021, 16(1): 29-38.
3
Geisler T, Poli S, Meisner C, et al. Apixaban for treatment of embolic stroke of undetermined source (ATTICUS randomized trial): rationale and study design [J]. Int J Stroke, 2017, 12(9): 985-990.
4
Huang WY, Ovbiagele B, Lee M. Oral anticoagulants vs antiplatelets in cryptogenic stroke with potential cardiac emboli: meta-analysis [J]. Eur J Internal Med, 2022, 95: 44-49.
5
Hart RG, Sharma M, Mundl H, et al. Rivaroxaban for stroke prevention after embolic stroke of undetermined source [J]. N Engl J Med, 2018, 378(23): 2191-2201.
6
Haeusler KG, Wilson D, Fiebach JB, et al. Brain MRI to personalise atrial fibrillation therapy: current evidence and perspectives [J]. Heart, 2014, 100(18): 1408.
7
Greenberg SM, Vernooij MW, Cordonnier C, et al. Cerebral microbleeds: a guide to detection and interpretation [J]. Lancet Neurol, 2009, 8(2): 165-174.
8
Yubi T, Hata J, Ohara T, et al. Clinical significance of Magnetic Resonance Imaging makers of vascular brain injury, a systematic review and Meta-anylasis [J]. JAMA Neurol, 2018, 10(28): E1-E14.
9
Yubi T, Hata J, Ohara T, et al. Prevalence of and risk factors for cerebral microbleeds in a general Japanese elderly community [J]. Neurol Clin Pract, 2018, 8(3): 223-231.
10
Akoudad S, Portegies MLP, Koudstaal PJ, et al. Cerebral microbleeds are associated with an increased risk of stroke: the Rotterdam study [J]. Circulation, 2015, 132(6): 509-516.
11
Charidimou A, Kakar P, Fox Z, et al. Cerebral microbleeds 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.
12
蒋在军, 王田, 刘辉. 脑微出血与不常见疾病相关性的研究进展 [J/OL]. 中华脑血管病杂志(电子版), 2020, 14(3): 172-174.
13
Poels MM, Vernooij MW, Ikram MA, et al. Prevalence and risk factors of cerebral microbleeds: an update of the Rotterdam scan study [J]. Stroke J Cereb Circ, 2010, 41(10 Suppl): S103-S106.
14
Horstmann S, Möhlenbruch M, Wegele C, et al. Prevalence of atrial fibrillation and association of previous antithrombotic treatment in patients with cerebral microbleeds [J]. Eur J Neurol, 2015, 22(10): 1355-1362.
15
Akoudad S, Darweesh SK, Leening MJ, et al. Use of coumarin anticoagulants and cerebral microbleeds in the general population [J]. Stroke J Cereb Circ, 2014, 45(11): 3436-3439.
16
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.
17
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.
18
Nam KW, Kwon HM, Lim JS, et al. The presence and severity of cerebral small vessel disease increases the frequency of stroke in a cohort of patients with large artery occlusive disease [J]. PLoS One, 2017, 12(10): e0184944.
19
Shoamanesh A, Hart RG, Connolly SJ, et al. Microbleeds and the effect of anticoagulation in patients with embolic stroke of undetermined source: an exploratory analysis of the NAVIGATE ESUS randomized clinical trial [J]. JAMA Neurol, 2021, 78(1): 11-20.
20
Gregoire SM, Brown MM, Kallis C, et al. MRI detection of new microbleeds in patients with ischemic stroke: five year cohort follow-up study [J]. Stroke, 2010, 41(1): 184-186.
21
孙伟, 张玉生. 进退维谷: 心房颤动患者抗凝治疗相关出血后的卒中预防 [J]. 中国卒中杂志, 2021, 16(8): 757-761.
22
Kimura T, Tucker A, Nakagaki A, et al. Anticoagulation protocol for secondary prevention of acute ischemic stroke associated with nonvalvular atrial fibrillation [J]. J Stroke Cerebrovasc Dis, 2021, 30(8): 105893.
23
Kuno T, Takagi H, Ando T, et al. Oral anticoagulation for patients with atrial fibrillation on long-term hemodialysis [J]. J Am Coll Cardiol, 2020, 75(3): 273-285.
24
Pasquini M, Benedictus MR, Boulouis G, et al. Incident cerebral microbleeds in a cohort of intracerebral hemorrhage [J]. Stroke, 2016, 47(3): 689-694.
25
Lim JS, Hong KS, Kim GM, et al. Cerebral microbleeds and early recurrent stroke after transient ischemic attack: results from the Korean Transient Ischemic Attack Expression Registry [J]. JAMA Neurol, 2015, 72(3): 301-308.
26
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.
27
Imaizumi T, Inamura S, Kohama I, et al. Antithrombotic drug uses and deep intracerebral hemorrhages in stroke patients with deep cerebral microbleeds [J]. J Stroke Cerebrovasc Dis, 2013, 22(6): 869-875.
28
Thijs V, Lemmens R, Schoofs C, et al. Microbleeds and the risk of recurrent stroke [J]. Stroke, 2010, 41(9): 2005-2009.
29
Soo YO, Yang SR, Lam WW, et al. Risk vs benefit of anti-thrombotic therapy in ischaemic stroke patients with cerebral microbleeds [J]. J Neurol, 2008, 255(11): 1679-1686.
30
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(2): e44-e71.
31
Tsivgoulis G, Zand R, Katsanos AH, et al. Risk of symptomatic intracerebral hemorrhage after intravenous thrombolysis in patients with acute ischemic stroke and high cerebral microbleed burden: a meta-analysis [J]. JAMA Neurol, 2016, 73(6): 675-683.
32
O'donnell MJ, Eikelboom JW, Yusuf S, et al. Effect of apixaban on brain infarction and microbleeds: AVERROES-MRI assessment study [J]. Am Heart J, 2016, 178: 145-150.
33
Chairidimou A, Shoamanesh A, Al-Shahi Salman R, et al. Cerebral amyloid anbgiopathy, cerebral microbleeds and implications for anticoagulation decisions: the need for a balanced approach [J]. Int J Stroke, 2018, 13(2): 117-120.
34
Charidimou A, Imaizumi T, Moulin S, et al. Brain hemorrhage recurrence, small vessel disease type, and cerebral microbleeds: a meta-analysis [J]. Neurology, 2017, 89(8): 820-829.
35
Eckman MH, Rosand J, Knudsen KA, et al. Can patients be anticoagulated after intracerebral hemorrhage? A decision analysis [J]. Stroke J Cereb Circ, 2003, 34(7): 1710-1716.
36
Kuramatsu JB, Gerner ST, Schellinger PD, et al. Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage [J]. JAMA J Am Med Assoc, 2015, 313(8): 824-836.
37
Horstmann S, Zugck C, Krumsdorf U, et al. Left atrial appendage occlusion in atrial fibrillation after intracranial hemorrhage [J]. Neurology, 2014, 82(2): 135-138.
[1] 张胜男, 苗雅敬, 周虹, 韩高洁, 王静, 仝巧立, 张旭倩, 尹洪宁. 左心耳三维经食管超声测量与Watchman左心耳封堵器大小的相关性研究[J/OL]. 中华医学超声杂志(电子版), 2024, 21(02): 107-113.
[2] 王永楠, 汤畅通, 殷杰, 谭溢涛. 微创钻孔引流术与神经内镜血肿清除术治疗临界量基底节脑出血的效果对比分析[J/OL]. 中华神经创伤外科电子杂志, 2024, 10(05): 286-292.
[3] 张志超, 李陈, 韩惠, 周夏, 洪家康. 经额平行白质纤维束立体定向血肿穿刺引流术与神经内镜下血肿清除术治疗基底节脑出血的临床对比分析[J/OL]. 中华神经创伤外科电子杂志, 2024, 10(05): 299-303.
[4] 苗楠, 宗子钰. 脑出血后继发性脑损伤与线粒体相关机制的研究进展[J/OL]. 中华神经创伤外科电子杂志, 2024, 10(02): 107-111.
[5] 刘国龙, 王鹏, 谭超, 杨辉, 彭菊红. 神经外科机器人辅助双通道颅内血肿清除术治疗高血压性脑出血[J/OL]. 中华脑科疾病与康复杂志(电子版), 2024, 14(04): 254-256.
[6] 景方坤, 周建波, 王全才, 黄海韬, 李岩峰, 徐杨熙. 神经导航引导下治疗基底节高血压脑出血的短期疗效预测[J/OL]. 中华脑科疾病与康复杂志(电子版), 2024, 14(03): 154-159.
[7] 董西朝, 王林林, 袁致海, 高文文. 超早期经脑沟裂入路与经脑回皮质入路显微手术治疗基底节区脑出血的疗效分析[J/OL]. 中华脑科疾病与康复杂志(电子版), 2024, 14(02): 100-105.
[8] 鲁悦, 李伟, 庄宗, 王娟, 赵鹏来, 杭春华. 脑出血继发吉兰-巴雷综合征二例报道并文献复习[J/OL]. 中华脑科疾病与康复杂志(电子版), 2024, 14(02): 120-123.
[9] 付明鹏, 牛国栋, 岑志富, 乔宇, 郭金锐, 郭雨龙, 谢阳, 刘晨, 袁华苑, 刘可, 何姗姗. 三维标测系统指导下国产花瓣状脉冲电场消融系统应用一例[J/OL]. 中华心脏与心律电子杂志, 2024, 12(03): 180-184.
[10] 文明, 张丽, 谢芳, 艾克拜尔·艾力, 克力木·阿不都热依木. 构建胃食管反流病患者发生心房颤动的临床预测模型[J/OL]. 中华胃食管反流病电子杂志, 2024, 11(03): 130-136.
[11] 郑屹, 刘莹, 张煜坤, 李广平, 陈康寅, 刘彤. 既往及新发心房颤动对急性心肌梗死患者远期卒中风险的影响[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(05): 406-417.
[12] 穆巴拉克·伊力哈, 徐霁华, 鲁明. 急性轻型卒中微量脑出血误诊病例的临床特点及影像学表现分析[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(05): 441-445.
[13] 李芳, 戴西望, 王凯, 郭廷昊, 涂江龙. 非瓣膜性心房颤动相关性卒中的治疗研究进展[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(04): 393-397.
[14] 邓仙裕, 罗钰璇, 张溱乐, 余展鹏, 彭亮. 自发性脑出血重症患者30 d死亡风险预测模型的建立及验证[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(02): 121-128.
[15] 王永彬, 贾彦迅, 尹轶广. 神经导航结合3D重建技术引导神经内镜血肿清除术对高血压脑出血患者的影响[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(02): 153-156.
阅读次数
全文


摘要