Treatment and Outcome of Thrombolysis-Related Hemorrhage: A Multicenter Retrospective Study.
Treatment and Outcome of Thrombolysis-Related Hemorrhage: A Multicenter Retrospective Study.
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DOI：
10.1001/jamaneurol.2015.2371
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发表时间：
2015-12
期刊：
影响因子：
29
通讯作者：
Willey JZ
中科院分区：
文献类型：
--
作者：
Yaghi S;Boehme AK;Dibu J;Leon Guerrero CR;Ali S;Martin-Schild S;Sands KA;Noorian AR;Blum CA;Chaudhary S;Schwamm LH;Liebeskind DS;Marshall RS;Willey JZ
症状性脑出血（sICH）的治疗基于专家意见，疗效数据有限。更好地了解溶栓相关sICH的自然史，重点关注所用各种治疗的疗效。2009年1月1日至2014年4月30日在美国10家主要和综合性卒中中心进行的多中心回顾性研究。参与者均为sICH患者，使用安全实施卒中溶栓监测研究（SITS-MOST）的定义，其中包括2型脑实质血肿和国立卫生研究院卒中量表评分至少增加4分。主要结局是院内死亡率，次要结局是血肿扩大，定义为随访成像时血肿体积增加33%。在缺血性卒中症状发作后4½小时内接受静脉重组组织纤溶酶原激活剂（rtPA）治疗的3894例患者中，128例（3.3%）患有sICH。从开始rtPA治疗到sICH诊断的中位时间为470分钟（范围：30-2572分钟），从sICH诊断到治疗的中位时间为112分钟（范围：12-628分钟）。住院死亡率为52.3%（67/128），26.8%（22/82）有血肿扩大。在多变量模型中，sICH诊断后代码状态变更为舒适措施是与院内死亡率增加相关的唯一因素（比值比，3.6; 95% CI，1.2-10.6）。重度低纤维蛋白原血症（纤维蛋白原水平，<150 mg/dL）与血肿扩大相关，发生在36.3%（8/22）的无血肿扩大患者中，发生在25.0%（15/60）的血肿扩大患者中（P = 0.01），突出了冷沉淀在逆转rtPA凝血病中的作用。在这项研究中，溶栓后sICH的治疗没有显著降低住院死亡率或血肿扩大的可能性。缩短诊断和治疗时间可能是改善sICH患者结局的关键变量。
Treatments for symptomatic intracerebral hemorrhage (sICH) are based on expert opinion, with limited data available on efficacy. To better understand the natural history of thrombolysis-related sICH, with a focus on the efficacy of various treatments used. Multicenter retrospective study between January 1, 2009, and April 30, 2014, at 10 primary and comprehensive stroke centers across the United States. Participants were all patients with sICH, using the definition by the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST), which included a parenchymal hematoma type 2 and at least a 4-point increase in the National Institutes of Health Stroke Scale score. The primary outcome was in-hospital mortality, and the secondary outcome was hematoma expansion, defined as a 33% increase in the hematoma volume on follow-up imaging. Of 3894 patients treated with intravenous recombinant tissue plasminogen activator (rtPA) within 4½ hours after symptom onset of ischemic stroke, 128 (3.3%) had sICH. The median time from initiation of rtPA therapy to sICH diagnosis was 470 minutes (range, 30–2572 minutes), and the median time from diagnosis to treatment of sICH was 112 minutes (range, 12–628 minutes). The in-hospital mortality rate was 52.3% (67 of 128), and 26.8% (22 of 82) had hematoma expansion. In the multivariable models, code status change to comfort measures after sICH diagnosis was the sole factor associated with increased in-hospital mortality (odds ratio, 3.6; 95% CI, 1.2–10.6). Severe hypofibrinogenemia (fibrinogen level, <150 mg/dL) was associated with hematoma expansion, occurring in 36.3% (8 of 22) of patients without hematoma expansion vs in 25.0% (15 of 60) of patients with hematoma expansion (P = .01), highlighting a role for cryoprecipitate in reversing rtPA coagulopathy. In this study, treatment of postthrombolysis sICH did not significantly reduce the likelihood of in-hospital mortality or hematoma expansion. Shortening the time to diagnosis and treatment may be a key variable in improving outcomes of patients with sICH.