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首页 脑静脉血栓形成指南

脑静脉血栓形成指南.pdf

脑静脉血栓形成指南

刘弘播
2013-09-14 0人阅读 举报 0 0 暂无简介

简介:本文档为《脑静脉血栓形成指南pdf》,可适用于自然科学领域

ISSN:Copyright©AmericanHeartAssociationAllrightsreservedPrintISSN:OnlineStrokeispublishedbytheAmericanHeartAssociationGreenvilleAvenue,Dallas,TXDOI:STRbeapublishedonlineFeb,StrokeonEpidemiologyandPreventionTsaiandonbehalfoftheAmericanHeartAssociationStrokeCouncilandtheCouncilYBushnell,BrettCucchiara,MaryCushman,GabrielledeVeber,JoseMFerro,FongGustavoSaposnik,FernandoBarinagarrementeria,RobertDBrown,Jr,CherylDAssociationStrokeHealthcareProfessionalsFromtheAmericanHeartAssociationAmericanDiagnosisandManagementofCerebralVenousThrombosis:AStatementforhttp:strokeahajournalsorglocatedontheWorldWideWebat:Theonlineversionofthisarticle,alongwithupdatedinformationandservices,ishttp:wwwlwwcomreprintsReprints:InformationaboutreprintscanbefoundonlineatjournalpermissionslwwcomEmail:Fax:KluwerHealth,WestCamdenStreet,Baltimore,MDPhone:Permissions:PermissionsRightsDesk,LippincottWilliamsWilkins,adivisionofWoltershttp:strokeahajournalsorgsubscriptionsSubscriptions:InformationaboutsubscribingtoStrokeisonlineatbyonFebruary,strokeahajournalsorgDownloadedfromAHAScientificStatementDiagnosisandManagementofCerebralVenousThrombosisAStatementforHealthcareProfessionalsFromtheAmericanHeartAssociationAmericanStrokeAssociationTheAmericanAcademyofNeurologyaffirmsthevalueofthisstatementasaneducationaltoolforneurologistsTheAmericanAssociationofNeurologicalSurgeonsandCongressofNeurologicalSurgeonshavereviewedthisdocumentandaffirmitseducationalcontentTheIberoAmericanStrokeSociety(SociedadIberoamericanadeEnfermedadCerebrovascular)endorsestherecommendationscontainedinthisreportEndorsedbytheSocietyofNeuroInterventionalSurgeryGustavoSaposnik,MD,MSc,FAHA,ChairFernandoBarinagarrementeria,MD,FAHA,FAANRobertDBrown,Jr,MD,MPH,FAHA,FAANCherylDBushnell,MD,MHS,FAHABrettCucchiara,MD,FAHAMaryCushman,MD,MSc,FAHAGabrielledeVeber,MDJoseMFerro,MD,PhDFongYTsai,MDonbehalfoftheAmericanHeartAssociationStrokeCouncilandtheCouncilonEpidemiologyandPreventionBackgroundThepurposeofthisstatementistoprovideanoverviewofcerebralvenoussinusthrombosisandtoproviderecommendationsforitsdiagnosis,management,andtreatmentTheintendedaudienceisphysiciansandotherhealthcareproviderswhoareresponsibleforthediagnosisandmanagementofpatientswithcerebralvenoussinusthrombosisMethodsandResultsMembersofthepanelwereappointedbytheAmericanHeartAssociationStrokeCouncil’sScientificStatementOversightCommitteeandrepresentdifferentareasofexpertiseThepanelreviewedtherelevantliteraturewithanemphasisonreportspublishedsinceandusedtheAmericanHeartAssociationlevelsofevidencegradingalgorithmtoratetheevidenceandtomakerecommendationsAfterapprovalofthestatementbythepanel,itunderwentpeerreviewandapprovalbytheAmericanHeartAssociationScienceAdvisoryandCoordinatingCommitteeConclusionsEvidencebasedrecommendationsareprovidedforthediagnosis,management,andpreventionofrecurrenceofcerebralvenousthrombosisRecommendationsontheevaluationandmanagementofcerebralvenousthrombosisduringpregnancyandinthepediatricpopulationareprovidedConsiderationsforthemanagementofclinicalcomplications(seizures,hydrocephalus,intracranialhypertension,andneurologicaldeterioration)arealsosummarizedAnalgorithmfordiagnosisandmanagementofpatientswithcerebralvenoussinusthrombosisisdescribed(Stroke:)KeyWords:AHAScientificStatements�venousthrombosis�sinusthrombosis,intracranial�braininfarction,venous�stroke�diseasemanagement�prognosis�outcomeassessment�anticoagulants�pregnancy�childrenAuthororderisalphabeticalafterthewritinggroupchairAllauthorshavecontributedequallytothepresentworkTheAmericanHeartAssociationmakeseveryefforttoavoidanyactualorpotentialconflictsofinterestthatmayariseasaresultofanoutsiderelationshiporapersonal,professional,orbusinessinterestofamemberofthewritingpanelSpecifically,allmembersofthewritinggrouparerequiredtocompleteandsubmitaDisclosureQuestionnaireshowingallsuchrelationshipsthatmightbeperceivedasrealorpotentialconflictsofinterestThisstatementwasapprovedbytheAmericanHeartAssociationScienceAdvisoryandCoordinatingCommitteeonOctober,Acopyofthestatementisavailableathttp:wwwamericanheartorgpresenterjhtmlidentifier�byselectingeitherthe“topiclist”linkorthe“chronologicallist”link(NoKB)Topurchaseadditionalreprints,calloremailkelleramsaywolterskluwercomTheAmericanHeartAssociationrequeststhatthisdocumentbecitedasfollows:SaposnikG,BarinagarrementeriaF,BrownRDJr,BushnellCD,CucchiaraB,CushmanM,deVeberG,FerroJM,TsaiFYonbehalfoftheAmericanHeartAssociationStrokeCouncilandtheCouncilonEpidemiologyandPreventionDiagnosisandmanagementofcerebralvenousthrombosis:astatementforhealthcareprofessionalsfromtheAmericanHeartAssociationAmericanStrokeAssociationStroke:●●●–●●●ExpertpeerreviewofAHAScientificStatementsisconductedattheAHANationalCenterFormoreonAHAstatementsandguidelinesdevelopment,visithttp:wwwamericanheartorgpresenterjhtmlidentifier�Permissions:Multiplecopies,modification,alteration,enhancement,andordistributionofthisdocumentarenotpermittedwithouttheexpresspermissionoftheAmericanHeartAssociationInstructionsforobtainingpermissionarelocatedathttp:wwwamericanheartorgpresenterjhtmlidentifier�Alinktothe“PermissionRequestForm”appearsontherightsideofthepage©AmericanHeartAssociation,IncStrokeisavailableathttp:strokeahajournalsorgDOI:STRbeabyonFebruary,strokeahajournalsorgDownloadedfromThrombosisoftheduralsinusandorcerebralveins(CVT)isanuncommonformofstroke,usuallyaffectingyoungindividualsDespiteadvancesintherecognitionofCVTinrecentyears,diagnosisandmanagementcanbedifficultbecauseofthediversityofunderlyingriskfactorsandtheabsenceofauniformtreatmentapproachCVTrepresents�toofallstrokesMultiplefactorshavebeenassociatedwithCVT,butonlysomeofthemarereversiblePriormedicalconditions(eg,thrombophilias,inflammatoryboweldisease),transientsituations(eg,pregnancy,dehydration,infection),selectedmedications(eg,oralcontraceptives,substanceabuse),andunpredictableevents(eg,headtrauma)aresomepredisposingconditions,Giventhediversityofcausesandpresentingscenarios,CVTmaycommonlybeencounterednotonlybyneurologistsandneurosurgeonsbutalsobyemergencyphysicians,internists,oncologists,hematologists,obstetricians,pediatricians,andfamilypractitionersOurpurposeinthepresentscientificstatementistoreviewtheliteratureonCVTandtoproviderecommendationsforitsdiagnosisandmanagementWritinggroupmemberswereappointedbytheAmericanHeartAssociation(AHA)StrokeCouncil’sScientificStatementOversightCommitteeandtheCouncilonEpidemiologyandPreventionThepanelincludedmemberswithseveraldifferentareasofexpertiseThepanelreviewedrelevantarticlesonCVTinadultsandchildrenusingcomputerizedsearchesofthemedicalliteraturethroughJulyThesearticlesweresupplementedbyotherarticlesknowntotheauthorsTheevidenceisorganizedwithinthecontextoftheAHAframeworkandisclassifiedaccordingtothejointAHAAmericanCollegeofCardiologyFoundationandsupplementaryAHAStrokeCouncilmethodsofclassifyingthelevelofcertaintyandtheclassandlevelofevidence(Tablesand)Afterreviewbythepanelmembers,themanuscriptwasreviewedbyexpertpeerreviewersandmembersoftheStrokeCouncilLeadershipCommitteeandwassubsequentlyapprovedbytheAHA’sScienceAdvisoryandCoordinatingCommitteeAlthoughinformationaboutthecauseandclinicalmanifestationsofCVTisincludedfortheconvenienceofreaderswhomaybeunfamiliarwiththesetopics,thegroup’srecommendationsemphasizeissuesregardingdiagnosis,management,andtreatmentTherecommendationsarebasedonthecurrentavailableevidenceandwereapprovedbyallmembersofthewritinggroupDespitemajorprogressintheevaluationandmanagementofthisrareconditioninrecentyears,muchoftheliteratureremainsdescriptiveInsomeareas,evidenceislackingtoguidedecisionmakinghowever,thewritinggroupmadeanefforttohighlightthoseareasandprovidesuggestions,withtheunderstandingthatsomephysiciansmayneedmoreguidance,particularlyinmakingdecisionswhenextensiveevidenceisnotavailableContinuedresearchisessentialtobetterunderstandissuesrelatedtothediagnosisandtreatmentofCVTIdentificationofsubgroupsathigherriskwouldallowamorecarefulselectionofpatientswhomaybenefitfromselectiveinterventionsortherapiesEpidemiologyandRiskFactorsforCVTCVTisanuncommonandfrequentlyunrecognizedtypeofstrokethataffectsapproximatelypeoplepermillionannuallyandaccountsfortoofallstrokesCVTismorecommonlyseeninyoungindividualsAccordingtothelargestcohortstudy(theInternationalStudyonCerebralVenousandDuralSinusesThrombosisISCVT),()ofcasesoccurredinpatients�yearsofage(Figure),Clinicalfeaturesarediverse,andforthisreason,casesshouldbesoughtamongdiverseclinicalindexconditionsApriorpathologicalstudyfoundaprevalenceofCVTofamongconsecutiveautopsiesNopopulationstudieshavereportedtheincidenceofCVTVeryfewstrokeregistriesincludedcaseswithCVTThismayresultinanoverestimationofriskassociatedwiththevariousconditionsowingtoreferralandascertainmentbiasesIntheRegistroNacionalMexicanodeEnfermedadVascularCerebral(RENAMEVASC),amultihospitalprospectiveMexicanstrokeregistry,ofallstrokecaseswereCVTAclinicbasedregistryinIranreportedanannualCVTincidenceofpermillionInaseriesofintracerebralhemorrhage(ICH)casesinyoungpeople,CVTexplainedofallcasesCauseandPathogenesis:UnderlyingRiskFactorsforCVTPredisposingcausesofCVTaremultipleTheriskfactorsforvenousthrombosisingeneralarelinkedclassicallytotheVirchowtriadofstasisoftheblood,changesinthevesselwall,andchangesinthecompositionofthebloodRiskfactorsareusuallydividedintoacquiredrisks(eg,surgery,trauma,pregnancy,puerperium,antiphospholipidsyndrome,cancer,exogenoushormones)andgeneticrisks(inheritedthrombophilia)Tablesummarizestheevidenceforacauseandeffectrelationship,betweenprothromboticfactorsandCVT–Evidenceforthestrengthandconsistencyofassociation,biologicalplausibility,andtemporalityissummarizedThesecriteriaaremostcloselymetfordeficiencyofantithrombinIII,proteinC,andproteinSfactorVLeidenpositivityuseoforalcontraceptivesandhyperhomocysteinemia,amongothersProthromboticConditionsThemostwidelystudiedriskfactorsforCVTincludeprothromboticconditionsThelargeststudy,theISCVT,isamultinational,multicenter,prospectiveobservationalstudywithpatientsThirtyfourpercentofthesepatientshadaninheritedoracquiredprothromboticconditionTheprevalenceofdifferentprothromboticconditionsissummarizedinTableRecently,anothergroupintheUnitedStatesreportedthatofCVTcasesubjectsinhospitalshadaprothromboticconditionAntithrombinIII,ProteinC,andProteinSDeficiencyTwostudieshaveanalyzedtheroleofnaturalanticoagulantproteindeficiencies(antithrombinIII,proteinC,andproteinS)asriskfactorsforCVTOnestudycomparedpatientswithafirstCVTwithhealthycontrolsubjectsTheotherstudycomparedpatientswithCVTwithhealthycontrolsubjectsOnlypatient()hadantithrombinIIIdeficiencyThecombinedoddsratio(OR)ofCVTwhenthesestudieswerecombinedwasforproteinCdeficiency(confiStrokeAprilbyonFebruary,strokeahajournalsorgDownloadedfromdenceintervalCItoP�)andforproteinSdeficiency(CItoP�)AntiphospholipidandAnticardiolipinAntibodiesThefirststudymentionedabovefoundahigherprevalenceofantiphospholipidantibodiesinpatientswithCVT(of)thanincontrolsubjects(of)InanotherstudyfromIndiawithCVTpatients,anticardiolipinantibodiesweredetectedinofCVTpatientscomparedwithofnormalcontrolsubjectsSimilarfindings()wereobservedintheISCVTstudyFactorVLeidenGeneMutationandResistancetoActivatedProteinCResistancetoactivatedproteinCismainlycausedbythepresenceofthefactorVLeidengenemutation,whichisacommoninheritedthrombophilicdisorderArecentmetaanalysisofstudies,includingCVTcasesandcontrolsubjects,reportedapooledORofCVTof(CIto)forfactorVLeiden,whichissimilartoitsassociationwithvenousthromboembolism(VTE)ingeneralProthrombinGAMutationTheprothrombinGAmutationispresentin�ofwhitesandcausesaslightelevationofprothrombinlevel,Ametaanalysisofstudies,includingCVTpatientsandcontrolsubjects,reportedapooledORofCVTof(CIto)forthismutation,whichisstrongerthanitsassociationwithVTEingeneralHyperhomocysteinemiaHyperhomocysteinemiaisariskfactorfordeepveinthrombosis(DVT)andstrokebuthasnotbeenclearlyassociatedwithanincreasedriskofCVTFivecasecontrolstudiesevaluatedTableApplyingClassificationofRecommendationsandLevelofEvidence*Dataavailablefromclinicaltrialsorregistriesabouttheusefulnessefficacyindifferentsubpopulations,suchasgender,age,historyofdiabetes,historyofpriormyocardialinfarction,historyofheartfailure,andprioraspirinuseArecommendationwithLevelofEvidenceBorCdoesnotimplythattherecommendationisweakManyimportantclinicalquestionsaddressedintheguidelinesdonotlendthemselvestoclinicaltrialsEventhoughrandomizedtrialsarenotavailable,theremaybeaveryclearclinicalconsensusthataparticulartestortherapyisusefuloreffective†Forrecommendations(ClassIandIIaLevelofEvidenceAandBonly)regardingthecomparativeeffectivenessofonetreatmentwithrespecttoanother,thesewordsorphrasesmaybeaccompaniedbytheadditionalterms“inpreferenceto”or“tochoose”toindicatethefavoredinterventionForexample,“TreatmentAisrecommendedinpreferencetoTreatmentBfor”or“ItisreasonabletochooseTreatmentAoverTreatmentBfor…”StudiesthatsupporttheuseofcomparatorverbsshouldinvolvedirectcomparisonsofthetreatmentsorstrategiesbeingevaluatedSaposniketalDiagnosisandManagementofCerebralVenousThrombosisbyonFebruary,strokeahajournalsorgDownloadedfromhyperhomocysteinemiainpatientswithCVT,,,,ResearchersfromMilanreportedonpatientswithafirstCVTandcontrolsubjects,findinghyperhomocysteinemiainpatients()andcontrolsubjects(OR,CIto)LowlevelsofserumfolateandtheTTmethylenetetrahydrofolatereductasegenotypewerenotassociatedwithCVTrisk,independentofhomocysteinelevelAstudyofpatientswithCVTandcontrolsubjectsinMexicoreportedanadjustedORofCVTof(CIto)associatedwithhighfastinghomocysteineandanORof(CIto)associatedwithlowfolateAsmallItalianstudyofconsecutivepatientswithCVTandhealthycontrolsubjectsreportedthatofcasesubjectsandofcontrolsubjectshadhyperhomocysteinemia(OR,CIto)NosignificantdifferenceswerefoundintheprevalenceofprothrombinormethylenetetrahydrofolatereductasemutationNofactorVLeidenmutationwasfoundAnotherItaliangroupfoundastrongandsignificantassociationoftheprothrombinGAmutation(versusinpatientsversuscontrolsubjects,respectively,P�OR,P�)andhyperhomocysteinemia(versus,P�OR,P�)PregnancyandPuerperiumPregnancyandthepuerperiumarecommoncausesoftransientprothromboticstatesApproximatelyofpregnancyassociatedstrokesareattributabletoCVTThefrequencyofCVTinthepuerperiumisestimatedatcasesperdeliveries,onlyslightlylowerthanpuerperalarterialstrokeInastudyfromMexico,�ofCVToccurredduringpregnancyorpuerperiumMostpregnancyrelatedCVToccursinthethirdtrimesterorpuerperiumSevenofCVTsamongadmissionsfordeliveryinCanadaoccurredpostpartumDuringpregnancyandfortoweeksafterbirth,womenareatincreasedriskofvenousthromboemboliceventsPregnancyinducesseveralprothromboticchangesinthecoagulationsystemthatpersistatleastduringearlypuerperiumHypercoagulabilityworsensafterdeliveryasaresultofvolumedepletionandtraumaDuringthepuerperium,additionalriskfactorsincludeinfectionandinstrumentaldeliveryorcesareansectionOnestudyreportedthattheriskofperipartumCVTincreasedwithincreasingmaternalage,increasinghospitalsize,andcesareandelivery,aswellasinthepresenceofhypertension,infections,andexcessivevomitinginpregnancyRecently,itwasreportedthatinpregnantwomen,hyperhomocysteinemiawasassociatedwithincreasedriskofpuerperalCVT(OR,CIto)inastudyofcasesubjectsandcontrolsubjectsOralContraceptivesAstudycomparedtheprevalenceofseveralriskfactors,includinguseoforalcontraceptives,amongfemalepatientswithCVT,femalepatientswithDVTofthelowerextremities,andfemalecontrolsubjectsNearlyallCVTcasesubjectswereusingoralcontraceptives(),whichconferredfoldincreasedoddsofCVT(CIto)TheORforwomenwiththeprothrombinGAmutationwhousedoralcontraceptiveswas(CIto)comparedwiththosewithneithercharacteristicStratificationforthepresenceoffactorVLeidenorprothrombinmutationandtheuse>MalesFemalesTotalNºcasesFigureAgeandsexdistributionofcerebralvenousandsinusthrombosis(CVT)inadultsBarsrepresentthenumberofpatientswithCVTforthespecificagesexcategoryDataprovidedbyDrJoseFerrofromtheInternationalStudyonCerebralVenousandDuralSinusesThrombosisTableDefinitionofClassesandLevelsofEvidenceUsedinAHAStrokeCouncilRecommendationsClassIConditionsforwhichthereisevidenceforandorgeneralagreementthatthepr

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