【摘要】：研究背景顱內(nèi)動脈瘤是目前危害人類健康的重癥腦血管疾病,其破裂后主要導(dǎo)致蛛網(wǎng)膜下腔出血(SAH,subarachnoid hemorrhage),年發(fā)病率為 6-35.6/10 萬,致死率及致殘率高,所以應(yīng)盡早的接受診斷和治療。顱內(nèi)支架輔助栓塞術(shù)是治療顱內(nèi)動脈瘤的主要方式之一,具有微創(chuàng)性、安全性、有效性、后遺癥發(fā)生率低等優(yōu)點,已被廣泛接受并在臨床逐漸普及應(yīng)用。但支架置入主要的并發(fā)癥是支架內(nèi)血栓形成,嚴(yán)重影響治療效果,所以在顱內(nèi)動脈支架置入術(shù)中、術(shù)后需行抗血小板聚集治療。目前多采用術(shù)前、術(shù)中及術(shù)后給予口服氯吡格雷和阿司匹林預(yù)防血栓的形成,但對于出血的動脈瘤患者,面臨著術(shù)前服用抗血小板藥物增加再次出血的風(fēng)險,以及對萬一栓塞治療失敗。需要改做外科手術(shù)的患者,血小板的功能不能及時恢復(fù),無法馬上接受外科手術(shù),所以臨床醫(yī)生在制定治療方案時會有很多顧慮。因此,顱內(nèi)支架植入術(shù)中及術(shù)后選擇有效的抗血小板聚集方案成為了手術(shù)成功的關(guān)鍵。由于替羅非班(timfiban)作為一種可以逆轉(zhuǎn)的非肽類拮抗血小板外層膜上的糖蛋白Ⅱb/Ⅲa受體的藥物,作用快、半衰期短,停藥后血小板功能迅速恢復(fù),除了對抑制血小板聚集有明顯的效果外,還能夠溶解新形成的血栓,為顱內(nèi)動脈支架植入的抗血小板治療提供了新的選擇。目的:探討替羅非班在顱內(nèi)動脈瘤支架輔助栓塞術(shù)中抗血小板聚集的有效性及安全性,為臨床治療提供臨床依據(jù)和指導(dǎo)。方法:回顧性分析2014年1月至2015年12月在中國人民解放軍武漢總醫(yī)院神經(jīng)外科行支架輔助栓塞治療顱內(nèi)動脈瘤的患者309例,其中破裂動脈瘤213例,未破裂動脈瘤79例。在成功置入支架后,應(yīng)用鹽酸替羅非班(2～4ug · kg-1(約2-4ml),靜脈推注,3～5 min內(nèi)),術(shù)后返回病房繼續(xù)給予(0.03～0.05ug · kg-1 · min1)持續(xù)泵24 h,次日過渡到口服抗血小板聚集藥物。結(jié)果:①309例患者中,應(yīng)用替羅非班期間動脈瘤再出血6例(1.9%),腦血栓2例(0.6%),氣管隆突處滲血1例(0.3%)。其中298例術(shù)后12～24 h成功過渡到口服抗血小板聚集藥物。②309例患者中,資料完整的76例患者血小板活化率(激活后CD62p)在術(shù)前、術(shù)后1 d(應(yīng)用替羅非班期間)的平均值分別為(75.7 ±10.4)%和(71.9 ±15.9)%(t = 2.147,P =0.035);133 例血小板活化率(激活后CD62p)在術(shù)前、術(shù)后3 d后的平均值分別為(73.2±13.2)%和(27.9 ±22.1)%(t = 20.25,P0.001)。結(jié)論:顱內(nèi)動脈瘤支架輔助栓塞治療中應(yīng)用替羅非班抗血小板聚集治療是安全有效的,但有出血傾向的患者應(yīng)用時需慎重。監(jiān)測血小板活化狀態(tài)能夠客觀反映血小板的抑制情況,對抗血小板聚集藥物的臨床應(yīng)用具有指導(dǎo)意義。
[Abstract]:Background intracranial aneurysm is a severe cerebral vascular disease which is currently harmful to human health. After its rupture, it mainly causes SAH (subarachnoid hemorrhage), the annual incidence is 6-35.6/10 million, the mortality rate and disability rate are high. Therefore, the diagnosis and treatment should be accepted as early as possible. Intracranial stent assisted embolization is the treatment of intracranial artery. One of the main ways of tumor, which has the advantages of minimally invasive, safe, effective, and low incidence of sequelae, has been widely accepted and widely used in clinical practice. However, the main complication of stent implantation is the formation of thrombus in the stent, which seriously affects the treatment effect. Therefore, in the operation of intracranial artery stenting, the antiplatelet aggregation should be performed after the operation. Treatment. The use of clopidogrel and aspirin to prevent thrombus formation is often taken before and after operation, but for patients with hemorrhagic aneurysms, the risk of increasing blood pressure by taking antiplatelet drugs before operation, and in case of failure in the case of embolization. It is impossible to undergo surgery immediately, so the clinician may have a lot of concerns when making a treatment plan. Therefore, the key to successful operation is to choose an effective antiplatelet aggregation program during and after intracranial stent implantation. As tirofiban (timfiban) is a reversible non peptide antagonist platelets The drug on the membrane of glycoprotein II b/ III a receptor has quick effect, short half life and rapid recovery of platelet function after stopping drug. Besides the obvious effect on inhibiting platelet aggregation, it can also dissolve newly formed thrombus and provide a new choice for antiplatelet therapy for intracranial artery stent implantation. Objective: To explore the intracranial artery of tironon class. The efficacy and safety of antiplatelet aggregation in stent assisted embolization for clinical treatment provides clinical basis and guidance. Methods: a retrospective analysis of 309 cases of intracranial aneurysm treated by stent assisted embolization in the Department of Neurosurgery, Wuhan General Hospital of the people's Liberation Army from January 2014 to December 2015, including 213 cases of ruptured aneurysm, 79 cases of unruptured aneurysm were treated with tirofiban (2 ~ 4ug / kg-1 (2-4ml), intravenous injection, 3~5 min) after a successful stent implantation, and returned to the ward to continue to give (0.03 to 0.05ug. Kg-1. Min1) continuous pump 24 h and the next day to oral antiplatelet aggregation drugs. Results: (1) 309 patients were used in tironon class. There were 6 cases of aneurysm rebleeding (1.9%), 2 cases of cerebral thrombosis (0.6%) and 1 cases of endotracheal eminence (0.3%). 298 cases were successfully transferred to the oral antiplatelet aggregation drug 12~24 h after operation. In 309 patients, the platelet activation rate (after activation CD62p) in 76 patients with complete data was before the operation, and the average value of the postoperative 1 D (tironon class) was the average after operation, respectively. (75.7 + 10.4)% and (71.9 + 15.9)% (t = 2.147, P =0.035); 133 cases of platelet activation (CD62p after activation) were (73.2 + 13.2)% and (27.9 + 22.1)% after 3 d after operation, respectively (t = 20.25, P0.001). Conclusion: the treatment of tironon anti platelet aggregation in stent assisted embolization for intracranial aneurysms is safe and effective, but it is safe and effective. Patients with hemorrhagic tendency should be carefully used. Monitoring platelet activation can objectively reflect the inhibition of platelets, and is of guiding significance against the clinical application of platelet aggregation drugs.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R743

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