替罗非班在颅内动脉瘤支架辅助栓塞术中抗血小板聚集的临床研究

发布时间：2018-08-08 20:33

【摘要】：研究背景颅内动脉瘤是目前危害人类健康的重症脑血管疾病,其破裂后主要导致蛛网膜下腔出血(SAH,subarachnoid hemorrhage),年发病率为 6-35.6/10 万,致死率及致残率高,所以应尽早的接受诊断和治疗。颅内支架辅助栓塞术是治疗颅内动脉瘤的主要方式之一,具有微创性、安全性、有效性、后遗症发生率低等优点,已被广泛接受并在临床逐渐普及应用。但支架置入主要的并发症是支架内血栓形成,严重影响治疗效果,所以在颅内动脉支架置入术中、术后需行抗血小板聚集治疗。目前多采用术前、术中及术后给予口服氯吡格雷和阿司匹林预防血栓的形成,但对于出血的动脉瘤患者,面临着术前服用抗血小板药物增加再次出血的风险,以及对万一栓塞治疗失败。需要改做外科手术的患者,血小板的功能不能及时恢复,无法马上接受外科手术,所以临床医生在制定治疗方案时会有很多顾虑。因此,颅内支架植入术中及术后选择有效的抗血小板聚集方案成为了手术成功的关键。由于替罗非班(timfiban)作为一种可以逆转的非肽类拮抗血小板外层膜上的糖蛋白Ⅱb/Ⅲa受体的药物,作用快、半衰期短,停药后血小板功能迅速恢复,除了对抑制血小板聚集有明显的效果外,还能够溶解新形成的血栓,为颅内动脉支架植入的抗血小板治疗提供了新的选择。目的:探讨替罗非班在颅内动脉瘤支架辅助栓塞术中抗血小板聚集的有效性及安全性,为临床治疗提供临床依据和指导。方法:回顾性分析2014年1月至2015年12月在中国人民解放军武汉总医院神经外科行支架辅助栓塞治疗颅内动脉瘤的患者309例,其中破裂动脉瘤213例,未破裂动脉瘤79例。在成功置入支架后,应用盐酸替罗非班(2～4ug · kg-1(约2-4ml),静脉推注,3～5 min内),术后返回病房继续给予(0.03～0.05ug · kg-1 · min1)持续泵24 h,次日过渡到口服抗血小板聚集药物。结果:①309例患者中,应用替罗非班期间动脉瘤再出血6例(1.9%),脑血栓2例(0.6%),气管隆突处渗血1例(0.3%)。其中298例术后12～24 h成功过渡到口服抗血小板聚集药物。②309例患者中,资料完整的76例患者血小板活化率(激活后CD62p)在术前、术后1 d(应用替罗非班期间)的平均值分别为(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)在术前、术后3 d后的平均值分别为(73.2±13.2)%和(27.9 ±22.1)%(t = 20.25,P0.001)。结论:颅内动脉瘤支架辅助栓塞治疗中应用替罗非班抗血小板聚集治疗是安全有效的,但有出血倾向的患者应用时需慎重。监测血小板活化状态能够客观反映血小板的抑制情况,对抗血小板聚集药物的临床应用具有指导意义。
[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.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R743

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