抗凝固療法・抗血小板療法下における脳出血の検討  [in Japanese] Intracerebral Hemorrhage under Anticoagulant and/or Antiplatelet Therapy  [in Japanese]

非心原性脳梗塞に対する抗血小板療法,心原性脳塞栓に対する抗凝固療法は,いずれも脳梗塞発生を有意に抑制することは周知の事実である.一方,抗凝固療法,抗血小板療法により出血性脳卒中のリスクは有意に増加し,抗血小板剤使用による頭蓋内出血の危険性は0.2-0.3%/年,抗凝固療法使用では0.3-1.1%/年とされる.抗血小板,抗凝固療法による脳梗塞再発予防効果は出血性脳卒中のリスクを上回るため,これらの治療法は正当化される.しかしながら,出血性合併症は患者の転帰を左右する重大な合併症と考えられ,その特徴を知ることは,日常臨床上,対策を講ずるのにきわめて重要である.これまで,抗凝固療法中に合併した脳出血の急性期死亡率は43-54%と高率であること,高血圧,抗凝固療法導入早期,INR高値,leucoaraiosis,アミロイドアンギオパチー,糖尿病などは抗凝固療法下における脳出血発症に対する危険因子となりうることなどが報告されている.しかしながら,出血の病態や転帰など臨床的特徴に関する報告は少なく,また抗血小板療法下における脳出血の臨床的特徴に関する報告は筆者らが渉猟しえた限りではほとんど見受けられない.そこで,今回われわれは,自験例を対象に抗血小板,抗凝固療法下における脳出血の臨床的特徴について検討したので報告する.

We investigated the clinical characteristics of intracerebral hemorrhage (ICH) under anticoagulant and/or antiplatelet therapy in 371 cases with spontaneous ICH treated during 2 years between November 2001 and October 2003. Forty-eight out of these 361 cases had received either anticoagulant and/or antiplatelet therapy before and at the onset of ICH. We compared the clinical characteristics of these 48 patients with those who had not, received anticoagulant or antiplatelet treatment. Patients were classified into 4 groups: those who had received anticoagulant only (Group A, n - 11), both anticoagulant and antiplatelet (Group B, n = 11), antiplatelet only (Group C, n = 26), and those who had not received anticoagulant or antiplatelet treatment (control group, n = 313). There was no significant difference between the control and group A, B, or C. in age, sex, history of hypertension, blood pressure at the time of admission, hematoma location, or initial hematoma size. The rebleeding rate was higher in groups with anticoagulant. treatment (A, B) than control. Rankin Scale at the time of discharge was significantly worse in groups with anticoagulant treatment (A. B) than control. However, the outcome did not significantly differ between group C, (antiplatelet only) and control. Anticoagulant therapy may be a risk factor of rebleeding, clinical deterioration, and poor outcome. In contrast, antiplatelet therapy may not be a risk factor of rebleeding, clinical deterioration or poor outcome.