静脉侧支回流在多发性脑静脉窦血栓病中的作用(附89例分析)

目的 探讨静脉侧支回流在多发性脑静脉窦血栓病程中的作用。方法对我科收治的89例多发性脑静脉窦血栓病人采用经颈动脉溶栓、静脉窦内留置微导管连续溶栓等治疗方法，同时辅以全身抗凝治疗，观察临床效果和侧支循环的变化。结果所有病例治疗后颅内压均明显下降，DSA示残留静脉窦有回流63例，海绵窦代偿性引流75例，椎静脉丛引流35例，头皮静脉代偿引流14例。结论血管内溶栓和抗凝是治疗脑静脉血栓较为可靠和安全的方法：静脉侧支回流的建立和加强对于多发性脑静脉窦血栓的治疗和预后判断意义重大。     

颅内静脉窦狭窄及血栓形成的血管内治疗

目的:探讨经血管内途径治疗颅内静脉窦狭窄及血栓形成的疗效和安全性。方法:对9例(8例颅内静脉窦血栓形成,1例静脉窦狭窄)患者进行了包括经静脉接触性溶栓、机械性破栓、经颈动脉溶栓多途径联合血管内治疗及支架置入术。病人均有颅内静脉窦血栓形成的危险因素。术后积极治疗原发病,抗凝治疗6个月。术后随访1～6个月,平均4个月。结果:1例患者施行静脉窦狭窄支架置入术;8例患者接受了经静脉途径溶栓治疗,其中5例患者同时接受机械性血栓开通吸栓治疗,所有8例患者同时接受经颈动脉途径团注肝素治疗,尿激酶使用总量800000～2900000U,每例患者平均每天剂量低于1000000U。出院时,所有患者的狭窄或闭塞静脉窦均获得再通,临床症状改善,颅内压恢复。结论:血管内治疗是颅内静脉窦狭窄及血栓的安全、有效治疗手段。     

跨横窦硬膜外血肿并脑静脉窦血栓形成的诊治

目的探讨跨窦硬膜外血肿并脑静脉窦血栓形成的诊疗方法。方法对近三年来临床工作中发现的9例跨窦硬膜外血肿并脑静脉窦血栓形成患者的临床资料进行回顾性分析。所有病例诊断均经MRI、MRV证实,并静脉使用尿激酶溶栓治疗,首剂20万U,每日增加5万U。最大剂量40万U。结果9例跨窦硬膜外血肿并脑静脉窦血栓形成经治疗后4例再通,5例建立侧支循环;无1例死亡,无原有血肿扩大及再出血病例。结论对临床工作中发现腰穿颅内压大于300mmH2O,跨窦骨折合并硬膜外血肿的病例,应警惕静脉窦血栓形成。     

尿激酶联合替罗非斑在颅内静脉窦血栓形成介入性治疗中的应用

目的 探讨尿激酶联合替罗非斑血管内溶栓治疗颅内静脉窦血栓形成(CVST)的疗效和安全性. 方法 广州军区武汉总医院神经外科自2009年1月至2011年1月行尿激酶联合替罗非斑经微导管选择性静脉窦内溶栓、机械性碎栓治疗9例重症CVST患者,分析其临床资料和疗效. 结果 出院前8例患者脑脊液(CSF)压力正常,DSA检查显示7例患者静脉窦主干通畅,皮层静脉和深静脉恢复正常.1例部分再通,皮层静脉部分代偿.术中和术后未发生手术操作相关的并发症;出院时8例患者症状、体征得到改善,其中头痛消失7例,遗留轻度头痛1例.1例死亡. 结论 尿激酶联合替罗非斑经微导管选择性静脉窦内溶栓治疗是CVST安全、有效的治疗手段.     

颅内静脉窦血栓形成11例分析

目的探讨颅内静脉窦血栓形成的诊治方法。方法本科1999年10月～2004年4月收治的11例经MRI、DSA确诊的颅内静脉窦血栓形成病例，其中9例进行了介入颈动脉内溶栓，2例进行了静脉溶栓，并同时进行了抗凝等治疗，现结合文献报道分析。结果采用介入颈动脉内溶栓治疗均获得良好效果．2例1周后复查脑血管造影大部分静脉窦再通，脑循环时间接近正常。治疗后2周颅内压降致250～300mm H2O。结论颈动脉内连续应用尿激酶溶栓并结合全身抗凝治疗颅内静脉窦血栓形成可能是目前较有效的方法。     

上矢状窦远端置管持续尿激酶泵入接触性溶栓治疗颅内静脉窦血栓形成(9例报道)

目的 探讨上矢状窦远端置管持续尿激酶泵入接触性溶栓治疗颅内静脉窦血栓形成的疗效和安全性. 方法 聊城市人民医院神经内科自2008年1月至2011年1月对9例难治性颅内静脉窦血栓形成患者进行了上矢状窦远端置管持续尿激酶泵入接触性溶栓治疗,辅以机械性血栓切割,以血栓全部或大部分溶解、闭塞的脑静脉窦主干再通为停止溶栓指征.术后积极治疗原发病及抗血小板聚集治疗6个月.出院后随访9～30个月,内容包括腰穿、眼底检查和MRV或DSA检查. 结果 出院时9例患者的闭塞静脉窦均再通,动静脉循环时间正常,皮层静脉和深静脉恢复正常,临床症状改善,颅内压恢复,眼底水肿明显减轻或消失,GCS评分由术前平均10分恢复到15分,未出现与血管内治疗相关的并发症;平均随访20个月后无一例患者血栓再形成,未出现新的神经功能缺失症状. 结论 上矢状窦远端置管持续尿激酶泵入接触性溶栓治疗颅内静脉窦血栓形成是一种安全、有效的治疗手段.     

脑静脉(窦)血栓的影像学特点与血管内治疗

目的探讨脑静脉(窦)血栓的影像学特点和经血管内治疗的疗效。方法对139例以顽固性头痛、头闷和颅内出血为主要症状的患者,采用头部MR和脑血管造影检查确立诊断,并施行经颈内动脉、静脉窦内接触性溶栓或静脉窦内支架血管成形术并协同长期抗凝治疗。结果治疗前MR检查显示颅内出血和静脉(窦)内血栓形成;脑血管造影检查可见脑静脉明显扩张、瘀滞,脑动脉至静脉窦间的血液循环时间显著延长(>11s),尤其静脉期(>5s)。治疗后130例患者临床症状迅速改善,治疗有效率达93.5%(130/139);并发症发生率0.7%(1/139);病死率2.2%(3/139)。对92例患者随访3个月～7年,1例死亡,91例疗效稳定,无明显复发。结论脑静脉(窦)血栓形成的主要病理表现为静脉回流障碍和血流动力学改变,通过脑血管造影检查可确定诊断;连续应用纤溶药物和长期抗凝治疗可获显著效果。     

血管内局部溶栓治疗颅内静脉窦血栓

目的评价局部溶栓与机械碎栓治疗静脉窦血栓的影像学资料与治疗效果。方法对7例静脉窦血栓病人经股静脉穿刺,将微导管选择性插入已闭塞的静脉窦内。6例行静脉窦局部灌注尿激酶或基因重组组织型纤溶酶原激活剂,1例采用球囊机械碎栓术;3例伴脑皮质或深部静脉血栓者同时经颈动脉给予溶栓药。结果造影示6例已闭塞的静脉窦部分再通,1例无明显再通;3例侧支静脉回流增多。1例溶栓后原有脑内血肿增大,导致偏瘫加重;1例术后发生无症状出血性静脉梗死。随访10个月~3年,6例mRankin评分0~1分,1例mRankin评分2分。结论血管内局部溶栓治疗静脉窦血栓,静脉窦完全再通率低,但血管部分再通及侧支静脉回流增多,可改善病人的临床预后。     

脑静脉窦血栓形成17例临床分析

目的总结颅内静脉窦血栓形成的治疗经验。方法回顾性分析17例颅内静脉窦血栓形成病人的临床资料,其中包括行单纯抗凝、经颈动脉溶栓和经静脉接触性溶栓治疗。术后继续抗凝治疗12～18个月。术后随访2～29个月,平均18个月。结果2例行单纯抗凝治疗,3例行以抗凝治疗及颈动脉穿刺尿激酶注射,4例行动脉内溶栓,8例在动脉内溶栓同时行静脉窦内超选插管溶栓治疗。出院时,所有病人临床症状改善和颅内压恢复,未出现与血管内治疗相关的并发症。结论血管内治疗是颅内静脉窦血栓安全、有效的治疗手段。     

脑静脉窦血栓的综合血管内治疗

目的评价综合应用颈动脉溶栓、静脉窦置管溶栓及静脉窦支架置入术治疗脑静脉窦血栓的疗效。方法对我科1997年7月～2005年6月收治的99例脑静脉窦血栓患者进行综合血管内治疗,其中5例患者接受静脉窦置管溶栓合并静脉窦支架置入术(方案1),38例患者接受颈动脉溶栓合并静脉窦置管溶栓(方案2),56例患者接受单纯颈动脉溶栓(方案3),观察3组患者的临床疗效。结果经治疗,99例患者中有94例颅内压降至300 mm H_2O, 75例患者静脉窦实现再通,93例患者循环时间降至11 s以下。结论综合应用颈动脉溶栓、静脉窦置管溶栓及静脉窦支架置入术等方法治疗脑静脉窦血栓是一种安全、有效的手段。     

Individual propensity for thrombosis: comparison of venous and arterial circulations

Introduction

The pathogenesis of venous thrombosis has been attributed to complex interaction between environmental and inherited variables. A basal predisposition for venous thrombophilia independent of environmental variables has not been previously defined experimentally. Both to address the existence of an individual propensity to venous thrombosis and to establish an animal model in which variables governing this propensity could be tested, we provoked venous thrombi in a cohort of pigs of uniform size and age. We furthermore sought to determine whether the thrombotic propensity in the venous circulation is associated with similar propensity for arterial thrombosis.

Materials and methods

Bilateral iliac venous stents were deployed and 2 h later, thrombi were harvested and weighed. The thrombotic response was compared to carotid arterial thrombi generated by crush injury within the same pig. Venous and arterial thrombus platelet deposition were measured by scintillation detection of autologous ¹¹¹In-platelet content.

Results

In a cohort of 27 pigs, venous thrombus weights and platelet content varied over greater trrhan 10-fold range from least to greatest responders. There was strong intra-individual correlation of thrombus platelet deposition (r = 0.86; p = 0.008) and thrombus weights (r = 0.68; p = 0.015) between stented iliac vein pairs. Venous thrombosis correlated with whole blood platelet counts but not carotid platelet-rich thrombus formation.

Conclusions

The wide variation in venous thrombotic response to a standardized injury appears to represent an intrinsic propensity of the individual. The poor correlation with arterial thrombosis implies unique mechanisms responsible for this propensity in arteries and veins.     

Dural sinus thrombosis: a mechanism-based classification and review of 42 cases

Cranial venous outflow obstruction due to dural sinus thrombosis may result in venous hypertension, cerebral infarction, cerebral haemorrhage or impaired cerebrospinal fluid (CSF) absorption with consequent pseudotumour syndrome. We propose a mechanism based classification of dural sinus thrombosis from these four outcomes. Forty two cases of dural sinus thrombosis presenting to Royal Prince Alfred Hospital between 1986-1997 were retrospectively reviewed. These cases were classified according to mechanism of presentation and relevance of this to site of thrombosis, treatment and prognosis. This study shows that the superior sagittal sinus and transverse sinus are the commonest sites of thrombosis, and multiple sites of thrombosis (69%) are more frequent than a single site. Magnetic resonance imaging (MRI) with venous flow studies is the investigation of first choice for diagnosis but angiography remains the gold standard. A pseudotumour syndrome is the commonest presentation (43%) followed by cerebral haemorrhage (31%). The overall prognosis for sinus thrombosis is good, with 71% of cases recovering to normal function.     

Antiphospholipid antibodies and thrombosis

Antiphospholipid syndrome is an autoimmune disease which combines vascular thrombosis and/or pregnancy complications with the presence of antiphospholipid antibodies. It could be a devastating and sometimes life-threatening condition. As vascular thrombosis presents as typical venous or arterial thromboembolism diagnosis is based on laboratory data. Therefore proper performance and interpretation of laboratory tests is crucial. Broader knowledge about clinical and laboratory aspects of the syndrome and their associations are essential for proper evaluation and management of the patients.     

Lipopolysaccharide augments venous and arterial thrombosis in the mouse

BACKGROUND: Animal models of diseases are essential for therapeutic target validation, drug discovery and development. Increasing evidence has demonstrated the importance of inflammation in thrombosis. Here, murine models of vena cava thrombosis and carotid arterial thrombosis augmented by lipopolysaccharide (LPS) were established and characterized to study the association between inflammation and thrombosis. MATERIALS AND METHODS: Murine (C57BL/6 mice) models of ferric chloride (FeCl(3))-induced carotid arterial and vena cava thrombosis were established. Thrombus formation was measured indirectly by Doppler blood flow (i.e., clot functional interference with blood flow) in the arterial thrombosis model and directly by protein content of the clot in the venous thrombosis model. An optimal concentration of FeCl(3) was defined to induce thrombus formation and used to study the effects of LPS (i.e., a well-known inflammatory stimulus under these conditions). Real-time polymerase chain reaction (PCR) was used to examine the effect of LPS on TNFalpha and IL-1beta mRNA expression in thrombus formation. RESULTS: Dose-dependent analysis demonstrated that 2 mg/kg, i.p., LPS provided a maximal prothrombotic effect in 2.5% ferric chloride-induced vena cava thrombosis, with a 60% increase in thrombus size (n=8, p<0.05) compared to vehicle treatment. In contrast, 2 mg/kg LPS had no significant effect on thrombus formation in a more severe, 3.5% FeCl(3)-induced vena cava thrombosis. A similar prothrombotic effect was observed for LPS in 2.5% FeCl(3)-induced carotid arterial thrombosis model. Treatment of 2 mg/kg LPS significantly augmented arterial thrombosis immediately (between 5-30 minutes) following FeCl(3) injury as assessed by change of Doppler blood flow (n=8, p<0.05). Real-time PCR demonstrated significant induction of TNFalpha and IL-1beta mRNA expression in the thrombus formation in the vessels in response to LPS challenge. CONCLUSION: These data demonstrate that LPS augments thrombus formation in acute vascular injury and that LPS-augmented thrombosis might be a useful tool to study the relationship between inflammation and thrombosis.     

Comparison of catheter-related large vein thrombosis in centrally inserted versus peripherally inserted central venous lines in the neurological intensive care unit

Objective

To compare cumulative complication rates of peripherally (PICC) and centrally (CICVC) inserted central venous catheters, including catheter-related large vein thrombosis (CRLVT), central line-associated bloodstream infection (CLABSI), and line insertion-related complications in neurological intensive care patients.

Methods

Retrospective cohort study and detailed chart review for 431 consecutive PICCs and 141 CICVCs placed in patients under neurological intensive care from March 2008 through February 2010. Cumulative incidence of CRLVT, CLABSI, and line insertion-related complications were compared between PICC and CICVC groups. Risk factors for CRLVT including mannitol therapy during dwell time, previous history of venous thromboembolism, surgery longer than 1 h during dwell time, and line placement in a paretic arm were also compared between groups.

Results

During the study period, 431 unique PICCs were placed with cumulative incidence of symptomatic thrombosis of 8.4%, CLABSI 2.8%, and line insertion-related complications 0.0%. During the same period, 141 unique CICVCs were placed with cumulative incidence of symptomatic thrombosis of 1.4%, CLABSI 1.4%, and line insertion-related complications 0.7%. There was a statistically significant difference in CRLVT with no difference in CLABSI or line insertion-related complications.

Conclusions

In neurological critical care patients, CICVCs appear to have a better risk profile compared to PICCs, with a decreased risk of CRLVT. As use of PICCs in critical care patients increases, a prospective randomized trial comparing PICCs and CICVCs in neurological critical care patients is necessary to assist in choosing the appropriate catheter and to minimize risks of morbidity and mortality associated with central venous access.     

两次单纯胰腺移植术后动脉血栓形成1例

目的：总结1例两次单纯胰腺移植术后血栓形成的原因和诊治体会。 方法：广西中医学院附属瑞康医院器官移植中心于2006-12，2007-01为1例1型糖尿病患者先后两次施行单纯胰腺移植，观察分析移植后血栓形成经过、实验室检查和影像学检查结果。 结果：两次移植术后血糖未能恢复正常，初次移植术后12 d，患者腹痛、发热、白细胞增加，CT血管三维成像证实移植胰动脉栓塞，遂行移植物切除，并行再次移植手术，术后第11天，患者无症状，血管三维成像提示移植胰动脉部分栓塞，抗凝治疗无效，2 d后移植胰动脉完全栓塞，行移植胰切除。 结论：血栓形成易导致单纯胰腺移植失败，其临床征象缺乏特异性，影像学检查有助于诊断，保守治疗效果不佳。