肝素联合华法林治疗脑静脉窦血栓形成12例临床探讨

目的探讨普通肝素联合华法林抗凝治疗脑静脉窦血栓形成（CVST）的安全性及疗效。方法经磁共振颅内静脉成像（MRV）或数字减影血管成像（DSA）确诊CVST12例，排除抗凝的禁忌证，以肝素1000u／h或750u／h持续的静脉泵注入，开始6h查aPTT1次，24h后、每12h查1次，维持aPTT在对照值的1．5-2．5倍，〉2．5倍肝素减半量，〉3倍停用1～2h后，肝素剂量减半，24h后aPTT未达1．5倍时肝素剂量追加250u／h，持续5～7d。同时第1天晚上6时按照Roberts依年龄调整华法林负荷量方案口服华法林1次，服药后16～17h复查INR，首剂后3d，根据当天INR的结果及对应的年龄组决定当天华法林用量。第4剂的华法林剂量设定为维持量，持续3～6个月（INR2．0-3．0）。结果从1000u／h开始8例，24h内aPTT达1．5～2．5倍占7例（87．5％），24～36h aPTT〈3倍5例，36h〉3倍2例，24h aPTT未达1．5倍1例。从750u／h开始4例，24h达1．5倍1例，3例追加剂量至1000u／h，分别在12、18h达1．5倍，24、36h后〉2．5倍。用药时每天查血小板、纤维蛋白原无异常。静脉注射处出现皮肤紫斑7例，BT延长11例，牙龈出血1例。无消化道或其它部位出血者。7d复查头颅CT见2例无症状新增的颅内点状出血。完全康复7例，明显好转4例，好转1例。随访3月～2年无复发。结论CVST患者使用肝素（1000u／h开始）可尽快达到有效抗凝水平，合用华法林治疗效果良好，无严重出血的不良反应。

Treated with Heparin and Warfarin in Cerebral Sinus Venous Thrombosis

Objective To explore safe and effective of heparn with warfarin treatment for patients si- nus venous thrombosis（CVST）. Methods 12 cases were diagnosed CVST by MRV or DSA, without the contraindication for anticoagulation, and were treated with persistent intravenous heparin 1 000 u/h or 750 u/h by venous injection pumps. In the first day aP＇IT was checked every 6 hours ,in 24 hours aPTT checked every 12 hours at least,to keep aPTT with 1.5 - 2.5 times of control value. If APTT exceed 2.5 times of control value ,reduce the dose of heparin to a half;if aPTT exceed 3 times, take out of service heparin for 1 - 2 hours, and reduce the dose of heparin to a half;if aP＇IT can not reach 1.5 times of control value after 24 hours, increase the dose of heparin 250 u/h. It did not stop to use heparin until INR was 2.0 - 3.0 for two days. War-farin was take orally according to Roberts warfarin dosing guidelines, international normalised ratio （INR） were performed every day to determine the next days＇ warfarin dose for five days. Warfarin were maintenance 3-6 months. （INR 2.0 - 3.0）. Results There were 8 cases treated with intravenous heparin 1 000 u/h. aPTT of 7 cases reached 1.5-2.5 times in 24 hours , 5 cases reached 2.5-3 times in 24-36 hours, 2 cases reached more than 3 times in 36 hours, 1 case could not reach 1.5 times in 24 hours. There were 4 cases treated with intravenous heparin 750u/h,aPTT of 1 cases reached 1.5 times in 24 hours,3 cases add the dose of heparin to 1 000 u/h. During using medicine, platelet and fibrinogen were checked every day. 7 cases appeared suggillation at the skin of intravenous injection, bleeding time of 11 cases extended after withdrawal of needles, 1 cases appeared gingiva bleeding , without alimentary canal or other part bleeding. 7 days rechecking cranium CT, 2 cases appeared Intracal punctate hemorrhage with absence of symptoms. 7 cases recovered completely, 4 cases improved significantly, 1 case improved. Follow-up 3 months to 2 years, there was no re currence. Conclus