脑静脉和静脉窦血栓形成的临床特点、近期预后及多因素预测模型

摘要/Abstract

摘要：

目的描述脑静脉和静脉窦血栓形成（cerebral vein and sinus thrombosis，CVST）的临床表现、影像学特点、诊治方法和预后，评价预后的影响因素。方法在单中心观察性研究中，连续性入选我院神经科诊断为CVST患者，进行回顾性分析。收集患者的人口学信息、症状和体征、辅助检查结果（脑电图、磁共振和全脑血管造影）和诊断治疗方法。随访在患者出院前一天完成。神经功能结局通过改良Rankin量表（modified Rankin Scale，mRS）评定， mRS≤2定义为神经功能结局良好。对神经功能预后进行单因素分析和多因素分析。应用受试者工作曲线（receiver operating curve，ROC）的曲线下面积（area under curve，AUC）评价多因素模型，并与CVST 预后量表比较。结果 2000年5月至2010年6月，共有171例CVST住院患者纳入研究。头痛是常见的症状，占91.8%，癫痫占36.5%，意识障碍占33.3%。89例（50.2%）患者出现脑梗死，54例（31.6%）出现脑出血。45例（26.3%）患者直窦受累。126例（73.7%）患者得到抗凝治疗，17例患者（10%）进行了溶栓治疗。随访时，137例（80.1%）患者预后良好（mRS≤2）。多因素分析显示年龄≥37岁［相对危险（relative risk，RR） 3.25，95%可信区间（confidence interval，CI）1.29～8.17］、性别（女性，RR 4.06，95%CI 1.43～11.5）、意识障碍（RR 3.92，95%CI 1.48～10.4）、直窦血栓形成（RR 7.78，95%CI 1.66～36.4）、抗凝治疗（RR 0.13，95%CI 0.05～0.35）与预后独立相关。本研究预测模型（不包括治疗因素）和CVST预后量表（取值范围0～9）的预测准确性由AUC表示，分别为0.85（95%CI 0.77～0.92，P＜0.001）和0.65 （95%CI 0.53～0.77，P＜0.01）。两模型的预测价值差异有显著性（P＜0.01）。结论 CVST患者预后相对良好，部分患者预后不良。多元统计分析显示，年龄（≥37岁）、女性、意识障碍、直窦血栓形成和预后独立相关。在本研究中，CVST的神经功能预后可以较准确地预测，需要进一步前瞻性多中心研究进行验证。

文章导读： 本研究通过较大样本量的脑静脉和静脉窦血栓形成的回顾性研究，结果显示，年龄（≥37岁）、女
性、意识障碍、直窦血栓形成和预后不良独立相关。

关键词: 脑静脉窦血栓形成; 临床特点; 预后

Abstract:

Objective To describe the clinical features of cerebral vein and sinus thrombosis (CVST), to evaluate the short-term prognosis of CVST and to determine the predictive factors for CVST. Methods In a single center observational study, consecutive patients who were diagnosed as having CVST were retrospectively investigated. Demographic data, symptoms and signs from onset to diagnosis, clinical and imaging features, location of the thrombus and therapy were collected. Patients were followed up on the day before discharge. Primary outcome as independence was assessed by modified Rankin Scale (mRS) score 2 at the end of follow-up. Univariate analysis and multivariate Logistic regression analysis were performed to predict the outcome. Receiver operating characteristic (ROC) curves were used to analyze the accuracy. The comparison of area under the curve (AUC) was calculated to test the superiority of the predicting model to the previous clinical score. Results From May 2000 to Jun 2010, we recruited 171 adult patients with CVST. Headache (91.8%) was the most common symptom, followed by seizure (36.5%) and disturbance of consciousness (33.3%). 50.2% (n =89) of the patients suffered from cerebral infarction, 31.6% (n =54) from cerebral hemorrhage. A straight sinus thrombosis was confirmed in 45 (26.3%) patients in the cohort. Anticoagulation was initiated in 126 (73.7%) patients and thrombolysis was needed in 17 (10.0%) patients. At the end of follow-up, 137 patients (80.1%) were independent by mRS 2. Multivariate Logistic regression analysis showed independent factors were age ( 37, relative risk [RR] 3.25, 95% confidence interval [CI] 1.29~8.17), sex (female, RR 4.06, 95%CI 1.43~11.5 ), conscious disturbance (RR 3.92, 95%CI 1.48~10.4), straight sinus thrombosis (RR 7.78, 95% CI 1.66~36.4) and coagulation (RR 0.13, 95%CI 0.05~0.35). The AUC of the predicting model in this study ( with the exception of anticoagulation ) and CVST score (range from 0 to 9) were 0.85 (95%CI 0.77~0.92, P <0.001) and 0.65 (95%CI 0.53~0.77, P <0.01) respectively. There was a significant difference between the two models (P <0.01). Conclusion The prognosis of CVST is relatively good and a subgroup (19.9%) of CVST patients is at increased risk of bad outcome. The short-term outcome of CVST patients can be predicted well in our study and need to be evaluated prospectively.

Key words: Cerebral vein sinus thrombosis; Clinical feature; Prognosis

郑华光1，莫大鹏2，王伊龙1，穆士清3，陆菁菁1，鞠奕1，郑颖4，周衡1，曲辉1，陈启东1，张宁1，. 脑静脉和静脉窦血栓形成的临床特点、近期预后及多因素预测模型[J]. 中国卒中杂志, 2014, 9(07): 564-570.

ZHENG Hua-Guang*, MO Da-Peng, WANG Yi-Long, MU Shi-Qing, LU Jing-Jing,JU Yi, ZHENG Ying, ZHOU Heng, QU Hui, CHEN Qi-Dong, ZHANG Ning, LIU Li-Ping.YANG Zhong-Hua, WANG Chun-Xue, DONG Ke-Hui, ZHANG Xing. Cerebral Vein and Dural Sinus Thrombosis: Clinical Features, Prognosis and Predictive
Models[J]. Chinese Journal of Stroke, 2014, 9(07): 564-570.

参考文献

1 Bousser MG, Ferro JM. Cerebral venous thrombosis:an

update[J]. Lancet Neurol, 2007, 6:162-170.

2 Ferro JM, Canh P, Stam J, et al. ISCVST Investigators.

P r og no s i s of c e r eb r a l ve i n a nd d u r a l s i nu s

thrombosis:results of the International Study on

Cerebral Vein and Dural Sinus Thrombosis (ISCVST)

[J]. Stroke, 2004, 35:664-670.

3 Wasay M, Bakshi R, Bobustuc G, et al. Cerebral

venous thrombosis:analysis of a multicenter cohort

from the United States[J]. J Stroke Cerebrovasc Dis,

2008, 17:49-54.

4 Fe r ro JM, Ca n hão P, St am J, e t a l . ISCVST

Investigators. Delay in the diagnosis of cerebral vein

and dural sinus thrombosis:influence on outcome[J].Stroke, 2009, 40:3133-3138.

5 Dentali F, Poli D, Scoditti U, et al. Long-term

outcomes of patients with cerebral vein thrombosis:a

multicenter study[J]. J Thromb Haemost, 2012,

10:1297-1302.

6 Ferro JM, Bacelar-Nicolau H, Rodrigues T, et al.

ISCVST and VENOPORT investigators. Risk score

to predict the outcome of patients with cerebral vein

and dural sinus thrombosis[J]. Cerebrovasc Dis, 2009,

28:39-44.

7 郑华光, 赵志茹, 李轶, 等. 脑静脉窦血栓形成患者预

后量表的有效性检验[J]. 中国卒中杂志, 2010, 10:13-

18.

8 Gulati D, Strbian D, Sundararajan S. Cerebral venous

thrombosis:diagnosis and management[J]. Stroke,

2014, 45:e16-e18.

9 Coutinho JM, Zuurbier SM, Stam J. Declining

mortality in cerebral venous thrombosis:a systematic

review[J]. Stroke, 2014, 45:1338-1341.

10 Mohammadian R, Sohrabi B, Mansourizadeh R, et al.

Treatment of progressive cerebral sinuses thrombosis

with local thrombolysis[J]. Interv Neuroradiol, 2012,

18:89-96.

11 Viegas LD, Stolz E, Canhão P, et al. Systemic

thrombolysis for cerebral venous and dural sinus

thrombosis:a systematic review[J]. Cerebrovasc Dis,

2014, 37:43-50.

12 Co u t i n h o JM, Fe r r o JM, Zu u r b i e r SM, e t

al.Thrombolysis or anticoagulation for cerebral

venous thrombosis:rationale and design of the TOACT

trial[J]. Int J Stroke, 2013, 8:135-140.

13 Sujith OK, Kr ishnan R, Asraf V, et al. Local

thrombolysis in patients with dural venous thrombosis

unresponsive to heparin[J]. J Stroke Cerebrovasc Dis,

2008, 17:95-100.

14 Saposnik G, Barinagarrementeria F, Brown RD Jr,

et al. Diagnosis and management of cerebral venous

thrombosis:a statement for healthcare professionals

from the American Heart Association/American

Stroke Association[J]. Stroke, 2011, 42:1158-1192.

15 Koopman K, Uyttenboogaart M, Vroomen PC, et al.

Development and validation of a predictive outcome

score of cerebral venous thrombosis[J]. J Neurol Sci,

2009, 276:66-68.

16 Bleeker SE, Moll HA, Steyerberg EW, et al. External

validation is necessary in prediction research:a clinical

example[J]. J Clin Epidemiol, 2003, 56:826-832.

17 Pfefferkorn T, Crassard I, Linn J, et al. Clinical

features, course and outcome in deep cerebral venous

system thrombosis:an analysis of 32 cases[J]. J Neurol,

2009, 256:1839-1845.

18 Benabu Y, Mark L, Daniel S, et al. Cerebral venous

thrombosis presenting with subarachnoid hemorrhage.

Case report and review[J]. Am J Emerg Med, 2009,

27:96-106.

19 Coutinho JM, Gerritsma JJ, Zuurbier SM, et al.

Isolated cortical vein thrombosis:systematic review of

case reports and case series[J]. Stroke, 2014 Apr 17.

[Epub ahead of print].

20 Simon Sl, Yao T, Ulm AJ, et al. Dural arteriovenous

fistulas masquerading as dural sinus thrombosis[J]. J

Neurosurg, 2009, 110:514-517.

[1]	王恺闻, 卢宝全, 吴秀玲, 马佳丽. 基于MRA评估基底动脉闭塞预后评分预测非重症基底动脉闭塞患者预后效能的研究 [J]. 中国卒中杂志, 2022, 17(12): 1335-1342.
[2]	吴晓莉, 刘丽旭. 肥胖对卒中预后的影响[J]. 中国卒中杂志, 2022, 17(12): 1391-1395.
[3]	邓宇含, 刘爽, 王子尧, 汪雨欣, 刘宝花. 基于结构化数据和机器学习模型预测普通人群卒中发病风险的系统评价和meta分析 [J]. 中国卒中杂志, 2022, 17(11): 1189-1197.
[4]	付江红, 陈树耿, 束小康, 蒋泽武, 魏栋帅, 贾杰. 脑机接口训练对卒中后感觉障碍患者运动功能恢复的影响：1项探索性研究[J]. 中国卒中杂志, 2022, 17(10): 1051-1057.
[5]	赵永瑞, 刘展会. 弥散张量成像在缺血性卒中患者运动功能预后评估中的研究进展[J]. 中国卒中杂志, 2022, 17(10): 1114-1119.
[6]	徐蔚海, 李顺, 程安琪. 青年卒中的诊治：勿过激[J]. 中国卒中杂志, 2022, 17(09): 915-918.
[7]	吕微, 王安心, 田雪, 张晓丽, 许玉园, 孟霞. 心血宁胶囊对伴高同型半胱氨酸水平缺血性卒中患者短期功能预后的影响[J]. 中国卒中杂志, 2022, 17(09): 972-976.
[8]	豆朋宇, 班梦苛, 贵永堃, 包万利, 张平. 脑白质高信号与孤立大脑中动脉重度狭窄或闭塞患者临床预后的相关性研究[J]. 中国卒中杂志, 2022, 17(09): 985-990.
[9]	吴倩, 陶立元, 陈思琪, 钟莲梅, 刘丽萍, 米东华. 血糖波动对动脉瘤性蛛网膜下腔出血后迟发性脑缺血及30天死亡的影响 [J]. 中国卒中杂志, 2022, 17(08): 845-850.
[10]	宋绪林, 陈来照, 韦明桂. 大脑前动脉A2段构型对左侧翼点入路夹闭前交通动脉瘤的影响 [J]. 中国卒中杂志, 2022, 17(08): 851-856.
[11]	杨佳蕾, 陈思玎, 孟霞, 姜勇, 王拥军. 基于机器学习预测血糖异常急性缺血性卒中患者预后模型研究[J]. 中国卒中杂志, 2022, 17(07): 730-736.
[12]	宋新杰, 姜睿璇, 张怡君, 王安心, 李子孝, 赵性泉. 脑出血急性期不同血压参数与预后的关系[J]. 中国卒中杂志, 2022, 17(07): 769-773.
[13]	刘艳芳, 贾娇坤, 赵性泉. 首次青年缺血性卒中短期预后不良危险因素分析[J]. 中国卒中杂志, 2022, 17(06): 600-604.
[14]	杨佳蕾, 陈思玎, 孟霞, 姜勇, 王拥军. 卒中预后量表对前、后循环缺血性卒中短期预后不良的预测价值研究[J]. 中国卒中杂志, 2022, 17(06): 616-621.
[15]	宋新杰, 王安心, 李子孝, 赵性泉. 下肢深静脉血栓形成与脑出血患者预后的关系研究[J]. 中国卒中杂志, 2022, 17(06): 634-637.