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Hemostaza w krwotoku wewnątrzczaszkowym
DOI: https://doi.org/10.26625/np.2017.0.3.21
Abstrakt
Spontaniczny nieurazowy krwotok śródmózgowy (intracerebral hemorrhage – ICH) jest związany z wysoką chorobowością oraz śmiertelnością na całym świecie i nie ma udowodnionego skutecznego leczenia. W większości przypadków krwiak powiększa
się w ciągu 4 godz. od wystąpienia objawów, co jest związane z wczesnym pogorszeniem i złym efektem klinicznym. Kluczową rolę w ICH odgrywa bardzo wczesne leczenie hemostatyczne ograniczające ekspansję krwiaka. Pacjenci z towarzyszącymi zaburzeniami hemostazy mają większe ryzyko ekspansji krwiaka. Strategie lecznicze u pacjentów z ICH powinny obejmować odpowiednie interwencje w zależności od wywiadu stosowania leków przeciwkrzepliwych lub towarzyszącej koagulopatii. W ICH związanym z leczeniem przeciwpłytkowym zaleca się na podstawie umiarkowanie wiarygodnych danych przerwanie leczenia przeciwpłytkowego i przetoczenie płytek krwi u pacjentów, którzy mają być poddani zabiegowi neurochirurgicznemu. W ICH związanym ze stosowaniem antagonistów witaminy K zaleca się podanie pacjentom z INR > 1,4 raczej 3-czynnikowych lub 4-czynnikowych koncentratów kompleksu protrombiny (prothrombin complex concentrates – PCC) niż świeżo mrożonego osocza. U pacjentów z ICH związanym z nowymi lekami przeciwkrzepliwymi zaleca się podanie węgla aktywowanego tym, u których nie upłynęły 2 godz. od przyjęcia leku. Idarucizumab, humanizowane przeciwciało monoklonalne przeciwko dabigatranowi (bezpośredni inhibitor trombiny), jest zarejestrowany przez FDA w sytuacjach zagrażających życiu. Jeśli idarucizumab nie jest dostępny lub jeśli krwotok jest związany z innym niż dabigatran bezpośrednim inhibitorem trombiny, należy podać aktywowany PCC (50 U/kg) lub 4-czynnikowy PCC (50 U/kg) pacjentom z ICH związanym z bezpośrednimi inhibitorami trom biny (direct thrombin inhibitors – DTI). W przypadku ICH związanym z inhibitorem czynnika Xa preferowane jest podanie 4-czynnikowego PCC lub aPCC zamiast rekombinowanego czynnika VIIa z powodu niższego ryzyka zakrzepowych zdarzeń niepożądanych.
Pełny tekst:
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