急性期脳出血患者における抗凝固療法導入による急性肺血栓塞栓症予防

Anticoagulation Therapy for Prevention of Acute Pulmonary Thromboembolism in Patients with Intracerebral Hemorrhage in Acute Phase

Ⅰ．はじめに

　脳出血患者における深部静脈血栓症（deep venous thrombosis：DVT）の発生率は8.8〜40.4%と高く^6,10)，脳出血はDVTおよび急性肺血栓塞栓症（pulmonary thromboembolism：PTE）の独立した危険因子である．PTEは亜区域枝よりも中枢側の閉塞がある場合には致死的となり得るため¹⁵⁾，脳出血患者においてもその予防は必須であるが，脳出血急性期には抗凝固療法導入による再出血や血腫増大の懸念から，DVTを認めた場合であっても抗凝固療法導入がためらわれることが多い．われわれは，脳出血患者において定期的にD-dimerを測定することでDVTの早期スクリーニングを行い，DVTを認めた症例では脳出血急性期であっても十分な血圧管理下に抗凝固療法によるPTE予防を行う治療方針をとっている．今回，当科に入院した脳出血患者250例を後方視的に解析し，DVTおよびPTEの危険因子を明らかにするとともに，脳出血急性期における抗凝固療法導入によるPTE予防の有効性および安全性を検証した．

　Pulmonary thromboembolism（PTE）can be a lethal complication in patients with intracerebral hemorrhage（ICH), and the early detection of deep venous thrombosis（DVT）is important for prevention of PTE. Anticoagulation therapy is effective for prevention of PTE；however, in ICH patients, the safety of anticoagulants is not established because of concern about ICH expansion. We investigated the clinical data of patients who developed ICH and assessed risk factors for DVT and the safety of anticoagulation therapy. Our study included 250 patients between 2014 and 2016. We performed weekly screening of D-dimer and ultrasonography of lower limb veins was performed when levels gradually increased or reached 10 μg/mL. In patients with DVT, we started anticoagulation therapy after systolic blood pressures were controlled at ≤140 mmHg. DVT was detected in 35（14.0%）patients, and 29（11.6%）underwent anticoagulation therapy. A hemorrhagic complication was observed in 1 case as gastrointestinal bleeding. Expansion of ICH was not detected in any cases. Symptomatic PTE occurred in 1 case with DVT, just before initiation of anticoagulants. Univariate logistic regression analysis revealed hemorrhage volume ≥30 mL and modified Rankin Scale score ≥5 at discharge were associated with increased risk of DVT, with odds ratios of 2.69 and 2.51, respectively.

　Our study suggests that DVT tends to occur in patients with severe ICH and that periodic measurement of D-dimer is useful for early detection of DVT. Anticoagulation therapy can be safely started in ICH patients under strict control of blood pressure.