急性腦中風病人之深層靜脈血栓研究 李孟珊、林重宏
E-mail: 387158@mail.dyu.edu.tw
摘 要
深層靜脈血栓(Deep Vein Thrombosis,DVT)指血栓形成於腿部靜脈處，無常規預防會併發高死亡率肺栓塞(Pulmonary embolism,PE)，為急性腦中風病人常見的併發症。臨床上利用抽血檢驗D-dimer與下肢超音波檢查來做診斷。在亞洲地區無 足夠的研究與正規的預防做法，本研究將以彰化基督教醫院病歷回顧的方式，探討缺血型和出血型的急性腦中風病人深層 靜脈血栓的發生率。研究結果136位急性腦中風病人，深層靜脈血栓19例(14.0%)，單變項分析在有和無深層靜脈血栓兩組 病人中，D-dimer (P = 0.025)、年齡>80歲(P = 0.041)、抗凝血藥物(P = 0.041)，有顯著統計學上的差異。經二元迴歸分析發 現，深層靜脈血栓獨立預測因子為:年齡>80歲(odds ratio=4.23,P = 0.017)與D-dimer(odds ratio=1.03 每100 ng/mL,P = 0.041)
。結果顯示，在高危險的急性腦中風病人中，有相當比率罹患深層靜脈血栓，而年齡>80歲與D-dimer可視為診斷深層靜脈 血栓的獨立預測因子。
關鍵詞 : 中風、深層靜脈血栓、D-dimer
目錄
中文摘要 iii 英文摘要 iv 誌謝 v 目錄 vi 圖目錄 viii 表目錄 ix 1.前言 1 2.文獻回顧 3 2.1中風介紹 3 2.2 D-D雙合試驗(D-dimer 介紹) 4 2.3 深層靜脈血栓介紹 5 2.4 NIHSS評分量表介紹 6 2.5靜脈血栓栓塞預防評估單介紹 6 3.材料和方法 8 3.1研究資料 收集與設定之條件 8 3.2研究說明 8 3.3彰化基督教醫院執行步驟 9 3.4本研究統計分析說明 9 3.5亞洲文獻回顧 12 4.結果與討 論 15 4.1本研究單變項分析結果總覽 15 4.2單變項分析顯著性差異 17 4.3二元迴歸分析 19 4.4亞洲文獻回顧分析 20 4.5深層 靜脈血栓其他疾病研究 32 4.6討論 37 5.結論 41 參考文獻 43 附錄1 NIHSS評分量表 48 附錄2 靜脈血栓栓塞預防評估單介紹 49 附錄3 彰化基督教醫院人體試驗委員同意臨床試驗證明書 51 圖目錄 圖1. 研究資料來源與說明 13 圖2. 彰化基督教醫院執 行步驟 14 表目錄 表4.1.1 急性腦中風之深層靜脈血栓臨床特徵分析 16 表4.1.2急性腦中風之深層靜脈血栓臨床特徵分析 17 表4.3 識別深層靜脈血栓因子分析 19 表4.4 亞洲國家對中風深層靜脈血栓研究 24 表4.5 深層靜脈血栓其他疾病研究 34 參考文獻
1.吳明隆、涂金堂。SPSS與統計應用分析。2005年初版。 2.康匯、黃小強、廖永華、鞏四海.抗凝並早期被動活動預防關節置換術後下肢 深靜脈血栓形成。陝西醫學雜誌2008年6月第37卷第6期。 3.梁蕙雯.腦中風之障礙與失能評估量表簡介。台北市醫師公會會刊2009年 第53卷第10期。 4.黃海燕。急性下肢深靜脈血栓形成56例臨床分析.吉林醫學2010年5月第31卷第15期。 5.黎燕飛、劉華敢.彩色多普勒超 聲診斷下肢靜脈血栓200例分析.廣東醫學院學報第28卷第1期2010年2月。 6.陳淑珍、趙麗淑、陳虹珍、吳宇暉。D-Dimer在早期診斷心 肌梗塞病患上之應用。 7.韓福勝、王長富、楊文珍、劉寶勳。下肢手術後深靜脈血栓形成的預防。中日友好醫院學報2008年第22卷第6 期。 8.羅東霞。下肢深靜脈血栓形成的護理和預防。吉林醫學2010年6月第31卷第18期。 9.Bates, S. M., D-dimer assays in diagnosis and management of thrombotic and bleeding disorders. Seminars in thrombosis and hemostasis 2012, 38 (7), 673-82. 10.Bembenek, J.; Karlinski, M.;
Kobayashi, A.; Czlonkowska, A., Early s troke-related deep venous thrombosis: risk factors and influence on outcome. Journal of thrombosis and hrombolysis 2011, 32 (1), 96-102. 11.Datta, I.; Ball, C. G.; Rudmik, L.; Hameed, S. M.; Kortbeek, J. B., Complications related to deep venous thrombosis prophylaxis in trauma: a systematic review of the literature. Journal of trauma management & outcomes 2010, 4, 1. 12.De Silva, D. A.;
Pey, H. B.; Wong, M. C.; Chang, H. M.; Chen, C. P., Deep vein thrombosis following ischemic stroke among Asians. Cerebrovasc Dis 2006, 22 (4), 245-50. 13.Fan, J.; Li, X.; Cheng, Y.; Yao, C.; Zhong, N., Measurement of D-dimer as aid in risk evaluation of VTE in elderly patients hospitalized for acute illness: a prospective, multicenter study in China. Clinical and investigative medicine. Medecine clinique et experimentale 2011, 34 (2), E96-104. 14.Goldstein, L. B.; Simel, D. L., Is this patient having a stroke? JAMA : the journal of the American Medical Association 2005, 293(19), 2391-402. 15.Heath, R.; Horton, S.; Martlew, V.; Thachil, J., A very elevated D-dimer level may potentially be useful. European journal of internal medicine 2013, 24 (2), e19-20. 16.Jauch, E. C.; Saver, J. L.; Adams, H. P., Jr.; Bruno, A.; Connors,J. J.; Demaerschalk, B. M.; Khatri, P.;
McMullan, P. W., Jr.; Qureshi, A. I.; Rosenfield, K.; Scott, P. A.; Summers, D. R.; Wang, D. Z.; Wintermark, M.; Yonas, H., Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke; a journal of cerebral circulation 2013, 44 (3), 870-947. 17.Kawase, K.; Okazaki, S.; Toyoda, K.; Toratani, N.;
Yoshimura, S.; Kawano, H.; Nagatsuka, K.; Matsuo, H.; Naritomi, H.; Minematsu, K., Sex difference in the prevalence of deep-vein thrombosis in Japanese patients with acute intracerebral hemorrhage. Cerebrovasc Dis 2009, 27 (4), 313-9. 18.Kong, K. H.; Chua, S. G.; Earnest, A., Deep vein
thrombosis in stroke patients admitted to a rehabilitation unit in Singapore. International journal of stroke : official journal of the International Stroke Society 2009, 4 (3), 175-9. 19.Kong, K. H.; Chua, S. G., Deep vein thrombosis based on D-dimer screening in ischaemic stroke patients undergoing rehabilitation. Singapore medical journal 2009, 50 (10), 971-5. 20.Kuwashiro, T.; Toyoda, K.; Oyama, N.; Kawase, K.; Okazaki, S.;
Nagano, K.; Koga, M.; Matsuo, H.; Naritomi, H.; Minematsu, K., High plasma D-dimer is a marker of deep vein thrombosis in acute stroke.
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association 2012, 21 (3), 205-9. 21.Mayo, N. E.; Goldberg, M. S.; Levy, A. R.; Danys, I.;Korner-Bitensky, N., Changing rates of stroke in the province of Quebec, Canada: 1981-1988. Stroke; a journal of cerebral circulation 1991, 22 (5), 590-5. 22.Ogata, T.; Yasaka, M.; Wakugawa, Y.; Inoue, T.; Ibayashi, S.; Okada, Y., Deep venous thrombosis after acute intracerebral hemorrhage. Journal of the neurological sciences 2008, 272 (1-2), 83-6. 23.Ogata, T.; Yasaka, M.; Wakugawa, Y.;
Kitazono, T.; Okada, Y., Association of Deep Venous Thrombosis with Calf Vein Diameter in Acute Hemorrhagic Stroke. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association 2012. 24.Sadanaga, T.; Sadanaga, M.; Ogawa, S., Evidence that D-dimer levels predict subsequent thromboembolic and cardiovascular events in patients with atrial fibrillation during oral anticoagulant therapy.
Journal of the American College of Cardiology 2010, 55 (20), 2225-31. 25.Struijk-Mulder, M. C.; Ettema, H. B.; Verheyen, C. C.; Buller, H. R., Deep vein thrombosis after arthroscopic anterior cruciate ligament reconstruction: a prospective cohort study of 100 patients. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2013, 29 (7), 1211-6. 26.Sun, K. K.; Wang, C.; Pang, B. S.; Yang, Y. H.; He, W.; Chen, T. F.; Zhao, Q. H.; Zhang, J., [Study on the risk factors of deep venous thrombosis in acute hospitalized stroke patients]. Zhonghua liu xing bing xue za zhi = Zhonghua liuxingbingxue zazhi 2004, 25 (12), 1019-23. 27.Sun, M. C.; Hsiao, P. J., In-hospital case management to increase anticoagulation therapy for stroke patients with atrial fibrillation: a hospital-based registry. Journal of the Formosan Medical Association = Taiwan yi zhi 2013, 112 (5), 263-8. 28.Tan, S. S.;
Venketasubramanian, N.; Ong, P. L.; Lim, T. C., Early deep vein thrombosis: incidence in Asian stroke patients. Annals of the Academy of Medicine, Singapore 2007, 36 (10), 815-20. 29.Verma, N.; Willeke, P.; Bicsan, P.; Lebiedz, P.; Pavenstadt, H.; Kumpers,P.,[Age-adjusted D-dimer cut-offs to diagnose thromboembolic events : Validation in an emergency department.]. Medizinische Klinik, Intensivmedizin und Notfallmedizin 2013. 30.Wik, H. S.; Jacobsen, A. F.; Fagerland, M. W.; Sandvik, L.; Sandset, P. M., Long-term mortality and incidence of cancer after
pregnancy-related venous thrombosis: Results of a population-based cohort study. Thrombosis research 2013, 131 (6), 497-501. 31.Yamane, K.;
Kimura, F.; Unoda, K.; Hosokawa, T.; Hirose, T.; Tani, H.; Doi, Y.; Ishida, S.; Nakajima, H.; Hanafusa, T., Postural abnormality as a risk marker for leg deep venous thrombosis in Parkinson's disease. PloS one 2013, 8 (7), e66984. 32.Yi, X.; Lin, J.; Han, Z.; Zhou, X.; Wang, X., The incidence of venous thromboembolism following stroke and its risk factors in eastern China. Journal of thrombosis and thrombolysis 2012, 34 (2), 269-7
