目的:脑海绵状畸形(CCMs)是血管病变,破裂的总体风险为每年2%至6%,这与显著的发病率和死亡率有关。诊断发病率正在增加,因此,根据破裂风险对患者进行分层是至关重要的。文献中的数据似乎表明特定的药物,特别是抗血栓和心血管药物,与降低出血风险有关。然而,患者凝血状态对累积出血风险的影响尚不清楚.这项研究的目的是评估不同放射学的影响,临床,和药理学因素对CCM出血风险的影响,并评估已经验证的一般出血风险量表的预测能力,HAS-BLED(高血压,肾/肝功能异常,中风,出血史或倾向,不稳定的国际标准化比率,老年人,药物/酒精伴随)。
方法:这是一项多中心回顾性观察研究。作者收集影像学资料,临床状态,在考虑变量与出血或非出血状态之间进行单变量分析和随后的多变量逻辑回归,以确定出血的潜在独立预测因素.
结果:作者收集了257例患者的数据(男性占46.7%,25.3%伴出血CCMs)。与非出血性病变患者相比,那些出血的CCMs更年轻,很少有高血压,较少需要抗血小板药物和β受体阻滞剂(所有p<0.05)。出血病变,然而,具有明显更高的中值体积(1050mm3比523mm3,p<0.001)。在多变量分析中,在调整了年龄之后,高血压和糖尿病史,使用抗血小板药物或β受体阻滞剂,病灶体积≥300mm3是出血的唯一显著预测指标(校正OR3.11,95%CI1.09~8.86).当探索不同体积阈值的诊断准确性时,体积≥300mm3显示有限的灵敏度(36.7%,95%CI24.6%-50.0%),但高特异性78.2%(95%CI71.3%-84.2%),曲线下面积为0.57(95%CI0.51-0.64)。
结论:本研究支持先前的发现,即CCM体积是影响出血风险的唯一因素。抗血栓药和普萘洛尔似乎对出血事件具有保护作用。高HAS-BLED评分与出血风险增加无关。需要进一步的研究来证实这些结果。
Cerebral cavernous malformations (CCMs) are vascular lesions with an overall risk of rupture from 2% to 6% per year, which is associated with significant morbidity and mortality. The diagnostic incidence is increasing, so it is of paramount importance to stratify patients based on their risk of rupture. Data in the literature seem to suggest that specific medications, particularly antithrombotic and cardiovascular agents, are associated with a reduced risk of bleeding. However, the effect of the patient coagulative status on the cumulative bleeding risk remains unclear. The aim of this study was to assess the impact of different radiological, clinical, and pharmacological factors on the bleeding risk of CCMs and to assess the predictive power of an already validated scale for general bleeding risk, the HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly).
This was a multicenter retrospective observational study. The authors collected imaging, clinical status, and therapy data on patients with bleeding and nonbleeding CCMs. Univariate analysis and subsequent multivariate logistic regression were performed between the considered variables and bleeding or nonbleeding status to identify potential independent predictors of bleeding.
The authors collected data on 257 patients (46.7% male, 25.3% with bleeding CCMs). Compared with patients with nonbleeding lesions, those with bleeding CCMs were younger, less frequently had hypertension, and less frequently required antiplatelet drugs and beta-blockers (all p < 0.05). Bleeding lesions, however, had significantly higher median volumes (1050 mm3 vs 523 mm3 , p < 0.001). On multivariate analyses, after adjusting for age, history of hypertension and diabetes, and use of antiplatelet drugs or beta-blockers, lesion volume ≥ 300 mm3 was the only significant predictor of bleeding (adjusted OR 3.11, 95% CI 1.09-8.86). When the diagnostic accuracy of different volume thresholds was explored, volume ≥ 300 mm3 showed a limited sensitivity (36.7%, 95% CI 24.6%-50.0%), but a high specificity 78.2% (95% CI 71.3%-84.2%), with an area under the curve of 0.57 (95% CI 0.51-0.64).
This study supports previous findings that the CCM volume is the only factor influencing the bleeding risk. Antithrombotic agents and propranolol seem to have a protective role against the bleeding events. A high HAS-BLED score was not associated with an increased bleeding risk. Further studies are needed to confirm these results.