临床流行病学循证报告流行病与卫生统计学桑灏 1020110112任课教师：李觉张丽娟一、临床病例患者，男性，79岁。
因“突发右侧肢体无力15小时”入院。
2010年10月22日0点左右患者发现右侧肢体无力，行走欠佳，无明显头痛、头晕，无恶心、呕吐，无进食困难，自服天丹通络胶囊后觉症状稍有改善，上午8点来我院急诊，查头颅CT示“两侧大脑深部多发腔梗灶，边界欠清，最大径约10mm，以左基底节区明显”，予疏血通改善循环，醒脑静改善脑功能，患者病情稳定。
为进一步诊治，故拟“脑梗塞”收治入院。
患者发病以来，二便尚正常，夜眠可，近期体重无明显下降。
头颅CT未见高密度病灶。
既往：有高血压史，规则服药。
否认糖尿病、冠心病、房颤史。
不嗜烟酒。
年轻时有肛瘘手术史（具体不详），3年前有右下肢骨折手术史，有置入物，行走基本如常。
体检：BP130/90mmHg。
神清，口齿稍欠清，双瞳等大等圆，φ2.5mm，对光反射（+），右鼻唇沟稍浅，伸舌居中。
颈软，四肢肌张力正常，右侧肢体肌力５0-，左侧肢体肌力５0，腱反射对称，双侧病理征（-），针刺觉对称，右手指鼻欠佳。
二、临床问题1.给病人用阿司匹林抗血小板聚集是否会诱发病人脑出血？该病人能否应用阿司匹林？2.伴高血压的老年病人脑梗塞后存活率？三．文献证据检索（一）检索词：脑梗塞（cerebral infarction）、脑出血（cerebral hemorrhage）、阿司匹林（aspirin）、副作用（adverse effect）检索策略：”erebral infarction”and”cerebral hemorrhage”and”aspirin”and”adverse effect”The Cochrane library：1篇1.Aspirin and risk of hemorrhagic stroke: a meta-analysis of randomized controlled trialsPubMed clinic Queries：相关文献12篇；符合文献：4篇1.Chen ZM, Sandercock P, Pan HC, Counsell C, Collins R, Liu LS, Xie JX,Warlow C, Peto RIndications for early aspirin use in acute ischemic stroke : A combined analysis of 40 000 randomized patients from the chinese acute stroke trial and the international stroke trial. On behalf of the CAST and IST collaborative groups. Aspirin use and incident stroke in the cardiovascular health study. CHS Collaborative Research Grou p.Stroke. 2000 Jun;31(6):1240-9.2.Maggioni AP, Franzosi MG, Santoro E, White H, Van de Werf F, TognoniG The risk of stroke in patients with acute myocardial infarction afterthrombolytic and antithrombotic treatment. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico II (GISSI-2), and The International Study Group. N Engl J Med. 1992 Jul 2;327(1):1-6.3.Shinohara Y, Nishimaru K, Sawada T, Terashi A, Handa S, Hirai S, HayashiK, Tohgi H, Fukuuchi Y, Uchiyama S, Yamaguchi T, Kobayashi S, Kondo K, Otomo E, Gotoh F; S-ACCESS Study Group. Sarpogrelate-Aspirin Comparative Clinical Study for Efficacy and Safety in Secondary Prevention of Cerebral Infarction (S-ACCESS): A randomized, double-blind, aspirin-controlled trial. Stroke. 2008 Jun;39(6):1827-33. Epub 2008 Apr 3.4.Kronmal RA, Hart RG, Manolio TA, Talbert RL, Beauchamp NJ, NewmanA.Aspirin use and incident stroke in the cardiovascular health study. CHSCollaborative Research Group. N Engl J Med. 1992 Jul 2;327(1):1-6. NGC: 查的14篇指南，选取其中2篇指南1. Aspirin for the prevention of cardiovascular disease: U.S. PreventiveServices Task Force recommendation statement. 1996 (revised 2009)2. Diagnosis and initial treatment of ischemic. 2001 Oct (revised 2009 Jun).（二）检索词：脑梗塞（cerebral infarction）、存活率（survival）The Cochrane Library检索策略："cerebral infarction in Keywords and survival in Keywords in Cochrane Central Register of Controlled Trials"共得相关文献：Cochrane Reviews [0] | Other Reviews [1]| Clinical Trials [44]| Methods Studies [0] | Technology Assessments [0] | Economic Evaluations [2]| Cochrane Groups [0]符合文献：共3篇1.Rønning OM, Guldvog B . Stroke units versus general medical wards, I:twelve- and eighteen-month survival: a randomized, controlled trial. 。
19982.Anderson CS, Jamrozik KD, Broadhurst RJ, Stewart-Wynne EG .Predicting survival for 1 year among different subtypes of stroke.Results from the Perth Community Stroke Study. 19943.Eriksson SE . Differences in the outcome of patients with TIA versusminor stroke. 1992PubMed Clinic Queries检索策略：(cerebral infarction and survival) AND systematic[sb]Limits Activated: Male, Clinical Trial, Meta-Analysis, Practice Guideline, Randomized Controlled Trial, English, Aged: 65+ years, published in the last 3 years共得相关文献：All (60) Review (19)Free Full Text (19)符合文献：共3篇1．Fagard RH, Celis H, Thijs L, Staessen JA, Clement DL, De Buyzere ML, De Bacquer DA. Daytime and nighttime blood pressure as predictors of death and cause-specific cardiovascular events in hypertension.Hypertension. 2008 Jan;51(1):55-61. Epub 2007 Nov 26.四．证据评价（一）The Cochrane library：1.Aspirin and risk of hemorrhagic stroke: a meta-analysis of randomized controlled trials证据等级：Ⅰa（同质RCT：16）证据内容：（1）阿司匹林治疗对心梗和缺血性发作能别减少万分之37和万分之39（95%IC：107-167，P＜0.01; 95%IC=17-61; P＜0.01）（2）阿司匹林会增加出血性卒中的发生（万分之12）（95%IC=5-20，P＜0.01）PubMed clinic Queries：1. Indications for early aspirin use in acute ischemic stroke : A combined analysis of 40 000 randomized patients from the chinese acute stroke trial and the international stroke trial. On behalf of the CAST and IST collaborative groups. Aspirin use and incident stroke in the cardiovascular health study. CHS Collaborative Research Grou p.证据等级：Ⅱa（同质性前瞻性队列研究：2）证据内容：（1）阿司匹林组与对照组相比增加了2‰的出血性卒中和从首次梗塞转化为出血事件的发生率。