Debiais S, Bonnaud I, Giraudeau B, Perrotin D, Gigot J-L, Saudeau D, De Toffol B, Autret A
Service de neurologie, CHRU, Tours.
Rev Neurol (Paris). 2007 Sep;163(8-9):817-22. doi: 10.1016/s0035-3787(07)91464-2.
Our university hospital serves a population of 300 000 inhabitants. Stroke is the leading cause of admission in our department of neurology. In June 2003, when the Emergency Department (ED) was closed in our institution, was created an acute stroke network (ASN), comprising 2 beds of direct admission and thrombolysis in the intensive care unit, and 4 beds dedicated to stroke care in the department of neurology, in which standardized stroke care protocols were implemented.
The aim of this study was to evaluate changes in stroke care related to the creation of the ASN in terms of delays of arrival, imaging, use of intravenous (IV) thrombolysis, and outcome of patients. We conducted a prospective study during 18 months to evaluate characteristics of patients admitted with suspected stroke or transient ischemic attack (TIA) in the newly created ASN and to assess conditions of treatment with IV thrombolysis in terms of safety and efficacy. We also compared the outcome data before and after the creation of the ASN.
For each patient admitted in our hospital for suspected stroke or TIA, were prospectively collected clinical and outcome data (age, mode of transport, delay of arrival after the onset of symptoms (OS), treatment with IV thrombolysis, outcome and discharge). This study was conducted in the ED during six months in 2002, and in the ASN during 18 months, for all patients admitted for stroke.
Three hundred and sixty four patients were admitted in the ASN. Emergency medical services (EMS) were used in half of cases for transport, and median delay of admission after the OS was 2h and 52 min. Median delay of imaging was 1 h and 45 min. Seventeen patients (8.5 p. 100 of ischemic stroke patients) were treated with IV thrombolysis, with an initial good outcome in 9 patients, 7 with a dramatic recovery). The main reason for therapeutic abstention for untreated patients admitted in the first 3 hours was a mild deficit with a NIHSS<6. Compared with the previous management in the ED, patients in the ASN were younger, had more severe neurological symptoms, the EMS transport was the main mode of transport (versus used in 17 p. 100 of cases in 2002), and the delay of admission was significantly lower: 2 h 52 versus 5 h 10 (p<0.02). After adjustment on the main predictive factors, only patients with hemorrhagic strokes had a better outcome after the creation of the ASN.
Creation of an ASN was associated with a significant decrease of admission and imaging delays, due to a strong collaboration with EMS, and with a better outcome for hemorrhagic stroke patients. Treatment with intravenous thrombolysis in the first 3 hours could be used widely and was efficient and safe. However, the creation of dedicated stroke units for all stroke patients remains necessary to improve quality of care and outcome.
我们的大学医院服务于30万居民。中风是我们神经内科收治患者的主要原因。2003年6月，当我们机构的急诊科关闭时，创建了一个急性中风网络（ASN），其中包括重症监护病房的2张直接收治和溶栓床位，以及神经内科的4张专门用于中风护理的床位，并实施了标准化的中风护理方案。
本研究的目的是评估与急性中风网络（ASN）创建相关的中风护理在到达延迟、成像、静脉（IV）溶栓使用和患者结局方面的变化。我们进行了一项为期18个月的前瞻性研究，以评估在新创建的急性中风网络（ASN）中因疑似中风或短暂性脑缺血发作（TIA）入院患者的特征，并从安全性和有效性方面评估静脉溶栓治疗的情况。我们还比较了急性中风网络（ASN）创建前后的结局数据。
对于我院因疑似中风或TIA入院的每位患者，前瞻性收集临床和结局数据（年龄、运输方式、症状发作后（OS）的到达延迟、静脉溶栓治疗、结局和出院情况）。本研究于2002年在急诊科进行了6个月，在急性中风网络（ASN）中对所有中风入院患者进行了18个月的研究。
364例患者入住急性中风网络（ASN）。半数病例使用了紧急医疗服务（EMS）进行转运，症状发作后（OS）的中位入院延迟为2小时52分钟。中位成像延迟为1小时45分钟。17例患者（缺血性中风患者的8.5%）接受了静脉溶栓治疗，9例患者初始结局良好，7例显著恢复。在前3小时内入院但未接受治疗的患者放弃治疗的主要原因是美国国立卫生研究院卒中量表（NIHSS）评分<6的轻度神经功能缺损。与急诊科之前的管理相比，急性中风网络（ASN）中的患者更年轻，神经症状更严重，EMS转运是主要的转运方式（2002年为17%的病例使用），入院延迟显著降低：2小时52分钟对5小时10分钟（p<0.02）。在对主要预测因素进行调整后，只有出血性中风患者在急性中风网络（ASN）创建后的结局更好。
急性中风网络（ASN）的创建与入院和成像延迟的显著减少相关，这归因于与EMS的紧密合作，并且出血性中风患者的结局更好。在最初3小时内进行静脉溶栓治疗可以广泛应用，且有效且安全。然而，为所有中风患者创建专门的中风单元对于提高护理质量和结局仍然是必要的。
