Zeenat Qureshi Stroke Research Center, University of Minnesota Medical Center, Minneapolis, MN 55455,USA.
Cerebrovasc Dis. 2012;34(5-6):400-5. doi: 10.1159/000343504. Epub 2012 Dec 4.
The American Heart Association and the American Stroke Association recommend intravenous (IV) thrombolysis up to 4.5 h from acute ischemic stroke symptom onset based on its proven benefit in improving patient outcomes. We analyzed data from the Minnesota Stroke Registry to assess the rates of IV thrombolytic utilization and the process of care in this expanded window.
We identified patients who had received IV recombinant tissue plasminogen activator (rt-PA) at any of the 19 participating hospitals from January 1, 2008 till December 31, 2010. Treatment groups were those actually treated by IV rt-PA in 0-3 h and those treated by IV rt-PA in 3-4.5 h. Duration from symptom onset to arrival in the emergency department (ED) was dichotomized to cohorts of 0-2 and 2-3.5 h. We determined the overall utilization of IV rt-PA in the expanded window and calculated door-to-needle times for the two treatment windows. We also ascertained the rates of symptomatic intracerebral hemorrhage between the two treatment groups.
Out of the total 519 patients who received IV rt-PA for acute ischemic stroke, 433 (83%) were treated within 0-3 h and 86 (17%) within 3-4.5 h. Of all the patients who received IV rt-PA within 3-4.5 h, 45% arrived at the ED within 2 h of symptom onset. Median door-to-needle time for the 0- to 3-hour window was 74.5 min [interquartile range (IQR) 57-90] and 54 min (IQR 43.5-70.5) for the 3- to 4.5-hour window. Based on arrival time to the ED, door-to-needle time of ≤60 min was achieved by only 31% (142/458) of patients who arrived within 0-2 h of their symptom onset compared to 61% (37/61) of those who arrived at the ED within 2-3.5 h of their symptom onset. Fifty-nine (14%) patients in the 0- to 3-hour group and 17 (20%) patients in the 3- to 4.5-hour group received a combination of IV rt-PA and endovascular treatments. Among patients with documented admission National Institutes of Health Stroke Scale scores, the values (median with IQR) were different between the 0- to 3- and the 3- to 4.5-hour group, i.e. 10 (IQR 5-18) and 7 (IQR 4-14), respectively.
Patients who received IV rt-PA within the 3- to 4.5-hour window comprised 17% of all IV rt-PA cases treated in the Minnesota Stroke Registry hospitals after the new guidelines recommended a time window expansion. Almost half of these patients would have qualified for treatment within the 0- to 3-hour window as they presented within 0-2 h of symptom onset. Patients arriving 2-3.5 h after symptom onset received thrombolysis on average 20 min faster than patients arriving within 2 h of symptom onset.
美国心脏协会和美国中风协会建议在急性缺血性中风症状发作后 4.5 小时内进行静脉（IV）溶栓治疗，这是基于其在改善患者预后方面的疗效。我们分析了明尼苏达州中风登记处的数据，以评估在这个扩大的时间窗内 IV 溶栓治疗的使用率和治疗过程。
我们从 2008 年 1 月 1 日至 2010 年 12 月 31 日，在 19 家参与医院中识别出接受 IV 重组组织型纤溶酶原激活剂（rt-PA）治疗的患者。治疗组为在 0-3 小时内接受 IV rt-PA 治疗的患者和在 3-4.5 小时内接受 IV rt-PA 治疗的患者。从症状发作到到达急诊室（ED）的时间被分为两个队列，即 0-2 小时和 2-3.5 小时。我们确定了在扩大的时间窗内 IV rt-PA 的总体使用率，并计算了两个治疗窗口的门到针时间。我们还确定了两个治疗组之间症状性颅内出血的发生率。
在接受 IV rt-PA 治疗的 519 例急性缺血性中风患者中，433 例（83%）在 0-3 小时内治疗，86 例（17%）在 3-4.5 小时内治疗。在所有在 3-4.5 小时内接受 IV rt-PA 治疗的患者中，45%在症状发作后 2 小时内到达 ED。0-3 小时治疗窗口的中位门到针时间为 74.5 分钟（四分位距 57-90），3-4.5 小时治疗窗口的门到针时间为 54 分钟（四分位距 43.5-70.5）。根据到达 ED 的时间，只有 31%（142/458）在症状发作后 0-2 小时内到达的患者达到了≤60 分钟的门到针时间，而在症状发作后 2-3.5 小时内到达的患者中，有 61%（37/61）达到了这一目标。在 0-3 小时治疗组的 59 例（14%）患者和 3-4.5 小时治疗组的 17 例（20%）患者中，接受了 IV rt-PA 和血管内治疗的联合治疗。在有记录的入院国立卫生研究院中风量表评分的患者中，0-3 小时和 3-4.5 小时治疗组的评分值（中位数和 IQR）分别为 10（IQR 5-18）和 7（IQR 4-14）。
在新指南推荐扩大时间窗后，明尼苏达州中风登记处医院接受 IV rt-PA 治疗的所有病例中，有 17%的患者在 3-4.5 小时的时间窗内接受治疗。其中近一半的患者如果在症状发作后 0-2 小时内就诊，将有资格在 0-3 小时的时间窗内接受治疗。在症状发作后 2-3.5 小时就诊的患者平均比在症状发作后 2 小时内就诊的患者接受溶栓治疗快 20 分钟。
