McTaggart Ryan A, Ansari Sameer A, Goyal Mayank, Abruzzo Todd A, Albani Barb, Arthur Adam J, Alexander Michael J, Albuquerque Felipe C, Baxter Blaise, Bulsara Ketan R, Chen Michael, Almandoz Josser E Delgado, Fraser Justin F, Frei Donald, Gandhi Chirag D, Heck Don V, Hetts Steven W, Hussain M Shazam, Kelly Michael, Klucznik Richard, Lee Seon-Kyu, Leslie-Mawzi Thabele, Meyers Philip M, Prestigiacomo Charles J, Pride G Lee, Patsalides Athos, Starke Robert M, Sunenshine Peter, Rasmussen Peter A, Jayaraman Mahesh V
Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
J Neurointerv Surg. 2017 Mar;9(3):316-323. doi: 10.1136/neurintsurg-2015-011984. Epub 2015 Aug 31.
To summarize the current literature regarding the initial hospital management of patients with acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO), and to offer recommendations designed to decrease the time to endovascular treatment (EVT) for appropriately selected patients with stroke.
Using guidelines for evidenced-based medicine proposed by the Stroke Council of the American Heart Association, a critical review of all available medical literature supporting best initial medical management of patients with AIS secondary to ELVO was performed. The purpose was to identify processes of care that most expeditiously determine the eligibility of a patient with an acute stroke for interventions including intravenous fibrinolysis with recombinant tissue plasminogen activator (IV tPA) and EVT using mechanical embolectomy.
This review identifies four elements that are required to achieve timely revascularization in ELVO. (1) In addition to non-contrast CT (NCCT) brain scan, CT angiography should be performed in all patients who meet an institutional threshold for clinical stroke severity. The use of any advanced imaging beyond NCCT should not delay the administration of IV tPA in eligible patients. (2) Activation of the neurointerventional team should occur as soon as possible, based on either confirmation of large vessel occlusion or a prespecified clinical severity threshold. (3) Additional imaging techniques, particularly those intended to physiologically select patients for EVT (CT perfusion and diffusion-perfusion mismatch imaging), may provide additional value, but should not delay EVT. (4) Routine use of general anesthesia during EVT procedures, should be avoided if possible. These workflow recommendations apply to both primary and comprehensive stroke centers and should be tailored to meet the needs of individual institutions.
Patients with ELVO are at risk for severe neurologic morbidity and mortality. To achieve the best possible clinical outcomes stroke centers must optimize their triage strategies. Strategies that provide patients with ELVO with the fastest access to reperfusion depend upon detail-oriented process improvement.
总结目前关于急性缺血性卒中（AIS）继发于急性大血管闭塞（ELVO）患者的初始院内管理的文献，并提供旨在减少经适当选择的卒中患者接受血管内治疗（EVT）时间的建议。
采用美国心脏协会卒中委员会提出的循证医学指南，对支持AIS继发于ELVO患者最佳初始药物管理的所有现有医学文献进行严格审查。目的是确定能最迅速确定急性卒中患者是否适合进行包括使用重组组织型纤溶酶原激活剂（IV tPA）进行静脉溶栓和使用机械取栓术进行EVT等干预措施的护理流程。
本综述确定了在ELVO中实现及时血管再通所需的四个要素。（1）除了进行非增强CT（NCCT）脑部扫描外，所有符合机构设定的临床卒中严重程度阈值的患者都应进行CT血管造影。对于符合条件的患者，使用NCCT以外的任何高级成像检查都不应延迟IV tPA的给药。（2）基于大血管闭塞的确认或预先设定的临床严重程度阈值，应尽快启动神经介入团队。（3）额外的成像技术，特别是那些旨在从生理角度选择适合进行EVT的患者的技术（CT灌注和弥散灌注不匹配成像），可能会提供额外价值，但不应延迟EVT。（4）如果可能，应避免在EVT手术过程中常规使用全身麻醉。这些工作流程建议适用于初级和综合卒中中心，并应根据个别机构的需求进行调整。
ELVO患者有发生严重神经功能缺损和死亡的风险。为了获得最佳临床结果，卒中中心必须优化其分诊策略。为ELVO患者提供最快再灌注途径的策略依赖于注重细节的流程改进。
