From the Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., B.K.M.); Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.P.J., T.J.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.D.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY (E.L.); Department of Radiology, Erlanger Hospital at the University of Tennessee, Chattanooga, Tenn (B.B.); and Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, Calif.
Radiology. 2016 Jun;279(3):888-97. doi: 10.1148/radiol.2016160204. Epub 2016 Apr 19.
Purpose To study the relationship between functional independence and time to reperfusion in the Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial in patients with disabling acute ischemic stroke who underwent endovascular therapy plus intravenous tissue plasminogen activator (tPA) administration versus tPA administration alone and to investigate variables that affect time spent during discrete steps. Materials and Methods Data were analyzed from the SWIFT PRIME trial, a global, multicenter, prospective study in which outcomes were compared in patients treated with intravenous tPA alone or in combination with the Solitaire device (Covidien, Irvine, Calif). Between December 2012 and November 2014, 196 patients were enrolled. The relation between time from (a) symptom onset to reperfusion and (b) imaging to reperfusion and clinical outcome was analyzed, along with patient and health system characteristics that affect discrete steps in patient workflow. Multivariable logistic regression was used to assess relationships between time and outcome; negative binomial regression was used to evaluate effects on workflow. The institutional review board at each site approved the trial. Patients provided written informed consent, or, at select sites, there was an exception from having to acquire explicit informed consent in emergency circumstances. Results In the stent retriever arm of the study, symptom onset to reperfusion time of 150 minutes led to 91% estimated probability of functional independence, which decreased by 10% over the next hour and by 20% with every subsequent hour of delay. Time from arrival at the emergency department to arterial access was 90 minutes (interquartile range, 69-120 minutes), and time to reperfusion was 129 minutes (interquartile range, 108-169 minutes). Patients who initially arrived at a referring facility had longer symptom onset to groin puncture times compared with patients who presented directly to the endovascular-capable center (275 vs 179.5 minutes, P < .001). Conclusion Fast reperfusion leads to improved functional outcome among patients with acute stroke treated with stent retrievers. Detailed attention to workflow with iterative feedback and aggressive time goals may have contributed to efficient workflow environments. (©) RSNA, 2016 Online supplemental material is available for this article.
目的 在接受血管内治疗联合静脉组织型纤溶酶原激活剂（tPA）与单独 tPA 治疗的致残性急性缺血性卒中患者中，研究 Solitaire 取栓装置伴血栓切除术意向作为急性缺血性卒中的主要血管内治疗（SWIFT PRIME）试验中功能独立性与再灌注时间之间的关系，并探讨影响各离散步骤时间的变量。
材料与方法 对 SWIFT PRIME 试验的数据进行了分析，该试验为一项全球性、多中心前瞻性研究，比较了单独接受静脉 tPA 治疗与联合使用 Solitaire 装置（Covidien，Irvine，加利福尼亚州）治疗的患者的结局。2012 年 12 月至 2014 年 11 月，共纳入 196 例患者。分析了（a）从症状发作到再灌注和（b）从影像学检查到再灌注的时间与临床结局之间的关系，以及影响患者工作流程中各离散步骤的患者和卫生系统特征。采用多变量逻辑回归评估时间与结局之间的关系；采用负二项回归评估对工作流程的影响。各入组中心的机构审查委员会均批准了该试验。患者提供了书面知情同意，或者在一些选择的中心，在紧急情况下可以免除获得明确知情同意的要求。
结果 在该研究的支架取栓组中，再灌注前的症状发作时间为 150 分钟时，其功能独立的估计概率为 91%，接下来的 1 小时内概率下降 10%，此后每增加 1 小时概率下降 20%。从到达急诊室到动脉入路的时间为 90 分钟（四分位间距，69120 分钟），再灌注时间为 129 分钟（四分位间距，108169 分钟）。与直接到有血管内治疗能力的中心就诊的患者相比，最初在转诊医院就诊的患者的症状发作至股动脉穿刺时间更长（275 分钟比 179.5 分钟，P<.001）。
结论 在接受支架取栓治疗的急性卒中患者中，快速再灌注可改善功能结局。对工作流程的详细关注、迭代反馈和积极的时间目标可能有助于高效的工作流程环境。
（©）RSNA，2016 年
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