From the Stroke Unit, Department of Neurology, Vall d'Hebron Research Institute (B.M., M. Requena, S.B., M. Rubiera, M.M., D.R.-L., N.R.-V., J.J., J.P., C.A.M., M. Ribo), Vall d'Hebron University Hospital, Barcelona, Spain.
Department of Vascular Neurology, National Institute of Neurology and Neurosurgery, Ciudad de Mexico, Mexico (B.M.).
Stroke. 2018 Nov;49(11):2723-2727. doi: 10.1161/STROKEAHA.118.021989.
Background and Purpose- Time to reperfusion is fundamental in reducing morbidity and mortality in acute stroke. We aimed to demonstrate that direct transfer to angio-suite (DTAS) of patients with suspected large vessel occlusion stroke improves workflow times and outcomes. Methods- A case-control matched study of the first 79 DTAS patients with confirmed large vessel occlusion (cases) and 145 no-DTAS patients (controls). DTAS protocol included a cone beam computed tomography in the angio-suite to rule out intracerebral hemorrhage for those patients with no prior neuroimaging in a referring center. Cases and controls were matched by location of vessel occlusion, age, baseline National Institutes of Health Stroke Scale (NIHSS) score and time from symptoms onset to Comprehensive Stroke Center arrival. Dramatic clinical improvement was defined as a decrease in NIHSS score of >10 points or final NIHSS score of ≤2. Favorable outcome was defined as modified Rankin Scale score of ≤2 at 90 days. Results- During an 18 months period a total of 97 patients were directly transferred to the angio-suite after admission: 11 (11.6%) showed an intracerebral hemorrhage on cone beam computed tomography, 7 (7.2%) did not have a large vessel occlusion on initial angiogram, and 79 (76.3%) had a large vessel occlusion and received endovascular treatment (cases). There were no differences in age, baseline NIHSS score, level of occlusion and time from onset-to-door between cases and controls. The median door-to-groin time (16 [12-20] versus 70 [45-105] minutes; P<0.01) and onset-to-groin times (222 [152-282] versus 259 [190-345] minutes; P<0.01) were shorter in the DTAS group. At 24 hours, DTAS patients presented lower NIHSS score (7 [4-16] versus 14 [4-20]; P=0.01), higher rate of dramatic improvement (50.6% Vs. 31.7%; P=0.04), and higher rate of favorable clinical outcome at 90 days (41% versus 28%; P=0.05). A logistic regression model adjusting for all matching variables showed that DTAS protocol was independently associated with 3 months favorable outcome (odds ratio, 2.5; 95% CI, 1.2-5.3; P=0.01). Conclusions- DTAS is an effective strategy to reduce workflow time which may significantly increase the odds of achieving a favorable outcome.
背景与目的- 恢复血流时间对于降低急性卒中的发病率和死亡率至关重要。我们旨在证明将疑似大血管闭塞性卒中的患者直接转入血管造影套件（DTAS）可改善工作流程时间和结局。
方法- 对前 79 例经证实存在大血管闭塞的 DTAS 患者（病例）和 145 例无 DTAS 患者（对照）进行病例对照匹配研究。DTAS 方案包括对无转诊中心神经影像学检查的患者进行锥形束 CT 检查以排除颅内出血。根据血管闭塞部位、年龄、基线 NIHSS 评分和从症状发作到综合卒中中心到达的时间对病例和对照进行匹配。明显临床改善定义为 NIHSS 评分下降≥10 分或最终 NIHSS 评分≤2 分。良好结局定义为 90 天时改良 Rankin 量表评分≤2 分。
结果- 在 18 个月的时间里，共有 97 名患者在入院后直接转入血管造影套件：11 名（11.6%）在锥形束 CT 上显示颅内出血，7 名（7.2%）在初始血管造影上未显示大血管闭塞，79 名（76.3%）有大血管闭塞并接受血管内治疗（病例）。病例和对照组之间的年龄、基线 NIHSS 评分、闭塞程度和从发病到到门的时间均无差异。门到腹股沟的中位时间（16 [12-20]分钟与 70 [45-105]分钟；P<0.01）和发病到腹股沟的时间（222 [152-282]分钟与 259 [190-345]分钟；P<0.01）在 DTAS 组更短。在 24 小时时，DTAS 患者的 NIHSS 评分较低（7 [4-16]分与 14 [4-20]分；P=0.01），戏剧性改善的比例较高（50.6%比 31.7%；P=0.04），90 天时的临床结局良好的比例较高（41%比 28%；P=0.05）。调整所有匹配变量的逻辑回归模型显示，DTAS 方案与 3 个月时的良好结局独立相关（优势比，2.5；95%置信区间，1.2-5.3；P=0.01）。
结论- DTAS 是一种有效缩短工作流程时间的策略，可能显著增加实现良好结局的几率。
