Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.
Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.
Neurosurgery. 2019 Jul 1;85(suppl_1):S38-S46. doi: 10.1093/neuros/nyz067.
Early recognition and differentiation of acute ischemic stroke from intracranial hemorrhage and stroke mimics and the identification of large vessel occlusion (LVO) are critical to the appropriate management of stroke patients. In this review, we discuss the current evidence and practices surrounding safe and efficient triage in the emergency room. As the indications of stroke intervention are evolving to further improve stroke care, focus has begun to revolve around recognition of LVO and provision of endovascular thrombectomy with or without the administration of tissue plasminogen activator. Systems of stroke care are being organized to achieve this goal without delay. Clinical history is important in determining time of onset or last known well time, but, alone or along with an examination, it cannot reliably predict an LVO or exclude intracranial hemorrhage and stroke mimics. The choice of imaging is influenced mainly by the duration of symptoms. On the basis of recent trials, patients presenting after the 6-h therapeutic window can be considered for endovascular thrombectomy if the computed tomographic or magnetic resonance perfusion imaging shows favorable findings. The Society of NeuroInterventional Surgery has established time metrics for each step of triage and initial management. Hospitals are required to develop multidisciplinary stroke teams and emergency protocols to meet these goals. There also needs to be coordination of the emergency medical services with the emergency facility of an appropriate stroke center (a primary stroke center, comprehensive stroke care center, or a thrombectomy-capable stroke center).
早期识别和区分急性缺血性卒中和颅内出血及卒中样发作，以及确定大血管闭塞（LVO），对于卒中患者的适当治疗至关重要。在这篇综述中，我们讨论了目前在急诊室进行安全高效分诊的证据和实践。随着卒中干预的适应证不断发展，以进一步改善卒中治疗，重点开始围绕识别 LVO 以及提供血管内血栓切除术，是否联合使用组织型纤溶酶原激活剂。正在组织卒中护理系统以实现这一目标，避免延误。临床病史对于确定发病时间或最后一次知晓时间很重要，但仅凭病史或结合体格检查，不能可靠地预测 LVO 或排除颅内出血和卒中样发作。影像学选择主要受症状持续时间的影响。基于最近的试验，如果 CT 或磁共振灌注成像显示有利结果，发病后 6 小时治疗窗口内的患者可以考虑进行血管内血栓切除术。神经介入外科学会已经为分诊和初始管理的每个步骤制定了时间指标。医院需要建立多学科卒中团队和急诊协议，以实现这些目标。还需要协调急救医疗服务和适当卒中中心的急救设施（初级卒中中心、综合卒中护理中心或可进行血栓切除术的卒中中心）。
