Department of Neurosurgery, Oslo University Hospital, Rikshospitalet, P.B. 0454, Nydalen, 0424, Oslo, Norway.
Institute of Clinical Medicine, University of Oslo, P.B. 1072, Blindern, 0316, Oslo, Norway.
Acta Neurochir (Wien). 2019 Aug;161(8):1497-1506. doi: 10.1007/s00701-019-03971-9. Epub 2019 Jun 13.
Guidelines state that patients with aneurysmal subarachnoid haemorrhage (aSAH) require neurosurgical treatment as early as possible. Little is known about the time frame of transport from the ictus scene to Neurosurgery in large, partially remote catchment areas. We therefore analysed the chronology and transport logistics of aSAH patients in the South-Eastern Norway Health Region and related them to the frequency of aneurysm rebleed and 1-year mortality.
Retrospective analysis of aSAH patients bleeding within our region admitted to Neurosurgery during a 5-year period. Date, time and site of ictus and arrival at Neurosurgery, distance and mode of transport and admission were obtained from our institutional quality register and the emergency medical communication centre log. We scored the patients' clinical condition, rebleeds and 1-year mortality.
Five hundred forty-four patients were included. Median time from ictus to arrival Neurosurgery was 4.5 h. Transport by road ambulance was most common at distances between the ictus scene and Neurosurgery below 50 km, whereas airborne transport became increasingly more common at larger distances. Direct admissions, frequency of intubation and airborne transport to Neurosurgery increased with the severity of haemorrhage, leading to shorter transport times. The risk of rebleed was 0.8%/hour of transport. The rebleed rate was independent of distances travelled, but increased with the severity of aSAH, reaching up to 6.54%/hour in poor-grade patients. Distance and time of transport had no impact on 1-year mortality, whereas poor-grade aSAH and rebleed were strong predictors of mortality.
Poor-grade aSAH patients have a high risk of rebleed independent of the distance between the ictus scene and Neurosurgery. As rebleeding triples 1-year mortality, patients with Glasgow Coma Score < 9 with suspected aSAH should be admitted directly to Neurosurgery without delay after best possible cardiovascular and airway optimisation on site by competent personnel.
指南指出，患有蛛网膜下腔出血（aSAH）的患者需要尽早接受神经外科治疗。对于在大面积、部分偏远的集水区，从发病现场到神经外科的转运时间框架知之甚少。因此，我们分析了东南挪威卫生区 aSAH 患者的时间顺序和转运情况，并将其与动脉瘤再出血和 1 年死亡率相关联。
回顾性分析了在 5 年期间在我们区域内出血并被收治到神经外科的 aSAH 患者。从我们的机构质量登记处和紧急医疗通信中心日志中获取发病时间、地点和到达神经外科的时间、距离和转运方式以及入院情况。我们对患者的临床状况、再出血和 1 年死亡率进行评分。
共纳入 544 例患者。从发病到到达神经外科的中位数时间为 4.5 小时。在距离神经外科 50 公里以内的地方，最常见的转运方式是公路救护车，而随着距离的增加，空运转运越来越常见。直接入院、气管插管和空运到神经外科的频率随着出血的严重程度增加而增加，从而缩短了转运时间。再出血的风险为每小时 0.8%。再出血率与所经过的距离无关，但随着 aSAH 的严重程度增加而增加，在预后不良的患者中达到每小时 6.54%。转运的距离和时间对 1 年死亡率没有影响，而预后不良的 aSAH 和再出血是死亡的强有力预测因素。
即使距离神经外科较近，预后不良的 aSAH 患者也有再出血的高风险。由于再出血使 1 年死亡率增加三倍，因此对于格拉斯哥昏迷评分 < 9 的疑似 aSAH 患者，在现场由有能力的人员进行最佳的心血管和气道优化后，应直接收入神经外科，而不应延误。
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