Department of Neurology, The Canberra Hospital, Canberra, Australia.
Australian National University Medical School, Canberra, Australia.
J Neurol. 2021 Aug;268(8):2723-2734. doi: 10.1007/s00415-020-09803-6. Epub 2020 Mar 21.
BACKGROUND/AIMS: This review examined factors that delay thrombolysis and what management strategies are currently employed to minimise this delay, with the aim of suggesting future directions to overcome bottlenecks in treatment delivery.
A systematic review was performed according to PRISMA guidelines. The search strategy included a combination of synonyms and controlled vocabularies from Medical Subject Headings (MeSH) and EmTree covering brain ischemia, cerebrovascular accident, fibrinolytic therapy and Alteplase. The search was conducted using Medline (OVID), Embase (OVID), PubMed and Cochrane Library databases using truncations and Boolean operators. The literature search excluded review articles, trial protocols, opinion pieces and case reports. Inclusion criteria were: (1) The article directly related to thrombolysis in ischaemic stroke, and (2) The article examined at least one factor contributing to delay in thrombolytic therapy.
One hundred and fifty-two studies were included. Pre-hospital factors resulted in the greatest delay to thrombolysis administration. In-hospital factors relating to assessment, imaging and thrombolysis administration also contributed. Long onset-to-needle times were more common in those with atypical, or less severe, symptoms, the elderly, patients from lower socioeconomic backgrounds, and those living alone. Various strategies currently exist to reduce delays. Processes which have achieved the greatest improvements in time to thrombolysis are those which integrate out-of-hospital and in-hospital processes, such as the Helsinki model.
Further integrated processes are required to maximise patient benefit from thrombolysis. Expansion of community education to incorporate less common symptoms and provision of alert pagers for patients may provide further reduction in thrombolysis times.
背景/目的：本综述旨在探讨导致溶栓延迟的因素，以及目前采用何种管理策略来尽量减少这种延迟，以期为克服治疗实施中的瓶颈提出未来的方向。
根据 PRISMA 指南进行系统综述。检索策略包括使用医学主题词（MeSH）和 EmTree 的同义词和受控词汇的组合，涵盖脑缺血、脑血管意外、纤维蛋白溶解治疗和阿替普酶。使用 Medline（OVID）、Embase（OVID）、PubMed 和 Cochrane 图书馆数据库进行搜索，使用截断和布尔运算符。文献检索排除了综述文章、试验方案、观点文章和病例报告。纳入标准为：（1）文章直接与缺血性脑卒中的溶栓治疗相关；（2）文章至少考察了一个导致溶栓治疗延迟的因素。
共纳入 152 项研究。发病前因素导致溶栓治疗开始时间的最大延迟。与评估、影像学和溶栓治疗相关的院内因素也有影响。非典型或症状较轻、年龄较大、社会经济地位较低以及独居的患者，其发病到溶栓治疗的时间较长。目前存在各种策略来减少延迟。整合了院外和院内流程的方法，如赫尔辛基模式，在缩短溶栓时间方面取得了最大的改进。
需要进一步整合流程，以最大限度地提高溶栓治疗对患者的获益。扩大社区教育，纳入不常见的症状，并为患者提供报警传呼器，可能进一步缩短溶栓时间。
