Department of Neurology, OLVG, Amsterdam, the Netherlands.
Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
Int J Stroke. 2021 Jul;16(5):534-541. doi: 10.1177/1747493020962236. Epub 2020 Sep 30.
In most hospitals, computed tomography angiography (CTA) is nowadays routinely performed in patients with acute ischemic stroke. However, it is unclear whether CTA is best performed before or after start of intravenous thrombolysis (IVT), since acquisition of CTA before IVT may prolong door-to-needle times, while acquisition after IVT may prolong door-to-groin times in patients undergoing endovascular treatment.
We performed a before-versus-after study (CTA following IVT, period I and CTA prior to IVT, period II), consisting of two periods of one year each. This study is based on a prospective registry of consecutive patients treated with IVT in two collaborating high-volume stroke centers; one primary stroke center and one comprehensive stroke center. The primary outcome was door-to-needle times. Secondary outcomes included door-to-groin times. Quantile regression analyses were performed to evaluate the association between timing of CTA and workflow times, adjusted for prognostic factors.
A total of 519 patients received IVT during the study period (246 in period I, 273 in period II). In the adjusted analysis, we found a nonsignificant 1.13 min median difference in door-to-needle times (95% confidence interval: 1.03-3.29). Door-to-groin times was significantly shorter in period II in both unadjusted and adjusted analysis with the latter showing a 19.16 min median difference (95% confidence interval: 3.08-35.24).
CTA acquisition prior to start of IVT did not adversely affect door-to-needle times. However, a significantly shorter door-to-groin times was observed in endovascular treatment eligible patients. Performing CTA prior to start of IVT seems the preferred strategy.
在大多数医院，急性缺血性脑卒中患者现在通常会进行计算机断层血管造影（CTA）检查。然而，CTA 究竟是在开始静脉溶栓（IVT）之前还是之后进行最佳，目前尚不清楚，因为在 IVT 之前进行 CTA 可能会延长门到针的时间，而在 IVT 之后进行 CTA 可能会延长接受血管内治疗的患者的门到腹股沟的时间。
我们进行了一项前后对照研究（IVT 后进行 CTA，第 I 期和 IVT 前进行 CTA，第 II 期），包括两个各为期一年的时期。本研究基于在两家合作的高容量卒中中心（一家初级卒中中心和一家综合卒中中心）连续接受 IVT 治疗的患者前瞻性登记。主要结局是门到针的时间。次要结局包括门到腹股沟的时间。使用分位数回归分析来评估 CTA 时机与工作流程时间之间的关联，调整了预后因素。
研究期间共有 519 例患者接受了 IVT（第 I 期 246 例，第 II 期 273 例）。在调整分析中，我们发现门到针的时间中位数差异为 1.13 分钟（95%置信区间：1.03-3.29），但无统计学意义。在未调整和调整分析中，第 II 期的门到腹股沟时间均明显缩短，后者显示中位数差异为 19.16 分钟（95%置信区间：3.08-35.24）。
在开始 IVT 之前进行 CTA 采集不会对门到针的时间产生不利影响。然而，在符合血管内治疗条件的患者中，门到腹股沟的时间明显缩短。在开始 IVT 之前进行 CTA 似乎是首选策略。
