Chiquete Erwin, Sandoval-Rodríguez Valeria, García-Grimshaw Miguel, Jiménez-Ruiz Amado, Gómez-Piña Juan J, Ruiz-Ruiz Eduardo, Ramírez-García Guillermo, Flores-Silva Fernando, Cantú-Brito Carlos, Ochoa-Guzmán Ana, Ruiz-Sandoval José L
Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
Molecular Biology Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City.
Rev Invest Clin. 2020 May 7;73(2):87-93. doi: 10.24875/RIC.20000238.
The recognition of stroke symptoms by patients or bystanders directly affects the outcomes of patients with acute cerebrovascular disease.
The objective of the study was to assess the predictive value of the medical his- tory and clinical features recognized by the patients' bystanders to classify neurovascular syndromes in pre-hospital settings.
We included 150 stroke patients of two Mexican referral centers: 50 with acute ischemic stroke (AIS), 50 with intracerebral hemorrhage (ICH), and 50 with subarachnoid hemorrhage (SAH). The performance of clinical prediction rules (CPR) to identify the stroke types was evaluated with features recognized by the patients' bystanders before hospital arrival. The impact of CPRs on early arrival and in-hospital mortality was also analyzed.
Overall, 72% of the patients had previous medical evaluations in other centers before final referral to our hospitals, and therefore, only 45% had a final onset- to-door time <6 h, even when the first medical assessment had occurred in ≤1 h in 75% of cases. Clinical features noticed by the patients' bystanders had low positive predictive values (PPV) for any stroke type. The CPR "language or speech disor- der + focal motor deficit" had 93% sensitivity and a negative predictive value (NPV) of 84% to distinguish AIS. In SAH, head- ache alone showed a sensitivity of 84% and NPV of 97%. No CPR had an adequate performance on ICH. CPRs were not as- sociated with final onset-to-door time. Altered consciousness, age ≥65 years, indirect arrival with stops before final referral, and atrial fibrillation increased in-hospital mortality.
Clinical features referred by the witness of a neurovascular emergency have limited PPV, but adequate NPV in ruling-out AIS and SAH among stroke types. The use of CPRs had no impact on onset-to-door time or in-hospital mortality when the final arrival to a third-level center occurs with previous medical refer- rals.
患者或旁观者对卒中症状的识别直接影响急性脑血管疾病患者的治疗结果。
本研究的目的是评估患者旁观者所识别的病史和临床特征在院前环境中对神经血管综合征分类的预测价值。
我们纳入了墨西哥两个转诊中心的150例卒中患者：50例急性缺血性卒中（AIS）患者、50例脑出血（ICH）患者和50例蛛网膜下腔出血（SAH）患者。在患者到达医院之前，根据旁观者所识别的特征评估临床预测规则（CPR）对卒中类型的识别性能。还分析了CPR对早期到达医院和院内死亡率的影响。
总体而言，72%的患者在最终转诊至我们医院之前曾在其他中心进行过医疗评估，因此，即使75%的病例首次医疗评估发生在≤1小时内，只有45%的患者最终发病到入院时间<6小时。患者旁观者所注意到的临床特征对任何卒中类型的阳性预测值（PPV）都较低。CPR“语言或言语障碍+局灶性运动功能缺损”区分AIS的敏感度为93%，阴性预测值（NPV）为84%。在SAH中，单独头痛的敏感度为84%，NPV为97%。没有CPR对ICH有足够的识别性能。CPR与最终发病到入院时间无关。意识改变、年龄≥65岁、最终转诊前间接到达且有停留以及心房颤动会增加院内死亡率。
神经血管急症目击者所提及的临床特征PPV有限，但在排除卒中类型中的AIS和SAH时NPV足够。当最终到达三级中心之前有过医疗转诊时，使用CPR对发病到入院时间或院内死亡率没有影响。
