School of Medicine, Duke University, Durham, NC, United States.
Department of Neurology, Duke University Medical Center, Durham, NC, United States.
J Stroke Cerebrovasc Dis. 2021 Apr;30(4):105616. doi: 10.1016/j.jstrokecerebrovasdis.2021.105616. Epub 2021 Jan 18.
Intracerebral hemorrhage comprises a large proportion of inter-hospital transfers to comprehensive stroke centers from centers without comprehensive stroke center resources despite lack of mortality benefit and low comprehensive stroke center resource utilization. The subset of patients who derive the most benefit from inter-hospital transfers is unclear. Here, we create a triage model to identify patients who can safely avoid transfer to a comprehensive stroke center.
A retrospective cohort of spontaneous intracerebral hemorrhage patients transferred to our comprehensive stroke center from surrounding centers was used. Patients with early discharge from the Neuroscience Intensive Care Unit without use of comprehensive stroke center resources were identified as low risk, non-utilizers. Variables associated with this designation were used to develop and validate a triage model.
The development and replication cohorts comprised 358 and 99 patients respectively, of whom 78 (22%) and 26 (26%) were low risk, non-utilizers. Initial Glasgow Coma Scale and baseline hemorrhage volume were associated with low risk, non-utilizers in multivariate analysis. Initial Glasgow Coma Scale >13, intracerebral hemorrhage volume <15ml, absence of intraventricular hemorrhage, and supratentorial location had an area under curve, specificity, and sensitivity of 0.72, 91.4%, 52.6%, respectively, for identifying low risk, non-utilizers, and 0.75, 84.9%, 65.4%, respectively, in the replication cohort.
Spontaneous intracerebral hemorrhage patients with Glasgow Coma Scale >13, intracerebral hemorrhage volume <15 ml, absence of intraventricular hemorrhage, and supratentorial location might safely avoid inter-hospital transfer to a comprehensive stroke center. Validation in a prospective, multicenter cohort is warranted.
尽管将患者从无综合卒中中心资源的医院转至综合卒中中心并未带来死亡率获益，且综合卒中中心资源利用率较低，但仍有很大一部分颅内出血患者需从这些医院转至综合卒中中心。目前尚不清楚哪些患者从院内转院中获益最大。本研究旨在建立一种分诊模型，以识别可安全避免转至综合卒中中心的患者。
本研究回顾性分析了我院综合卒中中心从周边医院转来的自发性颅内出血患者。从神经重症监护病房（Neuroscience Intensive Care Unit）早期出院且未使用综合卒中中心资源的患者被定义为低风险、非使用者。利用与该定义相关的变量建立并验证了一种分诊模型。
发展和复制队列分别包括 358 例和 99 例患者，其中 78 例（22%）和 26 例（26%）为低风险、非使用者。多变量分析显示，初始格拉斯哥昏迷量表（Glasgow Coma Scale）评分和基线出血量与低风险、非使用者相关。初始格拉斯哥昏迷量表评分＞13 分、颅内出血体积＜15ml、无脑室内出血和幕上出血的受试者工作特征曲线下面积、特异性和敏感性分别为 0.72、91.4%和 52.6%，用于识别低风险、非使用者；复制队列中，上述指标的受试者工作特征曲线下面积、特异性和敏感性分别为 0.75、84.9%和 65.4%。
格拉斯哥昏迷量表评分＞13 分、颅内出血体积＜15ml、无脑室内出血和幕上出血的自发性颅内出血患者可能可安全避免从医院转至综合卒中中心。尚需前瞻性、多中心队列研究进一步验证。
