急性脑缺血的神经功能改善：频率、幅度、预测因素和临床结局。
Neurologic Improvement in Acute Cerebral Ischemia: Frequency, Magnitude, Predictors, and Clinical Outcomes.
机构信息
From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD.
出版信息
Neurology. 2023 Mar 7;100(10):e1038-e1047. doi: 10.1212/WNL.0000000000201656. Epub 2022 Dec 7.
BACKGROUND AND OBJECTIVES
Investigations of rapid neurologic improvement (RNI) in patients with acute cerebral ischemia (ACI) have focused on RNI occurring after hospital arrival. However, with stroke routing decisions and interventions increasingly migrating to the prehospital setting, there is a need to delineate the frequency, magnitude, predictors, and clinical outcomes of patients with ACI with ultra-early RNI (U-RNI) in the prehospital and early postarrival period.
METHODS
We analyzed prospectively collected data of the prehospital Field Administration of Stroke Therapy-Magnesium (FAST-MAG) randomized clinical trial. Any U-RNI was defined as improvement by 2 or more points on the Los Angeles Motor Scale (LAMS) score between the prehospital and early post-emergency department (ED) arrival examinations and classified as moderate (2-3 point) or dramatic (4-5 point) improvement. Outcome measures included excellent recovery (modified Rankin Scale [mRS] score 0-1) and death by 90 days.
RESULTS
Among the 1,245 patients with ACI, the mean age was 70.9 years (SD 13.2); 45% were women; the median prehospital LAMS was 4 (interquartile range [IQR] 3-5); the median last known well to ED-LAMS time was 59 minutes (IQR 46-80 minutes), and the median prehospital LAMS to ED-LAMS time was 33 minutes (IQR 28-39 minutes). Overall, any U-RNI occurred in 31%, moderate U-RNI in 23%, and dramatic U-RNI in 8%. Any U-RNI was associated with improved outcomes, including excellent recovery (mRS score 0-1) at 90 days 65.1% (246/378) vs 35.4% (302/852), < 0.0001; decreased mortality by 90 days 3.7% (14/378) vs 16.4% (140/852), < 0.0001; decreased symptomatic intracranial hemorrhage 1.6% (6/384) vs 4.6% (40/861), = 0.0112; and increased likelihood of being discharged home 56.8% (218/384) vs 30.2% (260/861), < 0.0001.
DISCUSSION
U-RNI occurs in nearly 1 in 3 ambulance-transported patients with ACI and is associated with excellent recovery and decreased mortality at 90 days. Accounting for U-RNI may be useful for routing decisions and future prehospital interventions. TRIAL REGISTRATION INFORMATION: clinicaltrials.gov. Unique identifier: NCT00059332.
背景与目的
对急性脑缺血（ACI）患者的快速神经改善（RNI）的研究集中在入院后发生的 RNI 上。然而，随着卒中转运决策和干预措施越来越多地转移到院前环境，有必要描述在院前和急诊后早期具有超早期 RNI（U-RNI）的 ACI 患者的频率、幅度、预测因素和临床结局。
方法
我们分析了前瞻性收集的院前 Field Administration of Stroke Therapy-Magnesium（FAST-MAG）随机临床试验数据。任何 U-RNI 定义为院前和急诊后早期检查中洛杉矶运动量表（LAMS）评分提高 2 或更多点，分为中度（2-3 点）或明显（4-5 点）改善。主要转归包括 90 天内的良好恢复（改良 Rankin 量表[mRS]评分 0-1）和死亡。
结果
在 1245 例 ACI 患者中，平均年龄为 70.9 岁（标准差 13.2）；45%为女性；院前 LAMS 中位数为 4（四分位距[IQR]3-5）；最后一次已知到 ED-LAMS 的时间中位数为 59 分钟（IQR 46-80 分钟），院前 LAMS 到 ED-LAMS 的时间中位数为 33 分钟（IQR 28-39 分钟）。总体而言，任何 U-RNI 的发生率为 31%，中度 U-RNI 的发生率为 23%，明显 U-RNI 的发生率为 8%。任何 U-RNI 与改善的结局相关，包括 90 天内的良好恢复（mRS 评分 0-1），分别为 65.1%（246/378）和 35.4%（302/852），<0.0001；90 天内死亡率降低分别为 3.7%（14/378）和 16.4%（140/852），<0.0001；症状性颅内出血分别为 1.6%（6/384）和 4.6%（40/861），=0.0112；出院回家的可能性分别为 56.8%（218/384）和 30.2%（260/861），<0.0001。
讨论
在接受救护车转运的 ACI 患者中，近 1/3 发生 U-RNI，与 90 天内的良好恢复和死亡率降低相关。考虑 U-RNI 可能对路由决策和未来的院前干预有用。
试验注册信息
clinicaltrials.gov。独特标识符：NCT00059332。
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