院前转运方式对急性缺血性卒中静脉溶栓时间效率指标及早期神经功能改善的影响研究

目的分析院前转运方式对急性缺血性卒中患者入院后静脉溶栓时间效率指标及早期神经功能改善的影响。方法回顾性连续纳入2018年6月至2021年5月北京丰台医院神经内科急性缺血性卒中接受静脉溶栓治疗患者302例,均经头部CT或MR证实有新发梗死灶,并在院内接受静脉溶栓治疗,排除了静脉溶栓桥接取栓治疗患者。根据登记的院前转运方式,将通过“120”或“999”等急救系统到院的患者分为急救转运组,自驾或出租车等其他非急救系统到院方式者分为自行就诊组;根据早期神经功能是否改善,将患者分为早期神经功能改善组和未改善组。分别记录并比较两组患者的人口学资料(年龄、性别等)、动脉粥样硬化的危险因素(高血压病、糖尿病、高脂血症、冠心病、心房颤动及卒中史)及临床资料就诊时指尖血糖、血压、美国国立卫生研究院卒中量表(NIHSS)评分,发病前改良Rankin量表(mRS)评分,溶栓后24 h NIHSS评分等]。早期神经功能改善定义为静脉溶栓后24 h NIHSS评分较基线减少≥4分或溶栓后24 h NIHSS评分为0分。以早期神经功能改善为因变量,将单因素分析中P<0.1的参数纳入多因素Logistic回归分析,以观察院前转运方式对早期(溶栓后24 h)神经功能改善的影响。结果(1)302例接受静脉溶栓治疗的急性缺血性卒中患者中,急救转运组123例(40.7%),自行就诊组179例(59.3%)。急救转运组患者年龄、就诊时血糖均大于自行就诊组,男性及合并高血压病、冠心病和心房颤动比例均高于自行就诊组,组间差异均有统计学意义(70±13)岁比(64±12)岁,t=-3.916;8(6,10)mmol/L比7(6,9)mmol/L,Z=-2.578;74.8%(92/123)比61.5%(110/179),χ²=5.861;66.7%(82/123)比53.6%(96/179),χ²=5.119;26.8%(33/123)比15.6%(28/179),χ²=5.660;18.7%(23/123)比3.9%(7/179),χ²=17.812;均P<0.05],糖尿病、高脂血症、卒中史、血压、发病前mRS评分的组间差异均无统计学意义(均P>0.05)。(2)急救转运组就诊时和溶栓后24 h NIHSS评分均高于自行就诊组,组间差异均有统计学意义11(5,16)分比3(1,5)分,Z=-9.967;6(2,14)分比1(0,3)分,Z=-7.912;均P<0.01];发病到就诊时间、就诊到溶栓时间、就诊到签署静脉溶栓知情同意书时间、早期神经功能改善比例的组间差异均无统计学意义(均P>0.05)。(3)302例接受静脉溶栓的急性缺血性卒中患者中,早期神经功能改善组122例(40.4%),未改善组180例(59.6%)。与早期神经功能改善组比较,未改善组患者年龄更高、合并糖尿病、卒中及冠心病史的比例更高,就诊时血糖水平更高,组间差异具有统计学意义(68±12)岁比(64±13)岁,t=2.432;31.1%(56/180)比18.9%(23/122),χ²=5.657;26.7%(48/180)比15.6%(19/122),χ²=5.183;26.7%(48/180)比10.7%(13/122),χ²=11.564;7.6(6.2,10.7)mmol/L比6.6(5.8,7.8)mmol/L,Z=-4.251;均P<0.05];余基线特征的组间差异均无统计学意义(均P>0.05)。(4)与早期神经功能改善组比较,未改善组患者溶栓后24 h NIHSS评分更高3(1,10)分比0(0,3)分,Z=-8.328],组间差异具有统计学意义(P<0.01);就诊时NIHSS评分、发病到就诊时间、就诊到溶栓时间、就诊到签署静脉溶栓知情同意书时间、急救转运方式比例的组间差异均无统计学意义(均P>0.05)。(5)多因素Logistic回归分析显示,既往冠心病史(OR=0.382,95%CI:0.189~0.770,P=0.007)和就诊时血糖高水平(OR=0.822,95%CI:0.747~0.905,P<0.01)是影响静脉溶栓后早期神经功能改善的独立危险因素,年龄、糖尿病、卒中史、转运方式与接受静脉溶栓后早期神经功能改善无关(均P>0.05)。结论不同的院前转运方式对院内静脉溶栓各时间效率指标的影响无明显不同,既往冠心病史和就诊时血糖高水平是影响急性缺血性卒中静脉溶栓后早期神经功能改善的独立危险因素,而院前转运方式与早期神经功能改善无关。本研究结果有待进一步验证。

Effects of pre-hospital transfer mode on time-efficiency indexes and early neurological function improvement in acute ischemic stroke receiving intravenous thrombolysis

Objective To investigate the effect of pre-hospital transfer mode on time-efficiency indexes and early neurological function improvement of intravenous thrombolysis for acute ischemic stroke patients after admission.Methods A total of 302 patients with acute ischemic stroke who received intravenous thrombolysis in Department of Neurology,Beijing Fengtai Hospital from June 2018 to May 2021 were retrospectively enrolled.All patients had new infarcts confirmed by head CT or MR and received intravenous thrombolysis in hospital.Intravenous thrombolytic bridging thrombectomy were excluded.According to the registered pre-hospital transfer mode,the patients were classified as emergency transfer group if arriving at the hospital through“120”or“999”emergency system and the self-treatment group if through other non-emergency system such as self-driving by families or taxi.The patients were also divided into early neurological improvement group and non-early neurological improvement group according to whether the early neurological function was improved or not.Demographic dataage,gender,etc.],atherosclerosis risk factorshypertension,diabetes mellitus,hyperlipidemia,coronary heart disease,atrial fibrillation and stroke history]and clinical datafingertip blood glucose,blood pressure,National Institutes of Health Stroke Scale(NIHSS)score at visit,modified Rankin scale(mRS)score before onset,NIHSS score 24 h after thrombolysis,etc.]were recorded and compared between two groups.Early neurological improvement was defined as NIHSS score reduction≥4 from baseline or NIHSS score of 0 at 24 h after thrombolysis.Taking early neurological improvement as the dependent variable,the covariates with P<0.1 in univariate analysis were included in multivariate Logistic regression analysis to observe the effect of pre-hospital transfer mode on early neurological improvement(24 h after thrombolysis).Results(1)Among 302 acute ischemic stroke patients who received intravenous thrombolysis,123(40.7%)were in the emergency transfer group and 179(59.3%)in the self-treatment group.The age and blood glucose at visit in the emergency transfer group were higher than those in the self-treatment group,and the proportion of male patient and ratio of hypertension,coronary heart disease and atrial fibrillation were also higher than those in the self-treatment group with statistically significant difference(70±13]years old vs.64±12]years old,t=-3.916;86,10]mmol/L vs.76,9]mmol/L,Z=-2.578;74.8%92/123]vs.61.5%110/179],χ²=5.861;66.7%82/123]vs.53.6%96/179],χ²=5.119;26.8%33/123]vs.15.6%28/179],χ²=5.660;18.7%23/123]vs.3.9%7/179],χ²=17.812;all P<0.05).There were no significant differences in diabetes mellitus,hyperlipidemia,stroke history,blood pressure and mRS score before onset(all P>0.05).(2)The NIHSS scores of the emergency transfer group were higher than those of the self-treatment group at visit and 24 h after thrombolysis,and the differences were statistically significant(115,16]points vs.31,5]points,Z=-9.967;62,14]points vs.10,3]points,Z=-7.912;both P<0.01].There were no significant differences in the time from onset to visit,time from visit to thrombolysis,time from visit to signing informed consent for intravenous thrombolysis,and proportion of early neurological function improvement between two groups(all P>0.05).(3)Among the 302 acute ischemic stroke patients who received intravenous thrombolysis,122(40.4%)had early neurological function improvement and 180(59.6%)had no improvement.Compared with the patients with early improvement of neurological function,the patients in the group without improvement were older,had a higher proportion of diabetes mellitus,stroke and coronary heart disease history and higher blood glucose level at visit,with statistically significant difference(68±12]years old vs.64±13]years old,t=2.432;31.1%56/180]vs.18.9%23/122],χ²=5.657;26.7%48/180]vs.15.6%19/122],χ²=5.183;26.7%48/180]vs.10.7%13/122],χ²=11.564;7.66.2,10.7]mmol/L vs.6.65.8,7.8]mmol/L,Z=-4.251;all P<0.05]).There were no significant differences in other baseline characteristics between two groups(all P>0.05).(4)Compared with early neurological improvement group,non-early neurological improvement group had higher NIHSS score at 24 h after intravenous thrombosis(31,10]vs.00,3],Z=-8.328,P<0.01).There were no significant difference in NIHSS at visit,time from onset to visit,time from visit to thrombolysis,time from visit to signing informed consent for intravenous thrombolysis and transfer mode between the two groups(all P>0.05).(5)Multivariate Logistic regression analysis showed that history of coronary heart disease(OR,0.382,95%CI 0.189-0.770,P=0.007)and high blood glucose level(OR,0.822,95%CI 0.747-0.905,P<0.01)were independent risk factors for early neurological function improvement after intravenous thrombolysis,while age,diabetes mellitus,stroke history and transfer mode were not(all P>0.05).Conclusions There is no significant difference in the influence of different pre-hospital transfer modes on the time-efficiency indexes of in-hospital intravenous thrombolysis for acute ischemic stroke patients.History of coronary heart disease and high blood glucose level at visit are independent risk factors for the early improvement of neurological function after intravenous thrombolysis in acute ischemic stroke,but not pre-hospital transfer mode.The results of this study need to be further verified.