急性脑卒中病人院前延误就诊的原因分析

目的：调查急性脑血管病患者就诊现状。方法：对216例急性脑血管病患者就诊时间进行调查，在症状出现3小时后就诊者均视为有院前延误，分析院前延误的原因。结果：59例（27．3％）在3h内就诊，157例（72．7％）存在院前延误。严重卒中（BI低）、脑出血、白天发病及用救护车的病人就诊时间较早。结论：院前延误普遍存在，主要原因为患者及家庭对脑卒中治疗紧迫性认识不足。     

急性脑卒中病人院前延误就诊的原因分析

目的 :调查急性脑血管病患者就诊现状。方法 :对 2 16例急性脑血管病患者就诊时间进行调查 ,在症状出现 3小时后就诊者均视为有院前延误 ,分析院前延误的原因。结果 :5 9例 (2 7 3 % )在 3h内就诊 ,15 7例 (72 7% )存在院前延误。严重卒中 (BI低 )、脑出血、白天发病及用救护车的病人就诊时间较早。结论 :院前延误普遍存在 ,主要原因为患者及家属对脑卒中治疗紧迫性认识不足。     

脑梗死患者就诊延迟的影响因素分析

目的分析影响脑梗死患者急性期就诊延迟的相关因素,从而寻找可能的解决办法。方法采用问卷调查的方法,随机选取2011-06—2012-11来院就诊的182例急性脑梗死患者,对患者及家属进行问卷调查,详细记录患者发病时间及就诊过程,采用卡方检验和Logistic回归模型分析就诊延迟的相关因素。结果全部脑梗死患者均经头颅CT/MTR证实,对病情不重视、对卒中知识不了解以及抵院方式、首次就诊医院等有关。结论导致急性脑梗死患者就诊延迟的相关因素很多,其中最重要原因是患者对脑梗死早期诊治认识不足,加强公众脑卒中相关医学知识教育,对减少这些因素的影响将具有重要意义。     

影响脑卒中病人就诊时间早晚的因素分析

目的 了解影响脑卒中病人就诊时间早晚的因素。方法 对８４例因急性脑卒中住院患者的自然条件、座中知识和就诊时间等进行调查。并分析影响就诊时间早晚的因素。症状出现３小时内就诊者为早就诊。结果 ４５例（５３．６％）病人早就诊。早就诊与用救护车和后循环卒中有关。６９．２％的病人认为症状不严重而来迟。有卒中史者虽能认识到患卒中，工没有早就诊。结论 广泛的卒中知识教育，可增加早就诊病人的比例，使人得到有效地治     

卒中患者就诊延误的影响因素及其干预措施

缺血性卒中超早期溶栓治疗的有效性早已经被循证医学所证实,但国内外缺血性卒中的溶栓率普遍较低,发达国家的溶栓率仅能迟到3.8%～10.2%,我国更是显著低于国外,2006年我国一项七城市卒中患者溶栓率的调查显示仅为2.7%。溶栓率较低的重要原因之一即是院前延误。减少院前延误,增加患者接受溶栓治疗的机会,需要公众、社区医生和急救医务人员的紧密配合,共同努力。通过对公众的教育及对社区医生和急救医务人员的培训,期望能达到公众对脑卒中症状能够早期识别,紧急呼叫急救系统。社区医生和急救人员对患者进行快速正确的院前鉴别和筛检,将可疑脑卒中的患者转送至最适合的医院,取得最佳的治疗效果。     

脑卒中对患者生活质量影响的分析

为了解脑卒中对患者的危害及生活质量的影响,回顾性地分析了自1972年～1998年宣武医院就诊的12679例脑血管病例资料,针对脑血管病友病次数、病残及死亡情况进行分析研究。本资料显示脑卒中的复发比例达53．6％,死亡比例为12.7%,76.2％的患者遗留残疾,其中使患者丧失劳动能力、影响其生活质量的中、重度病残比例达61.5％,说明脑卒中是严重影响人类的生活质量及生命的疾病,     

醒后卒中的研究进展

醒后卒中（WUS）是指入睡时无神经系统症状，觉醒后患者本人或目击者发现有卒中症状， 占急性缺血性脑卒中的 14.3%～29.6%。由于发病时间的不确定，通常不适用于急性缺血性卒中时间窗 内特殊治疗。近年来，随着多模式CT及磁共振成像对缺血性卒中梗死灶及缺血半暗带识别的技术发展， 越来越多的证据表明静脉溶栓、机械取栓等治疗方案使 WUS 患者更好地获益。现对 WUS 的病理生理 机制、危险因素、临床及影像学特征、治疗方案的最新进展作一综述     

鄂尔多斯地区脑梗死院前患者延误的影响因素

目的探讨鄂尔多斯地区脑梗死(CI)患者院前延误的特征和影响因素。方法前瞻性连续登记2012年1月1日至2015年12月31日期间因CI入院的患者,采用问卷和访视调查方法调查院前延误(从卒中症状出现至做出就医决定)和运送所需时间(从做出就医决定至到达医院),记录卒中现场情况、认识行为和社会人口学变量等,采用单变量和多变量分析方法研究院前延误的影响因素。结果纳入490例,其中147例(30%)发病2h内做出就医决定(早期就医决定组),343例(70%)发病2 h后做出就医决定(延误决定就医组)。NIHSS评分、Barthel指数、以意识障碍起病、既往因脑卒中曾住院治疗、发病现场认识到卒中、发病现场有家属或同事、症状进行性加重、患者或家属或同事知晓溶栓治疗对院前时间差异有统计学意义。是否使用120救护车对院前时间有显著性影响。多变量Logistic回归分析显示,发病时有家属或同事或既往因脑卒中曾住院治疗是促进早期决定就医的独立影响因素,而症状较轻或夜间发病是造成就医定延误的独立影响因素。结论就医决定延误是本地区CI院前延误的主要原因,家属或同事或既往因脑中曾住院是减少决定延误的重要因素,普及本地区居民卒中知识、增加使用救护车及改善本地区医院布可能使更多脑梗死患者获益。     

ESO2009会议的最新报道：短暂性脑缺血发作和小卒中专题

一、短暂性脑缺血发作（transient ischemia attack，TIA）或小卒中后患者行为学的时间趋势：2002～2009 基于Oxfordshire人群的前瞻性研究，首诊NIHSS-5分定义为小卒中。虽然发现7年随访未发现就诊时间差异造成的预后显著性差别，但对TIA症状有正确认识的患者（31％）可能提前就诊（2．33vs7．25h）。令人意外的是，周末比工作日就诊时间延迟（25．13vs3．00h，P〈0．01）。     

有卒中危险因素患者脑卒中症状认知及急救意识临床分析

目的探讨有卒中危险因素患者对脑卒中症状的认知及脑卒中发生时的急救意识。方法选取2012-07—2014-07收治的230例具有脑卒中危险因素的患者为研究对象,根据自编问卷对其行脑卒中症状认知及急救意识的调查,采用Logistic逐步回归分析,分析影响其对脑卒中症状认知及急救意识调查的相关因素。结果 230例患者中认为高血压、高脂血、高胆固醇、年龄、卒中史、高盐高脂饮食是卒中危险因素的患者较多,分别占总调查人数的45.22%、28.70%、28.26%、27.39%、23.48%、16.09%;另外有少数患者认为心理压力、情绪激动、天气、跌倒及季节也是发生卒中的危险因素,分别占3.91%、3.04%、3.48%、2.17%、5.22%;脑卒中病史、高血压、高脂血、冠心病、2型糖尿病、文化程度、人均收入是影响有卒中危险因素患者对卒中症状及急救意识认知情况的相关因素(P0.05);Logistic多因素分析进一步表明,有卒中危险因素患者对卒中症状及急救意识认知情况的独立影响因素是脑卒中史(OR=3.353)、文化程度(OR=2.756)、高血压(OR=2.249)、冠心病(OR=1.878)等。结论具有脑卒中高危因素的患者对脑卒中危险因素、卒中的风险、卒中症状和卒中发生时的急救意识较差,为提高其对脑卒中风险和急救意识的认知水平,需要加强对其健康教育和宣传。     

Sources and reasons for delays in the care of acute stroke patients

OBJECTIVE: This study aimed to identify sources and reasons for delays in the care of our acute stroke patients. METHODS: Data on time interval from symptom onset or awareness to initial presentation, to neurology assessment, to performance of cranial CT scan, and demographic and medical factors associated with delays among stroke patients admitted at St. Luke's Medical Center from May to October 2000 were obtained by interview and record review. RESULTS: Of 259 patients (mean age 61.5+/-13.6 years, 43% females), 63% had infarction (INF), 32% intracerebral hemorrhage (ICH) and 5% subarachnoid hemorrhage (SAH). Fifty-nine percent presented within 3 h of symptom onset or awareness, 73% within 6 h (median=2 h). Patients with ICH presented earlier than those with infarction. Reasons for delayed consultation included failure to recognize symptoms as serious and stroke-related. A non-neurologist was initially consulted in 97% of cases. Median delay from presentation to neurology evaluation was 7.5 h. Median time from presentation to brain imaging was significantly shorter for patients brought to CT-equipped facilities (2 h) than for those needing transfer to other hospitals (11.5 h). CONCLUSIONS AND RECOMMENDATIONS: Patient delay in presentation is only one cause of delay in acute stroke care. Longer delays arise from healthcare-related factors such as delays in neurologist referral and neuroradiologic diagnosis. Professional and public education on the necessity of early neurologic evaluation and patient transport to CT-equipped "Stroke Centers" is recommended.     

Utilización de transporte sanitario urgente por los pacientes con ictus isquémico e impacto en los tiempos de atención

Introduction

According to numerous studies, using emergency medical services (EMS) to transport stroke patients to hospitals decreases diagnostic and treatment delays.

院内卒中再灌注治疗研究进展

院内卒中患者虽然卒中发病时置身医院环境，但由于其基础病情复杂、识别困难、治疗禁忌证多等因素，存在再灌注治疗延迟和再灌注率低等情况，是导致院内卒中预后不良的重要因素。针对院内卒中再灌注治疗流程中不同环节的延误原因，加强院内卒中识别、改进溶栓绿色通道流程、重视头颅影像学中灌注成像检查等措施有利于改善院内卒中再灌注治疗的延误。我国院内卒中救治体系尚未完善，未来需结合我国国情、院内卒中的特征以及先进中心的经验，加强绿色通道诊治流程建设和改良，以改善院内卒中患者的预后。     

In‐hospital stroke: a multi‐centre prospective registry

Background: In‐hospital strokes (IHS) are relatively frequent. Avoidable delays in neurological assessment have been demonstrated. We study the clinical characteristics, neurological care and mortality of IHS. Methods: Multi‐centre 1‐year prospective study of IHS in 13 hospitals. Demographic and clinical characteristics, admission diagnosis, quality of care, thrombolytic therapy and mortality were recorded. Results: We included 273 IHS patients [156 men; 210 ischaemic strokes (IS), 37 transient ischaemic attacks (TIA) and 26 cerebral haemorrhages]. Mean age was 72 ± 12 years. Cardiac sources of embolism were present in 138 (50.5%), withdrawal of antithrombotic drugs in 77 (28%) and active cancers in 35 (12.8%). Cardioembolic stroke was the most common subtype of IS (50%). Reasons for admission were programmed or urgent surgery in 70 (25%), cardiac diseases in 50 (18%), TIA or stroke in 30 (11%) and other medical illnesses in 71 (26%). Fifty‐two per cent of patients were evaluated by a neurologist within 3 h of stroke onset. Thirty‐three patients received treatment with tPA (15.7%). Thirty‐one patients (14.7%) could not be treated because of a delay in contacting the neurologist. During hospitalization, 50 patients (18.4%) died, 41 of them because of the stroke or its complications. Conclusions: Cardioembolic IS was the most frequent subtype of stroke. Cardiac sources of embolism, active cancers and withdrawal of antithrombotic drugs constituted special risk factors for IHS. A significant proportion of patients were treated with thrombolysis. However, delays in contacting the neurologist excluded a similar proportion of patients from treatment. IHS mortality was high, mostly because of stroke.     

The chain of care enabling tPA treatment in acute ischemic stroke: a comprehensive review of organisational models

Protracted and partial implementation of treatment with intravenous tissue plasminogen activator (tPA) within 4.5 h after acute stroke onset results in potentially eligible patients not receiving optimal treatment. The goal of this study was to review the performance of various organisational models of acute stroke care delivery, and subsequent attempts to improve implementation of tPA treatment. Publications comprehensively reporting on organisational models to improve implementation of i.v. tPA treatment of acute ischemic stroke patients were selected. The efficacy of organisational models was assessed using process outcome measures: thrombolysis rates, time-dependent operational endpoints (time delays), functional outcomes: safety (rate of symptomatic intracranial hemorrhage, mortality rates) and clinical outcome at 90 days (modified Rankin Scale). Fifty-eight published studies assessing organisational models were identified. Four dominant models of acute stroke care delivery were discerned, i.e., primary and comprehensive stroke centres, telemedicine, and the mobile stroke unit. Performance reported for these models suggest a large variation in administration of thrombolytic therapy (0.7–30 %). Time delays and functional outcomes found varied considerably, just like safety and mortality (0.0–11.5 %, and 3.4–31.9 %, respectively). These findings suggest that improving organisational models for tPA treatment may improve acute stroke care. However, implementation may be hampered by regional variation in acute stroke care capacity, expertise, and a fragmented approach towards organising stroke care.     

Delay between stroke onset and emergency department evaluation

BACKGROUND: Public educational programs have been developed to reduce delays between the onset of ischemic stroke symptoms and emergency department evaluation. An increase in the proportion of patients presenting soon after stroke would reflect the effectiveness of these efforts. METHODS: All patients (n = 506) with ischemic stroke admitted to an academic medical center located within the 'Stroke Belt' of the USA were prospectively identified over 2 years (1998-1999). Demographics, stroke characteristics and time from symptom onset to arrival in the emergency department were recorded. RESULTS: A higher proportion of ischemic stroke patients presented within 3 h of symptoms in 1998 than in 1999 (18% of 234 vs. 8% of 272, p = 0.0001). Those with less severe strokes (Canadian Neurological Scale score; Spearman r = 0.18, p < 0.0001) and younger patients (r = -0.09, p = 0.04) had greater delays. There was no difference in time to presentation based on race (13% of whites and blacks presented within 3 h, p = 0.70) or sex (16% of women vs. 9% of men, p = 0.10). Logistic regression showed that time to presentation was independently related to both stroke severity and year. CONCLUSIONS: These data show that, after accounting for other variables, the proportion of stroke patients presenting within 3 h of symptom onset to one academic medical center decreased by 10% between 1998 and 1999. Revision of public stroke-related educational programs may need to be considered.     

Creation of a regional stroke network in Tours hospital (France): consequences for stroke care and thrombolysis

INTRODUCTION: Our university hospital serves a population of 300 000 inhabitants. Stroke is the leading cause of admission in our department of neurology. In June 2003, when the Emergency Department (ED) was closed in our institution, was created an acute stroke network (ASN), comprising 2 beds of direct admission and thrombolysis in the intensive care unit, and 4 beds dedicated to stroke care in the department of neurology, in which standardized stroke care protocols were implemented. OBJECTIVE: The aim of this study was to evaluate changes in stroke care related to the creation of the ASN in terms of delays of arrival, imaging, use of intravenous (IV) thrombolysis, and outcome of patients. We conducted a prospective study during 18 months to evaluate characteristics of patients admitted with suspected stroke or transient ischemic attack (TIA) in the newly created ASN and to assess conditions of treatment with IV thrombolysis in terms of safety and efficacy. We also compared the outcome data before and after the creation of the ASN. METHODS: For each patient admitted in our hospital for suspected stroke or TIA, were prospectively collected clinical and outcome data (age, mode of transport, delay of arrival after the onset of symptoms (OS), treatment with IV thrombolysis, outcome and discharge). This study was conducted in the ED during six months in 2002, and in the ASN during 18 months, for all patients admitted for stroke. RESULTS: Three hundred and sixty four patients were admitted in the ASN. Emergency medical services (EMS) were used in half of cases for transport, and median delay of admission after the OS was 2h and 52 min. Median delay of imaging was 1 h and 45 min. Seventeen patients (8.5 p. 100 of ischemic stroke patients) were treated with IV thrombolysis, with an initial good outcome in 9 patients, 7 with a dramatic recovery). The main reason for therapeutic abstention for untreated patients admitted in the first 3 hours was a mild deficit with a NIHSS<6. Compared with the previous management in the ED, patients in the ASN were younger, had more severe neurological symptoms, the EMS transport was the main mode of transport (versus used in 17 p. 100 of cases in 2002), and the delay of admission was significantly lower: 2 h 52 versus 5 h 10 (p<0.02). After adjustment on the main predictive factors, only patients with hemorrhagic strokes had a better outcome after the creation of the ASN. CONCLUSIONS: Creation of an ASN was associated with a significant decrease of admission and imaging delays, due to a strong collaboration with EMS, and with a better outcome for hemorrhagic stroke patients. Treatment with intravenous thrombolysis in the first 3 hours could be used widely and was efficient and safe. However, the creation of dedicated stroke units for all stroke patients remains necessary to improve quality of care and outcome.     

Are stroke units cost effective? Evidence from a New Zealand stroke incidence and population-based study

Background and aim Acute stroke units in hospitals are known to be more costly than standard care, but proponents claim that the health gains will justify the expense. Yet, despite widespread adoption of stroke units, the evidence on the cost effectiveness of stroke units has been mixed, due in part to differences in the pathway of care across hospitals. The purpose of this study is to compare costs and outcomes for patients admitted to a stroke unit with those admitted to a general ward. Methods Data on 530 stroke sufferers from a large incidence study of stroke (the Auckland Regional Community Stroke Outcome Study) were used. Cost of health services, places of discharge were identified at one-, six- and 12 months poststroke and were linked with long-term cost and survival five-years poststroke. A decision analytical model was developed, including the relationship between waiting time for discharge and probability of admission to stroke unit. Cost effectiveness was determined using a willingness to pay threshold of NZ$20?000 (US$15?234). Results Regression analysis suggested that there were no significant differences between patients admitted to a stroke unit and a general ward. The incremental cost-utility ratio for the first-year was NZ$42?813/quality-adjusted life year (US$32?610/quality-adjusted life year), but fell substantially to NZ$6747/quality-adjusted life year (US$5139/quality-adjusted life year) when lifetime costs and outcomes were considered. Probabilistic and one-way sensitivity analysis suggests that the results are robust to areas of uncertainty or delays in the pathway of care. Conclusion Stroke unit care was cost effective in Auckland, New Zealand.     

Prehospital and in-hospital delays in acute stroke care

Current guidelines emphasize the need for early stroke care. However, significant delays occur during both the prehospital and in-hospital phases of care, making many patients ineligible for stroke therapies. The purpose of this study was to systematically review and summarize the existing scientific literature reporting prehospital and in-hospital stroke delay times in order to assist future delivery of effective interventions to reduce delay time and to raise several key issues which future studies should consider. A comprehensive search was performed to find all published journal articles which reported on the prehospital or in-hospital delay time for stroke, including intervention studies. Since 1981, at least 48 unique reports of prehospital delay time for patients with stroke, transient ischemic attack, or stroke-like symptoms were published from 17 different countries. In the majority of studies which reported median delay times, the median time from symptom onset to arrival in the emergency department was between 3 and 6 h. The in-hospital times from emergency department arrival to being seen by an emergency department physician, initiation and interpretation of a computed tomography (CT) scan, and being seen by a neurologist were consistently longer than recommended. However, prehospital delay comprised the majority of time from symptom onset to potential treatment. Definitions and methodologies differed across studies, making direct comparisons difficult. This review suggests that the majority of stroke patients are unlikely to arrive at the emergency department and receive a diagnostic evaluation in under 3 h. Further studies of stroke delay and corresponding interventions are needed, with careful attention to definitions and methodologies.     

Effect of the COVID-19 pandemic on acute stroke reperfusion therapy: data from the Lyon Stroke Center Network

Background

The coronavirus disease 2019 (COVID-19) pandemic would have particularly affected acute stroke care. However, its impact is clearly inherent to the local stroke network conditions. We aimed to assess the impact of COVID-19 pandemic on acute stroke care in the Lyon comprehensive stroke center during this period.

Methods

We conducted a prospective data collection of patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis (IVT) and/or mechanical thrombectomy (MT) during the COVID-19 period (from 29/02/2020 to 10/05/2020) and a control period (from 29/02/2019 to 10/05/2019). The volume of reperfusion therapies and pre and intra-hospital delays were compared during both periods.

Results

A total of 208 patients were included. The volume of IVT significantly decreased during the COVID-period [55 (54.5%) vs 74 (69.2%); p = 0.03]. The volume of MT remains stable over the two periods [72 (71.3%) vs 65 (60.8%); p = 0.14], but the door-to-groin puncture time increased in patients transferred for MT (237 [187–339] vs 210 [163–260]; p < 0.01). The daily number of Emergency Medical Dispatch calls considerably increased (1502 [1133–2238] vs 1023 [960–1410]; p < 0.01).

Conclusions

Our study showed a decrease in the volume of IVT, whereas the volume of MT remained stable although intra-hospital delays increased for transferred patients during the COVID-19 pandemic. These results contrast in part with the national surveys and suggest that the impact of the pandemic may depend on local stroke care networks.