应用移动卒中单元对急性缺血性卒中院前静脉溶栓的初步探索

目的 大多数急性缺血性卒中患者难以在发病早期接受静脉溶栓治疗,而移动卒中单元（mobile stroke unit,MSU）的应用将静脉溶栓治疗从院内提到院前。本研究初步探讨中国首台MSU在急性卒中 患者院前静脉溶栓中的作用。 方法 回顾性分析荥阳市人民医院卒中中心2018年11月-2019年4月期间应用MSU进行院前静脉溶 栓的患者（MSU溶栓组）和使用传统救护车转运至院内静脉溶栓的患者（常规溶栓组）的临床资料。 观察终点包括主要时间指标从呼叫至溶栓时间、从发病至溶栓时间;疗效指标为90 d良好预后（mRS 评分≤2分）率;安全性指标包括溶栓后48 h内症状性颅内出血及随访90 d内的全因死亡。比较静脉 溶栓患者应用两种治疗模式的终点差异。 结果 MSU溶栓组共计14例患者接受了院外静脉溶栓,同时期常规溶栓组有24例患者在院内进行了 静脉溶栓治疗。与常规溶栓组相比,MSU溶栓组呼叫至溶栓时间（59 min vs 92 mi n,P =0.001）、发病 至溶栓时间（73 min vs 114 mi n,P =0.002）均较短。两组的90 d良好预后率（79% vs 67%,P =0.488） 和安全性指标均未见统计学差异。 结论 基于MSU的急性缺血性卒中院前溶栓可以显著缩短患者从发病至溶栓时间及呼叫至溶栓时 间,但对于急性卒中的救治疗效仍需要多中心前瞻性研究进一步验证。     

第五代移动通信技术移动卒中单元的研究进展

移动卒中单元（mobile stroke unit,MSU）和第五代移动通信技术（5th generation mobile communication technology,5G）相结合构成了5G移动卒中单元（5G MSU）,其在卒中急救方面表现出强 大的应用潜力。5G MSU利用物联网、移动互联网、云计算、5G等新一代信息通信技术,将MSU、急救中 心、卒中中心和医疗机构等各模块有效地连接起来,改变了传统的卒中院前救治模式,将急救工作 前移,实现“上车即入院”的目标,显著缩短了患者发病到静脉溶栓时间。在早期研究中,多项临床研 究证实了MSU在急性卒中救治中的可行性和安全性,但其能否改善患者的预后及降低死亡率尚未明 确。本文就5G MSU的概念、发展、国内外研究进展等内容进行综述。     

移动卒中单元在院前救治急性缺血性脑卒中的应用

急性缺血性脑卒中是严重威胁人类健康的疾病,时间窗内的治疗对该病至关重要。传统模式往往由于院前时间的延误以及入院后头颅CT检查时间的延误,使患者错过了最佳的治疗时间。移动卒中单元的出现使救治时间大大缩短,患者在配备头颅CT的急救车上即可进行诊治,为院内的下一步治疗节约了时间,提高了急性脑卒中患者的救治率,降低了致残率。     

时间窗超过3h急性缺血性卒中患者动脉溶栓治疗观察

目的 评价时间窗超过3 h的急性缺血性卒中患者动脉溶栓治疗的疗效及影响因素.方法 选择法国南锡大学中心医院神经影像科自2008年1月至2009年1月收治的16例急性缺血性卒中患者(时间窗均达到或超过3 h,颈内动脉系统卒中时间窗不超过6 h,椎基底动脉系统卒中时间窗不超过24h.昏迷不超过6 h),行动脉内药物联合机械溶栓治疗,分析不同因素对疗效的影响.结果 7例患者闭塞血管达到完全再通,7例达到部分再通,另有2例闭塞血管未再通,再通率为87.5%.患者动脉溶栓后与溶栓前NIHSS评分比较明显降低.时间窗大于5 h的前循环系统闭塞患者溶栓前后NIHSS评分无改善,与时间窗较短患者相比较,出院时mRS评分明显较高.5例颈内动脉闭塞患者溶栓前后NIHSS评分无改善,与9例大脑中动脉闭塞患者、2例基底动脉闭塞患者相比预后较差.4例患者溶栓后24h出现症状性颅内出血,3例为颈内动脉闭塞,1例死亡.1例溶栓后发生血管再闭,但因侧支循环血流丰富,最终临床预后仍较好.结论 对于时间窗超过3 h大脑中动脉和基底动脉闭塞急性缺血性卒中患者,动脉溶栓可使闭塞血管达到较高的再通率,短期内使临床神经功能恢复,改善临床结局.临床应用动脉溶栓时应注意个体化选择性治疗,评价其疗效需结合时间窗、血管闭塞部位、侧支循环、并发症等因素,避免出血等并发症.

Abstract：

Objective To evaluate the efficacy of intra-arterial hrombolytic therapy in patients with acute ischemic stroke having their time window over 3 h and analyze its influencing factors.Methods Sixteen patients with acute ischemic stroke having their time window over 3 h, admitted to Department of Neuroradiology of Central Hospital of Nancy University from January 2008 to January 2009, were treated by intra-arterial thrombolysis using chemical (rt-PA) and mechanical technique. These patients had carotid stroke for less than 3 h, vertebrobasilar stroke for less than 24 h or coma for less than 6 h. According to the images of DSA, the recanalization after thrombolysis was evaluated by thrombolysis in cerebral infarction (TICI) grades. CT scans 24 h after thrombolysis were operated to detect the hemorrhage complications. NIHSS at baseline and 24 h after thrombolysis and modified Rankin Scale (mRS) were recorded to evaluate the clinical efficacy. Results After intra-arterial thrombolysis, 7 (43.75%) in 16 patients got totally recanalization (TICI grade 3), another 7 partial recanalization (TICI grade 2), and the left 2 patients failed in recanalization (TICI grade 1); the total recanalization rate was 87.5%. A significant reduction of NIHSS scores after the thrombolysis was noted as compared with that before the thrombolysis. The atients with occlusion of anterior ciculation having time window over 5 h enjoyed no reduction of NIHSS scores after thrombolysis; mRS scores in patients having time window over 5 h were ignificantly higher as compared with those in patients having time window less than 5 h.The patients having ICA occlusion (n=5) had no reduction of NIHSS scores after thrombolysis, and enjoyed poorer prognosis as compared with whose occlusion lay in the middle cerebral artery (MCA,n=9) and basilar artery (BA, n=2). By CT scan 24 h after thrombolysis, 4 patients were detected with symptomatic intra cerebral hemorrhage (ICH, 25%) and all of them with occlusion in the internal carotid artery system: 1 patient with occlusion in MCA died of cerebral hernia causing by the large hematoma;the other 3 were all occlusion in ICA. Although reocclusion after thrombolysis occurred, 1 patient was benefitted from the affluent collateral perfusion and got a good prognosis. Conclusion For patientswith BA and MCA occlusion having time window over 3 h, intra-arterial thrombolytic therapy is effective and selective resulting from their high recanalization rate, improvement of neurological function and clinical end. The therapy should be individually chosen; mutiple factors as time window of stroke,location of stroke, ompensatory circulation and complications should be considered in evaluating the efficacy; and the hemorrhage complications should be avoided.     

急性缺血性卒中静脉溶栓治疗研究新进展

随着静脉溶栓时间窗从3 h扩展到了9 h，研究重点也从时间窗理念扩展至组织窗理念。对
于发病时间不明、醒后卒中或者一定时间内的超时间窗患者，需完善相关神经影像学检查，权衡利弊
后决定是否静脉溶栓治疗。本文重点梳理了近年来根据组织窗寻找静脉溶栓获益患者的各种不同
筛选方法及静脉溶栓的药物选择，希望能为临床提供参考。     

急性缺血性卒中静脉溶栓治疗研究新进展

随着静脉溶栓时间窗从3 h扩展到了9 h,研究重点也从时间窗理念扩展至组织窗理念。对 于发病时间不明、醒后卒中或者一定时间内的超时间窗患者,需完善相关神经影像学检查,权衡利弊 后决定是否静脉溶栓治疗。本文重点梳理了近年来根据组织窗寻找静脉溶栓获益患者的各种不同 筛选方法及静脉溶栓的药物选择,希望能为临床提供参考。     

时间窗超过3h急性缺血性卒中患者动脉溶栓治疗观察

目的 评价时间窗超过3 h的急性缺血性卒中患者动脉溶栓治疗的疗效及影响因素.方法 选择法国南锡大学中心医院神经影像科自2008年1月至2009年1月收治的16例急性缺血性卒中患者(时间窗均达到或超过3 h,颈内动脉系统卒中时间窗不超过6 h,椎基底动脉系统卒中时间窗不超过24h.昏迷不超过6 h),行动脉内药物联合机械溶栓治疗,分析不同因素对疗效的影响.结果 7例患者闭塞血管达到完全再通,7例达到部分再通,另有2例闭塞血管未再通,再通率为87.5%.患者动脉溶栓后与溶栓前NIHSS评分比较明显降低.时间窗大于5 h的前循环系统闭塞患者溶栓前后NIHSS评分无改善,与时间窗较短患者相比较,出院时mRS评分明显较高.5例颈内动脉闭塞患者溶栓前后NIHSS评分无改善,与9例大脑中动脉闭塞患者、2例基底动脉闭塞患者相比预后较差.4例患者溶栓后24h出现症状性颅内出血,3例为颈内动脉闭塞,1例死亡.1例溶栓后发生血管再闭,但因侧支循环血流丰富,最终临床预后仍较好.结论 对于时间窗超过3 h大脑中动脉和基底动脉闭塞急性缺血性卒中患者,动脉溶栓可使闭塞血管达到较高的再通率,短期内使临床神经功能恢复,改善临床结局.临床应用动脉溶栓时应注意个体化选择性治疗,评价其疗效需结合时间窗、血管闭塞部位、侧支循环、并发症等因素,避免出血等并发症.     

时间窗超过3h急性缺血性卒中患者动脉溶栓治疗观察

目的 评价时间窗超过3 h的急性缺血性卒中患者动脉溶栓治疗的疗效及影响因素.方法 选择法国南锡大学中心医院神经影像科自2008年1月至2009年1月收治的16例急性缺血性卒中患者(时间窗均达到或超过3 h,颈内动脉系统卒中时间窗不超过6 h,椎基底动脉系统卒中时间窗不超过24h.昏迷不超过6 h),行动脉内药物联合机械溶栓治疗,分析不同因素对疗效的影响.结果 7例患者闭塞血管达到完全再通,7例达到部分再通,另有2例闭塞血管未再通,再通率为87.5%.患者动脉溶栓后与溶栓前NIHSS评分比较明显降低.时间窗大于5 h的前循环系统闭塞患者溶栓前后NIHSS评分无改善,与时间窗较短患者相比较,出院时mRS评分明显较高.5例颈内动脉闭塞患者溶栓前后NIHSS评分无改善,与9例大脑中动脉闭塞患者、2例基底动脉闭塞患者相比预后较差.4例患者溶栓后24h出现症状性颅内出血,3例为颈内动脉闭塞,1例死亡.1例溶栓后发生血管再闭,但因侧支循环血流丰富,最终临床预后仍较好.结论 对于时间窗超过3 h大脑中动脉和基底动脉闭塞急性缺血性卒中患者,动脉溶栓可使闭塞血管达到较高的再通率,短期内使临床神经功能恢复,改善临床结局.临床应用动脉溶栓时应注意个体化选择性治疗,评价其疗效需结合时间窗、血管闭塞部位、侧支循环、并发症等因素,避免出血等并发症.     

急性缺血性卒中治疗时间窗的研究进展

急性缺血性卒中再通治疗是一个多因素、多环节作用的复杂临床干预过程。在长期的临床 实践过程中,“时间窗”是一个普遍沿用的概念。早在1996年,3 h内溶栓治疗就已经被证明是急性缺 血性卒中的有效治疗手段,然而获得治疗的患者很少,除了治疗时间窗的限制、未能及时就诊等原因, 单纯的“时间窗”往往提供不了足够的信息以保证溶栓治疗的安全性和有效性。基础血管病变、侧支 循环和缺血耐受的不同,时间窗是否也存在个体差异呢？随着神经影像技术的发展与进步,20多年 来国内外学者一直致力于延长卒中治疗时间窗等方面的研究。     

Pre-Hospital Diagnosis in Mobile Stroke Unit

ObjectivesMobile stroke unit (MSU) has been shown to rapidly provide pre-hospital thrombolysis in acute ischemic stroke (AIS). MSU encounters neurological disorders other than AIS that require emergent treatment.Methods/MaterialsWe obtained pre-hospital diagnosis and treatment data from the prospectively collected dataset on 221 consecutive MSU encounters. Based on initial clinical evaluation and neuroimaging obtained on MSU, the diagnosis of AIS (definite, probable, and possible AIS, transient ischemic attack), intracranial hemorrhage, and likely stroke mimics was made.ResultsFrom July 2014 to April 2015, 221 patients were treated on MSU. 78 (35%) patients had initial clinical diagnosis of definite/probable AIS or TIA, 69 (31%) were diagnosed as possible AIS or TIA, 15 (7%) had intracranial hemorrhage while 59 patients (27%) were diagnosed as likely stroke mimics. Stroke mimics encountered included 13 (6%) metabolic encephalopathy, 11 (5%) seizures, 9 (4%) migraines, 3 (1%) substance abuse, 2 (1%) CNS tumor, 3 (1%) infectious etiology and 3 (1%) hypoglycemia. Fifty-four (24%) patients received non-thrombolytic treatments on MSUConclusionAbout one third of MSU encounters were not AIS initially, including intracranial hemorrhage and stroke mimics. MSU can be utilized to provide pre-hospital treatments in emergent neurological conditions other than AIS.     

Integration of Real-Time Electronic Health Records and Wireless Technology in a Mobile Stroke Unit

Background: UCHealth's Mobile Stroke Unit (MSU) at University of Colorado Hospital is an ambulance equipped with a computed tomography (CT) scanner and tele-stroke capabilities that began clinical operation in Aurora, Colorado January 2016. As one of the first MSU's in the United States, it was necessary to design unique and dynamic information technology infrastructure. This includes high-speed cellular connectivity, Health Insurance Portability and Accountability Act compliance, cloud-based and remote access to electronic medical records (EMR), and reliable and rapid image transfer. Here we describe novel technologies incorporated into the MSU. Technological data-handling aspects of the MSU were reviewed. Functions evaluated include wireless connectivity while in transit, EMR access and manipulation in the field, CT with image transfer from the MSU to the hospital's Picture Archiving Communication System (PACS), and video and audio communication for neurological assessment. Methods/Results: The MSU wireless system was designed with redundancy to avoid dropped signals during data transfer. Two separate Internet Protocol destinations with split-tunnel architecture are assigned, for videoconferencing and for EMR data transfer. Brain images acquired in the ambulance CT scanner are transferred initially to an onboard laptop, then via Citrix Receiver to the hospital-based PACS server where they can be viewed in PACS or EMR by the stroke neurologist, neuroradiologist, and other providers. PACS and Radiology Information System are 2 of the XenApps utilized by CT technologists on board the MSU. Discussion/Conclusions: These technologies will serve as a blueprint for development of similar units elsewhere, and as a framework for improvement in this technology.     

第五代移动通信技术移动卒中单元车载手术1例报告

1 病例介绍 患者男性,37岁,主因"突发头痛、头晕2?d,意识障碍5?h"于2021年5月26日在当地医院就诊.该患者就诊前两天,无明显诱因出现持续性头痛、头晕,伴恶心、喷射性呕吐,呕吐物为胃内容物,无肢体无力及麻木症状,在家中观察逐渐加重,就诊当日中午出现意识障碍,表现为问话不答,偶有遵嘱动作.2021年5月26日...     

Stroke Mimics: Experience of a Moroccan Stroke Unit

Background: Stroke mimic is a medical condition presenting with acute neurological deficit and simulate real stroke. The objective of this study was to evaluate the frequency and the various etiologies of stroke mimics in our center. Methods: We retrospectively reviewed the Thrombolysis Alert registry and we studied the frequency and characteristics of patients with stroke mimic. Results: Among 673 patients who were admitted to the emergency department within 4.5 hours for sudden focal neurological deficit suggestive of acute stroke, 105 patients (15.6 %) had a stroke mimic. The mean age of patients with mimics and brain strokes were 66.3 and 64.8, respectively. The mean Onset-to-door time was 136.82 minutes and the mean door-to-imaging time was 32.63 minutes in stroke mimics. Seizure (28.5%) was the most common diagnosis of stroke mimics followed by conversion disorder (25.7%). Conclusions: Stroke mimic is frequent and heterogeneous entity that can be difficult to identify. Fortunately, most previous studies show no harmful effects when using thrombolysis in a stroke mimic.     

中西医结合卒中单元的疗效和卫生经济学评价

目的探讨中西医结合卒中单元治疗急性缺血性脑卒中的临床疗效和卫生经济学价值。方法随机选取符合入选标准的260例急性缺血性脑卒中(风痰瘀阻症)患者,分为实验组(中西医结合卒中单元组)和对照组(常规治疗组),两组均为130例。采用美国国立卫生院卒中量表(NIHSS)评分、Barthe1指数(BI)、改良的Rankin量表(mRS)为疗效观察指标;住院时间、住院费用、药品费用、检查和治疗费用为卫生经济学指标。比较NIHSS评分每减少1分、BI评分每增加5分、mRS评分每减少1分,患者每人每天所花费的住院费用。结果①与对照组比较,实验组治疗后14 d时NIHSS、BI、mRS改善程度明显优于对照组(P0.05)。实验组14 d后NIHSS评分下降主要在构音和运动功能方面优于对照组(P0.001);实验组BI评分提高主要在用厕、吃饭、移动、行走、穿衣、上楼、洗浴方面优于对照组(P0.01),实验组mRS(0~2)分的患者近期残障功能的改善优于对照组(P0.01)。②住院期间,两组患者的住院费用和检查费用差异无统计学意义(P0.05);实验组的平均住院时间和药品费用明显低于对照组(P0.01),治疗费用高于对照组(P0.001)。③NIHSS评分每减少1分,BI评分每增加5分,MRS评分每减少1分,实验组所需费用均较对照组少。结论中西医结合卒中单元治疗急性缺血性脑卒中更具有社会效益和经济效益。