转诊对大血管闭塞急性缺血性脑卒中血管内治疗救治效果的影响

Effect of referral on intravascular treatment of acute ischemic stroke with large vessel occlusion

目的探讨转诊对大血管闭塞急性缺血性脑卒中(AIS-LVO)患者血管内治疗救治效果的影响,并对影响AIS-LVO患者血管内治疗预后影响因素进行分析。方法回顾性纳入2013年9月至2018年2月在我院脑血管病中心接受血管内治疗的AIS-LVO患者。按患者的就诊模式分成直接就诊组和转诊组,直接就诊组患者通过院前急救医疗服务体系或其他交通工具从发病地点直接至我院急诊就诊,转诊组患者从其他医院转至我院急诊就诊,分析两组的临床特征、疗效和预后。根据预后将患者分成预后良好组(术后90 d改良Rankin量表评分为0~2分)和预后不良组(>2分),单因素分析两组的临床资料和就诊模式,并对其中P<0.1的变量进行多因素logistic回归分析。结果共316例患者纳入研究,其中直接就诊组195例(61.7%),转诊组121例(38.3%)。与直接就诊组比较,转诊组患者既往缺血性脑卒中、桥接治疗的患者比例低(χ~2=4.549,P=0.033;χ~2=29.319,P<0.001)。转诊组患者的发病至入院时间(ODT)和发病至血管再通时间(ORT)均长于直接就诊组[239(168,238)min vs 85(55,170)min,Z=1.779,P<0.001;397(306,472)min vs 285(214,364)min,Z=6.779,P<0.001],短期治疗有效率和预后良好率均较直接就诊组差[52.9%(64/121)vs 64.1%(125/195),χ~2=3.903,P=0.048;46.3%(56/121)vs 57.9%(113/195),χ~2=4.806,P=0.043]。预后良好组患者为169例(53.5%),预后不良组为147例(46.5%)。与预后不良组相比,预后良好组患者年龄小、高脂血症比例少、桥接治疗比例高[(64.2±12.8)岁vs(69.9±11.9)岁,t=4.095,P<0.001;0.6%(1/169)vs 6.1%(9/147),χ~2=7.848,P=0.005;70.4%(119/169)vs 13.6%(20/147),χ~2=102.975,P<0.001]。预后良好组中直接就诊的患者比例高于预后不良组[66.9%(113/169)vs 55.8%(82/147),χ~2=4.086,P=0.043],并且ODT、ORT均短于预后不良组[106(59,214)min vs 184(91,281)min,Z=3.997,P<0.001;308(226,389)min vs 350(267,453)min,Z=2.999,P=0.003]。多因素logistic回归分析显示,桥接治疗、直接就诊和ODT短是AIS-LVO患者血管内治疗预后良好的独立预测因素(P均<0.01)。结论 AIS-LVO血管内治疗患者中,转诊患者的预后较直接就诊的患者差。桥接治疗、直接就诊和ODT短预示着AIS-LVO患者血管内治疗预后良好。

Objective To explore the impact of referral on intravascular treatment of acute ischemic stroke patients with large vessel occlusion(AIS-LVO),and to analyze the influence factors of prognosis.Methods We retrospectively analyzed the clinical data of the AIS-LVO patients who received intravascular treatment from Sep.2013 to Feb.2018 in Stroke Center of our hospital.The patients were divided into directly admitted group and referral group.The patients in the directly admitted group went directly to the Emergency of our hospital through the pre-hospital emergency medical service or other vehicles.The patients in the referral group were transferred from other hospitals to the Emergency of our hospital.The clinical features,curative effect and prognosis were analyzed between the two groups.Then the patients were divided into good prognosis group(modified Rankin scale score at 90 d after operation being 0-2)and poor prognosis group(>2).The clinical data and visit methods were analyzed between the good prognosis and poor prognosis groups,and logistic regression analysis was used to analyze the P<0.1 variables.Results A total of 316 patients were included,and the directly admitted group had 195 cases(61.7%)and the referral group had 121 cases(38.3%).Compared with the directly admitted group,the proportions of the patients with ischemic stroke and bridging therapy were significantly lower in the referral group(χ2=4.549,P=0.033;χ2=29.319,P<0.001).The onset-to-door time(ODT)and onset-to-recanalization time(ORT)were significantly longer in the referral group than those in the directly admitted group(239[168,238]min vs 85[55,170]min,Z=1.779,P<0.001;397[306,472]min vs 285[214,364]min,Z=6.779,P<0.001).The short-term treatment efficiency and good prognosis rate were significantly worse in the referral group than those in the directly admitted group(52.9%[64/121]vs 64.1%[125/195],χ2=3.903,P=0.048;46.3%[56/121]vs 57.9%[113/195],χ2=4.806,P=0.043).There were 169 cases(53.5%)in the good prognosis group and 147 cases(46.5%)in the poor prognosis group.Compared with the poor prognosis group,the patients were significantly younger,the proportion of the patients with hyperlipidemia was significantly lower and the proportion of the patients with bridging therapy was significantly higher in the good prognosis group([64.2±12.8]years vs[69.9±11.9]years,t=4.095,P<0.001;0.6%[1/169]vs 6.1%[9/147],χ2=7.848,P=0.005;70.4%[119/169]vs 13.6%[20/147],χ2=102.975,P<0.001).Compared with the poor prognosis group,the proportion of directly admitted patients was significantly higher in the good prognosis(66.9%[113/169]vs 55.8%[82/147],χ2=4.086,P=0.043),and ODT and ORT were significantly shorter in the good prognosis group(106[59,214]min vs 184[91,281]min,Z=3.997,P<0.001;308[226,389]min vs 350[267,453]min,Z=2.999,P=0.003).Logistic regression analysis showed that bridging therapy,direct visit and short ODT were independent predictors of good prognosis in AIS-LVO patients with intravascular treatment.Conclusion The prognosis of referral AIS-LVO patients with intravascular treatment is poorer compared with the directly admitted patients.Bridging therapy,direct visit and short ODT indicate good prognosis in AIS-LVO patients.