• 作者：M. Zuber
• 关键词：Ischaemic stroke ; Intravenous thrombolysis ; Stroke units ; Symptomatic intracranial bleeding
• 刊名：La Revue de Medecine Interne
• 出版年：2008
• 期刊代码：237_02488663
• 类别：med
• 出版时间：July 2008
• 卷：29
• 期：7
• 页码：529-530
• 文件大小：85 K

Résultats

Trois cent soixante-quatre patients ont été inclus dans l’étude. La création de la filière s’est accompagnée d’une diminution significative des délais d’admission des patients et des délais d’imagerie, et d’une plus grande implication des services de transport d’urgence (SAMU). La proportion de patients ayant une mauvaise évolution est moindre dans la filière, cette diminution ne restant significative après ajustement que pour les patients ayant un AVC hémorragique. Les conditions d’utilisation du traitement thrombolytique dans notre centre sont comparables à celles de la littérature en terme de sécurité et d’efficacité.

Conclusion

Cette étude montre que la création d’une filière neuro-vasculaire d’accueil direct et de thrombolyse s’est globalement accompagnée d’une amélioration de la qualité des soins, avant même la création d’une unité neuro-vasculaire répondant aux recommandations.

Summary

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.