Trois cent soixante-quatre patients ont été inclus dans lx2019;étude. La création de la filière sx2019;est accompagnée dx2019;une diminution significative des délais dx2019;admission des patients et des délais dx2019;imagerie, et dx2019;une plus grande implication des services de transport dx2019;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 dx2019;utilisation du traitement thrombolytique dans notre centre sont comparables à celles de la littérature en terme de sécurité et dx2019;efficacité.
Cette étude montre que la création dx2019;une filière neuro-vasculaire dx2019;accueil direct et de thrombolyse sx2019;est globalement accompagnée dx2019;une amélioration de la qualité des soins, avant même la création dx2019;une unité neuro-vasculaire répondant aux recommandations.
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.
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.
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.
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.
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.
oat:right; padding-left:5px">onclick="InfoBubble.hide()">ose.gif" alt="Close" title="Close" onmouseover="javascript:this.src='/scidirimg/btn_xclose_hov.gif';" onmouseout="javascript:this.src='/scidirimg/btn_xclose.gif';"> order=0 src="/scidirimg/jrn_nsub.gif" alt="You are not entitled to access the full text of this document" title="You are not entitled to access the full text of this document" width=12 height=14"> om/science?_ob=ArticleURL&_udi=B75BJ-4M942C4-3&_user=10&_coverDate=12%2F31%2F2006&_rdoc=1&_fmt=high&_orig=article&_cdi=12984&_sort=v&_docanchor=&view=c&_ct=8&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c74278a817bd47a9102571158470ba5c">Infarctus cérébral : stratégie de prise en charge précoce et de reperfusion en urgenceRéanimation, Volume 15, Issues 7-8, December 2006, Pages 540-545 K. Vahedi Abstract oll"> RésuméLes accidents vasculaires cérébraux (AVC) sont une pathologie fréquente et grave, touchant chaque année environ 120 000 nouveaux patients en France. Une prise en charge spécialisée dans une structure hospitalière dédiée (unité neurovasculaire) dès les premières heures du début des signes neurologiques, permet d'améliorer le pronostic des AVC à la fois en termes de mortalité et de récupération fonctionnelle. Dans le cas d'une ischémie cérébrale, le bénéfice de la recanalisation artérielle par le recombinant du tissu plasminogène activateur, administré par voie intraveineuse en extrême urgence, moins de trois heures après le début des signes cliniques, permet d'augmenter d'un tiers la probabilité de récupération sans séquelles neurologiques ou avec des séquelles minimes sans modifier la mortalité. La fenêtre des trois heures est extrêmement courte pour permettre à tous les patients victimes d'un accident ischémique cérébral qui n'auraient par ailleurs pas de contre-indications au traitement thrombolytique d'en bénéficier. Il est probable que dans un futur proche cette fenêtre thérapeutique de trois heures sera dépassée grâce à de nouveaux thrombolytiques, des techniques de désobstruction mécanique et surtout à la sélection des patients basée sur l'imagerie par résonance magnétique cérébrale. Cet examen, indiqué en urgence devant tout patient suspect d'un AVC, permet de sélectionner le patient chez qui il existe une zone de pénombre ischémique encore récupérable et permet de mieux évaluer le risque hémorragique.Cerebro-vascular diseases are a leading cause of death and disability worldwide. Their incidence is estimated near 120000 patients in France. Patients with ischemic or hemorrhagic stroke should receive specific management in dedicated stroke units by dedicated stroke teams because of a significant reduction of mortality and institutionalization. Since the results of the National Institute of Neurological Disorders and Stroke trial in 1995, showing a substantial benefit of early administration of tissue-type plasminogen activator no later than 180 minutes after onset of neurological symptoms, specific guidelines have been published for the routine use of this thrombolytic agent in patients with acute ischemic stroke. However the approach of the early recanalisation in acute ischemic stroke has changed since the advent of modern brain imaging including diffusion and perfusion imaging and magnetic resonance angiography. These modern techniques should allow the use of tPA even after the 3 hours time window with a reduced risk of symptomatic brain hemorrhages. In the future, new thrombolytic agents such as desmoteplase or mechanical clots retrieval devices may be used to reperfuse the ischemic tissues in a larger time window from stroke onset and with fewer safety concerns. om/science?_ob=MImg&_imagekey=B75BJ-4M942C4-3-7&_cdi=12984&_user=10&_orig=article&_coverDate=12%2F31%2F2006&_sk=999849992&view=c&wchp=dGLbVzz-zSkWb&md5=026d84feff577eb2a40e3151b940949a&ie=/sdarticle.pdf">order="0" src="http://www.sciencedirect.com/scidirimg/icon_pdf.gif" alt=""> Purchase PDF (789 K) |
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