转诊可能导致缺血性卒中结局恶化

圣迭戈——美国神经放射学会(ASN)2013年会上公布的一项回顾性分析显示，需转至综合卒中中心接受动脉内治疗的急性缺血性卒中(AIS)患者，治疗后90天功能结局不佳的几率显著高于直接到这些中心就诊的患者。

这项分析由芝加哥西北大学放射学与神经外科部的Ali Shaibani博士及其同事进行，分析对象是4个芝加哥地区中心收治的116例适合接受动脉内治疗的AIS患者。半数以上(58.6%)患者从其他医院转来。

研究者发现，与非转诊患者相比，转诊患者的年龄较小(59岁vs. 69岁，P=0.002)，具有卒中(3% vs. 22%，P=0.002)或心脏问题(18% vs. 37%，P=0.040)既往史的比例较低，基线时国立卫生研究院卒中量表评分较差(20 vs. 17，P=0.005)，颈内动脉闭塞的比例较高(45.6% vs. 22.9%，P=0.012)。两组的THRIVE(血管事件总健康风险)评分无差异，该评分是一个旨在帮助临床医生预测患者在AIS后获得良好结局的几率的临床评分系统。

结果显示，动脉内治疗后90天时，仅16%的转诊患者获得良好功能结局(定义为改良Rankin量表评分0~2分)。非转诊组结局良好的患者比例(60%)显著高于转诊组(P＜0.001)。校正相关协变量如基线危险因素、卒中严重程度、至动脉内治疗时间、操作成功或并发症后，多因素分析显示，转诊状态是不良功能结局的独立预测因素(校正比值比= 0.05；95%置信区间，0.011~0.222)。从出现症状至腹股沟穿刺的中位间隔时间、成功再通(定义为脑梗死血栓溶解≥2b级)率和症状性颅内出血方面，两组无差异。

研究者表示，尚不清楚上述分析结果是由哪些因素引起，需进一步探讨基线/最终梗死体积、发病前功能状态和卒中后护理的影响。

Shaibani博士声明无相关经济利益冲突。

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By: AMY ROTHMAN SCHONFELD, Cardiology News Digital Network

SAN DIEGO – Acute ischemic stroke patients who required transfer to a comprehensive stroke center in order to receive intra-arterial therapy were significantly more likely to have worse functional outcomes at 90 days than were patients who presented directly to such centers in a retrospective analysis of 166 patients.

The poor outcome of the transferred patients was independent of baseline risk factors, stroke severity, time to intra-arterial therapy, and whether the process was a success or the patient had complications, according to Dr. Ali Shaibani, who presented the findings at the annual meeting of the American Society of Neuroradiology.

"The time to intervention is critical for AIS [acute ischemic stroke] patients who are candidates for intra-arterial therapy. Access to endovascular therapy is often limited to comprehensive stroke centers. An increasing number of institutions are transferring AIS patients for therapy. The outcome for this subset of patients who are being transferred has not been studied well," said Dr. Shaibani of the departments of radiology and neurologic surgery at Northwestern University, Chicago.

This retrospective analysis analyzed 116 AIS patients deemed eligible for intra-arterial therapy who were seen at four Chicago-area medical centers. More than half (58.6%) were transferred from outside institutions.

Dr. Shaibani and his colleagues found that transfer patients tended to be younger than nontransfers (59 years vs. 69 years, P = .002) and were less likely to have had a history of prior stroke (3% vs. 22%, P = .002) or cardiac problems (18% vs. 37%, P = .040). Transfer patients had worse National Institutes of Health Stroke Scale scores at baseline (20 vs. 17, P = .005) and were more likely to have internal carotid artery occlusions (45.6% vs. 22.9%, P = .012). No differences between groups were found for THRIVE (Totaled Health Risks in Vascular Events) scores, a clinical scoring system designed to help clinicians predict a patient’s chances of achieving a good outcome after AIS).

At 90 days after intra-arterial therapy, only 16% of transfer patients had a good functional outcome, as defined by a modified Rankin Scale score of 0-2. Significantly more nontransferred patients (60%) had a good outcome (P less than .001). In a multivariate analysis, transfer status was an independent predictor of poor functional outcome (adjusted odds ratio = 0.05; 95% confidence interval, 0.011-0.222), after the findings were adjusted for relevant covariates such as baseline risk factors, stroke severity, time to intra-arterial therapy, or procedural success or complications. No differences between groups were found for median symptom onset to groin puncture times, rates of successful recanalization (defined as thrombolysis in cerebral infarction grade 2b or higher), or the presence of symptomatic intracranial hemorrhage.

Dr. Shaibani said it was not clear what factors were contributing to the findings. He said future work should explore the influence of baseline/final infarct volume, premorbid functional status, and poststroke care.

Dr. Shaibani reported that he had no relevant financial disclosures.