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浙江大学学报（医学版）
J Zhejiang Univ (Med Sci)  2019, Vol. 48 Issue (3): 247-253    DOI: 10.3785/j.issn.1008-9292.2019.06.03
    
Advanced treatment time improves outcomes of patients with ischemic stroke undergoing reperfusion therapy
CHEN Hongfang1(),GONG Xiaoxian2,XU Dongjuan3,WANG Zhimin4,HU Haifang5,WU Chenglong6,ZHANG Xiaoling7,MA Xiaodong8,WANG Yaxian9,HU Haitao2,LOU Min2,CHEN Zhicai2,*(),Improving In-hospital Stroke Service Utilisation (MISSION) in Zhejiang Province
1. Department of Neurology, Jinhua Hospital of Zhejiang University, Jinhua Municipal Central Hospital, Jinhua 321000, Zhejiang Province, China
2. Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
3. Department of Neurology, Dongyang People's Hospital, Dongyang 322100, Zhejiang Province, China
4. Department of Neurology, Taizhou First People's Hospital, Taizhou 318020, Zhejiang Province, China
5. Department of Neurology, the First People's Hospital of Xiaoshan District, Hangzhou 311201, China
6. Department of Neurology, Shaoxing People's Hospital, Shaoxing 312000, Zhejiang Province, China
7. Department of Neurology, Jiaxing Second Hospital, Jiaxing 314000, Zhejiang Province, China
8. Department of Neurology, Haiyan People's Hospital, Haiyan 314300, Zhejiang Province, China
9. Department of Neurology, Huzhou Central Hospital, Huzhou 313003, Zhejiang Province, China
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Abstract  

Objective: To investigate the effect of treatment time on the outcome of patients with ischemic stroke undergoing reperfusion therapy. Methods: The clinical data of 3229 ischemic stroke patients who received intravenous thrombolysis with or without arterial thrombolysis from 71 hospitals in Zhejiang province from June 2017 to September 2018 were retrospectively reviewed. The good outcome was defined as modified Rankin Scale (mRS) ≤ 2. Binary logistic regression analysis was used to investigate the association of door to needle time (DNT), or door to reperfusion time (DRT) with the outcomes in patients treated by intravenous thrombolysis or bridging arterial thrombolysis, respectively. Results: Binary logistic regression showed that DNT (OR=0.994, 95%CI:0.991-0.997, P < 0.01) or DRT (OR=0.989, 95%CI:0.983-0.995, P < 0.01) were independently associated with good outcomes, respectively. Every hour decreases in DNT resulted in a 4.7%increased probability of functional independence (mRS 0-2) in patients treated by intravenous thrombolysis; Every hour decreases in DRT was associated with a 11.4%increased probability of functional independence in patients treated by intravenous thrombolysis with arterial thrombolysis. Conclusion: Good outcomes are associated with lower DNT in ischemic stroke patients treated by intravenous thrombolysis or lower DRT in patients treated by intravenous thrombolysis bridging arterial thrombolysis.

Key words： Stroke/therapy      Brain ischemia/therapy      Plasminogen activators/therapeutic use      Thrombolytic therapy      Reperfusion      Endovascular treatment      Time factors      Prognosis     
Received: 04 February 2019      Published: 04 September 2019
CLC:  R743  
Corresponding Authors: CHEN Zhicai     E-mail: jhchf894@163.com;chenzhicai@zju.edu.cn
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CHEN Hongfang
GONG Xiaoxian
XU Dongjuan
WANG Zhimin
HU Haifang
WU Chenglong
ZHANG Xiaoling
MA Xiaodong
WANG Yaxian
HU Haitao
LOU Min
CHEN Zhicai
Improving In-hospital Stroke Service Utilisation (MISSION) in Zhejiang Province
Cite this article:

CHEN Hongfang, GONG Xiaoxian, XU Dongjuan, WANG Zhimin, HU Haifang, WU Chenglong, ZHANG Xiaoling, MA Xiaodong, WANG Yaxian, HU Haitao, LOU Min, CHEN Zhicai, Improving In-hospital Stroke Service Utilisation (MISSION) in Zhejiang Province . Advanced treatment time improves outcomes of patients with ischemic stroke undergoing reperfusion therapy. J Zhejiang Univ (Med Sci), 2019, 48(3): 247-253.

URL:

http://www.zjujournals.com/med/10.3785/j.issn.1008-9292.2019.06.03     OR     http://www.zjujournals.com/med/Y2019/V48/I3/247


治疗时间提前可改善缺血性脑卒中患者再灌注治疗的预后

目的: 探究缺血性脑卒中患者再灌注治疗时间与预后的关系。方法: 纳入2017年6月至2018年9月在浙江省卒中急救平台上报的71家医院中接受单纯静脉溶栓或者桥接动脉取栓治疗的缺血性脑卒中患者3229例。3个月改良Rankin量表（mRS）2分及以下为预后良好。采用二元Logistic回归分析法研究入院至溶栓时间（DNT）、入院至再灌注时间（DRT）与患者治疗后3个月预后的关系。结果: DNT和DRT分别是单纯静脉溶栓治疗、静脉溶栓桥接动脉取栓治疗患者预后的独立影响因素（OR=0.994，95%CI：0.991~0.997，P < 0.01；OR=0.989，95%CI：0.983~0.995，P < 0.01）。对于单纯静脉溶栓治疗的患者，DNT每减少1 h，3个月预后良好的比例提高约4.7%；而对于静脉溶栓桥接动脉取栓治疗的患者，DRT每减少1 h，3个月预后良好的比例提高约11.4%。结论: 缩短时间窗内缺血性脑卒中患者的DNT或DRT，可以不同程度地提高患者再灌注治疗3个月预后良好的比例。


关键词： 卒中/治疗,  脑缺血/治疗,  纤溶酶原激活剂/治疗应用,  血栓溶解疗法,  再灌注,  血管内治疗,  时间因素,  预后 
[${\bar x}$±s或M(Q1, Q3)或n(%)]
影响因素 预后良好组(n=2011) 预后不良组(n=1218) t/χ2/Z值 P值
NIHSS：美国国立卫生研究院卒中量表；mRS：改良Rankin量表；TIA：短暂性脑缺血发作；rt-PA：重组组织型纤溶酶原激活剂；DNT：入院至溶栓时间；ODT：起病至入院时间；ONT；起病至溶栓时间；DRT：入院至再灌注时间；ORT：起病至再灌注时间.1 mmHg=0.133 kPa.
年龄(岁) 66±12 73±12 -15.765 ＜0.01
女性 730(36.3) 525(43.1) 14.776 ＜0.01
基线NIHSS评分 4(3, 9) 14(8, 19) -28.383 ＜0.01
发病前mRS评分 0(0, 0) 0(0, 0) -4.695 ＜0.01
高血压史 1255(62.4) 852(70.0) 19.040 ＜0.01
心房颤动史 395(19.6) 453(37.2) 120.652 ＜0.01
糖尿病史 327(16.3) 222(18.2) 2.078 ＞0.10
高脂血症史 339(16.9) 220(18.1) 0.770 ＞0.10
卒中/TIA史 252(12.5) 208(17.1) 12.833 ＜0.01
心血管病家族史 96(4.8) 49(4.0) 0.997 ＞0.10
吸烟 710(35.3) 316(25.9) 30.667 ＜0.01
二次溶栓 23(1.1) 21(1.7) 1.901 ＞0.10
抗血小板药物使用史 291(14.5) 206(16.9) 3.475 ＜0.10
溶栓前收缩压(mmHg) 153±21 156±22 -3.996 ＜0.01
溶栓前舒张压(mmHg) 86±14 85±14 0.817 ＞0.10
血小板计数(×109/L) 197±58 191±62 2.454 ＜0.10
血红蛋白量(g/L) 140±18 136±19 5.606 ＜0.01
使用rt-PA静脉溶栓 1924(95.7) 1173(96.3) 0.772 ＞0.10
使用尿激酶静脉溶栓 87(4.3) 45(3.7) 0.772 ＞0.10
DNT(min) 62±30 67±34 -4.022 ＜0.01
ODT(min) 116±67 123±69 -2.667 ＜0.01
ONT(min) 178±69 189±70 -4.417 ＜0.01
桥接动脉取栓 95(4.7) 170(14.0) 84.897 ＜0.01
DRT(min) 189±61 237±92 -3.917 ＜0.01
ORT(min) 304±83 379±103 -3.599 ＜0.01
血管再通 84(88.4) 134(78.8) 3.198 ＜0.10
Tab 1 Univariate analysis of influencing factors for prognosis of reperfusion treatment in patients with ischemic stroke
影响因素 OR值 95%CI P值
NIHSS:美国国立卫生研究院卒中量表；mRS:改良Rankin量表；ODT:起病至入院时间；DNT:入院至溶栓时间；TIA:短暂性脑缺血发作.
年龄 0.965 0.956~0.974 ＜0.01
女性 1.176 0.920~1.503 ＞0.05
基线NIHSS评分 0.858 0.844~0.872 ＜0.01
发病前mRS评分 0.541 0.413~0.709 ＜0.01
溶栓前收缩压 0.993 0.988~0.998 ＜0.01
血小板计数 0.998 0.996~1.000 ＜0.05
血红蛋白量 1.000 0.994~1.006 ＞0.05
ODT 0.997 0.996~0.999 ＜0.01
DNT 0.994 0.991~0.997 ＜0.01
高血压史 0.830 0.667~1.032 ＞0.05
心房颤动史 0.816 0.642~1.038 ＞0.05
卒中/TIA史 0.846 0.625~1.146 ＞0.05
吸烟史 1.225 0.957~1.569 ＞0.05
抗血小板药物使用史 1.169 0.874~1.562 ＞0.05
Tab 2 Binary logistic regression analysis for good prognosis after intravenous thrombolysis in patients with ischemic stroke
影响因素 OR值 95%CI P值
NIHSS:美国国立卫生研究院卒中量表；mRS:改良Rankin量表；ODT:起病至入院时间；DRT:入院至再灌注时间；TIA:短暂性脑缺血发作.
年龄 0.985 0.941~1.030 ＞0.05
女性 1.959 0.664~5.780 ＞0.05
基线NIHSS评分 0.960 0.909~1.013 ＞0.05
发病前mRS评分 0.000 0.000~0.000 ＞0.05
溶栓前收缩压 0.985 0.965~1.005 ＞0.05
血小板计数 1.001 0.994~1.008 ＞0.05
血红蛋白量 1.018 0.989~1.048 ＞0.05
ODT 0.999 0.993~1.004 ＞0.05
DRT 0.989 0.983~0.995 ＜0.01
高血压史 1.008 0.432~2.349 ＞0.05
心房颤动史 0.778 0.330~1.834 ＞0.05
卒中/TIA史 1.078 0.339~3.428 ＞0.05
吸烟史 1.335 0.447~3.983 ＞0.05
抗血小板药物使用史 1.098 0.377~3.199 ＞0.05
Tab 3 Binary logistic regression analysis for good prognosis after intravenous thrombolysis combined with arterial thrombolysis in patients with ischemic stroke
Fig 1 Predicted probability and 95 % CI of good prognosis at 3-month after intravenous thrombolysis in patients with ischemic stroke based on binary logistic regression with door to needle time as a continuous variable
Fig 2 Predicted probability and 95 % CI of good prognosis at 3 months after intravenous thrombolysis combined with arterial thrombolysis in patients with ischemic stroke based on binary logistic regression with door to reperfusion time as a continuous variable
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