改善急性腦中風病人血栓溶解治療評估效率之經驗及探討

Improving Experiences of Thrombolytic Therapy in Acute Ischemic Stroke

顏正昌(Cheng-Chung Yen) ； 盧玉強(Yuk-Keung Lo) ； 萬樹人(Shu-Ren Wann) ； 林清煌(Ching-Hwung Lin) ； 張運德(Yun-Te Chang) ； 羅崇誠(Chung-Cheng Lo) ； 陳立偉(Li-Wei Chen) ； 高志翔(Chih-Hsiang Kao)

《重症醫學雜誌》 11卷4期 (2010/12) Pp. 231-238

https://doi.org/10.30035/TCCM.201012.0001

摘要

目的：靜脈注射血栓溶解劑(recombinant tissue plasminogen activator, rtPA)目前已證實是治療急性缺血性腦中風最有效及重要的治療方式。衛生署及國際上都針對病患在急診室時血栓溶解治療的評估流程提出建議。因此，我們嘗試改善急性缺血性腦中風病患在急診室時的評估流程。方法：由本醫院腦中風登記資料庫中回溯分析2007年04月至2008年03月所有住院的急性缺血性腦中風病患資料。本院於2008年4月開始實施新的評估流程，同時繼續收集到本院急診就醫的急性腦中風病人資料。資料收集到2009年9月為止。紀錄了急性缺血性腦中風病人的「症狀發生時間」、「到急診時間」、「進行腦部電腦斷層時間」、「神經內科醫師會診時間」及「血栓溶解劑施打時間」。每位施打血栓溶解劑的急性缺血性腦中風病人，在治療前和治療後24小時，皆進行神經功能評估(NIH stroke scale)。結果：新的評估流程實施後，共有缺血性腦中風病患830人，2小時內到院的急性腦中風人數133人(16%)，進行血栓溶解治療評估有119人(14.3%)，最後施打rtPA的急性腦中風病人共有18人(2.2%)。「從症狀發生到急診就醫」的中位數時間是56分鐘、「到院到腦部電腦斷層檢查時間」的中位數時間是20分鐘、「到院到神經內科醫師會診時間」的中位數時間是20分鐘、「到院到施打rtPA時間」的中位數時間是71分鐘。比較新流程實施前一年資料，「到院到腦部電腦斷層檢查時間」36分鐘和「到院到神經內科醫師會診時間」49分鐘都有統計意義的縮短。但是「到院到施打rtPA時間」並沒有變化。統計2007年4月到2009年9月，本院總共有27位及性缺血性腦中風患者接受rtPA治療，其中有明顯神經功能恢復者有9人(33%)有1位(3.6%)病患發生有症狀的腦出血併發症。結論：急性腦中風病人急診評估流程改善後，急性缺血性腦中風符合黃金三小時之評估率及施打rtPA之人數增加，而且施打完rtPA後有明顯神經功能恢復。但是，病人進行血栓溶解治療前血壓過高、缺血性腦中風診斷未明須確認、病人和家屬考慮過久以及後段評估過程遲緩等，都是影響最後施打rtPA時間的因素，需要再改進。

關鍵字

急性缺血性腦中風 ； 血栓溶解劑 ； 到院到腦部電腦斷層檢查時間 ； 到院到上針時間 ； 明顯神經功能改善

並列摘要

Background: Intravenous thrombolytic therapy has been documented as important treatment for acute ischemic stroke. We tried to improve the procedure of evaluation of acute stroke for thrombolytic therapy at emergency department (ER).Method: From the stroke registration data of Kaohsiung Veterans General Hospital (KSVGH), all patients with acute ischemic stroke admitted between April. 2007 and March. 2008 were identified, retrospectively. Since April 2008, we started the new procedure to evaluate the patient with acute stroke at ER. From April 2008 to Sep. 2009, the patients with acute stroke at ER were enrolled. We recorded time of stroke onset、time of arrival、time of CT scan examination、time of neurologist visit and time of intravenous recombinant tissue plasminogen activator (rt-PA) injection. Those who were eligible were treated with intravenous rt-PA. NIH Stroke Scale (NIHSS) was recorded before and after the treatment at 24hr. Major neurologic improvement defined as an NIHSS score equal to 0 or 1 at 24 hours or an improvement of 8 points compared to baseline.Results: After the new procedure, 830 patients with acute ischemic stroke were noted. Among them, 133 (16%) patients visited our ER within the eligible time after onset of acute stroke. 119 (14.3%) patients were evaluated for thrombolytic therapy. The median time of onset-to-door、door-to-CT scan、door-to-CT interpretation、door-to-neurologist were 56、20、28、20 minutes. However, median door-to-needle time was 71 minutes. From April 2007 to September 2009, total 27 patients with acute ischemic stroke were treated by rt-PA. Major neurologic improvement was found in 9 (33%) patients. One (3.6%) patient suffered from symptomatic intracerebral hemorrhage.Conclusion: To compared with that before new procedure, door-to-CT scan、door-to-neurologist visit time improved. However, the procedure of evaluation of acute stroke has just been improved partially. The below factors may delay final rtPA injection, including severe hypetension before rtPA treatmtent、uncertain diagnosis of ischemic stroke、patient and families' hesitation for rtPA treatment and intactive assessment.

並列關鍵字

Acute ischemic stroke ； Thrombolytic therapy ； Door to CT scan time ； Door to neurologist visit time ； Door to needle time ； Major neurologic improvement