Frequency, Predictors, and Outcomes of Prehospital and Early Postarrival Neurological Deterioration in Acute Stroke Exploratory Analysis of the FAST-MAG Randomized Clinical Trial
Frequency, Predictors, and Outcomes of Prehospital and Early Postarrival Neurological Deterioration in Acute Stroke Exploratory Analysis of the FAST-MAG Randomized Clinical Trial
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DOI：
10.1001/jamaneurol.2018.1893
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发表时间：
2018-11-01
期刊：
影响因子：
29
通讯作者：
Sanossian, Nerses
中科院分区：
文献类型：
--
作者：
Shkirkova, Kristina;Saver, Jeffrey L.;Sanossian, Nerses
重要性卒中神经功能恶化的研究主要集中在亚急性期，但卒中治疗越来越多地转移到院前环境，在那里神经过程尚未得到很好的描述。目的描述缺血性卒中或颅内出血后超早期患者神经功能恶化的频率，预测因子和结局。和参与者探索性分析2005年至2013年在南加州的315辆救护车和60名卒中患者接收医院中进行的卒中治疗-镁（FAST-MAG）试验的院前随机现场管理。参与者是连续登记的疑似急性中风患者，他们在中风发作后2小时内由救护车运送。主要结局和测量主要结局是神经功能恶化，定义为格拉斯哥昏迷量表（GCS）的2分或2分以上的恶化，意识水平量表范围从3到15，分数越高表示越警觉。影像学结局是在首次脑成像扫描期间确定的缺血性或出血性损伤程度。3个月时的结果包括总体残疾水平（使用改良的兰金量表[mRS]评估;范围，0-6，数字越高表示残疾越大）和死亡率。结果在1690例患者（99.4%）中，平均（SD）年龄为69.4（13.5）岁，43%为女性。最终诊断为急性脑缺血1237例（73.2%），颅内出血386例（22.8%），神经血管样病变67例（4.0%）。最后一次已知时间与GCS评估之间的中位（四分位距[IQR]）分钟为23（14-42）分钟（院前）、58（46-79）分钟（艾德到达）和149（120-180）分钟（早期艾德病程评估）。从入院前到入院后早期，1690例患者中有200例（11.8%）发生了超早期神经功能恶化（U-END），颅内出血患者比急性脑缺血患者更常见（386例中有119例[30.8%] vs 1237例中有75例[6.1%]，P <0.001）。U-END的类型为院前U-END，30/965例（3.1%）未早期恢复，49/965例（5.1%）院前病程稳定但早期艾德恶化，27/965例（2.8%）在院前和早期艾德阶段持续恶化。超早期神经功能恶化与3个月预后差相关，包括总体残疾增加（mRS评分，4.6 vs 2.4; P < .001），功能独立性降低（mRS评分0-2，32/200 [16.0%] vs 844/1490 [56.6%] P < .001），死亡率增加（87/200 [43.5%] vs 176/1490 [11.8%]; P < .001）。结论和相关性救护车运送的急性脑血管病患者中，有八分之一出现超早期神经功能恶化，包括3例颅内出血患者中的1例和16例急性脑缺血患者中的1例，并且与显著降低的功能独立性和增加的死亡率相关。避免U-END可能是未来院前治疗的目标。
IMPORTANCE Studies of neurological deterioration in stroke have focused on the subacute period, but stroke treatment is increasingly migrating to the prehospital setting, where the neurological course has not been well delineated.OBJECTIVE To describe the frequency, predictors, and outcomes of neurological deterioration among patients in the ultra-early period following ischemic stroke or intracranial hemorrhage.DESIGN, SETTINGS, AND PARTICIPANTS Exploratory analysis of the prehospital, randomized Field Administration of Stroke Therapy-Magnesium (FAST-MAG) Trial conducted from 2005 to 2013 within 315 ambulances and 60 stroke patient receiving hospitals in Southern California. Participants were consecutively enrolled patients with suspected acute stroke who were transported by ambulance within 2 hours of stroke onset.MAIN OUTCOMES AND MEASURES The main outcome was neurological deterioration, defined as a worsening of 2 or more points on the Glasgow Coma Scale (GCS), a level of consciousness scale ranging from 3 to 15, with higher scores indicating more alertness. Imaging outcomes were ischemic or hemorrhagic injury extent identified during the first brain imaging scan. Outcomes at 3 months included global disability level (assessed using the modified Rankin Scale [mRS]; range, 0-6, with higher numbers indicating greater disability) and mortality.RESULTS Among the 1690 patients (99.4%), the mean (SD) age was 69.4 (13.5) years, and 43% were female. Final diagnoses were acute cerebral ischemia in 1237 patients (73.2%), intracranial hemorrhage in 386 patients (22.8%), and neurovascular mimic in 67 patients (4.0%). The median (interquartile range [IQR]) minutes between the last well-known time and GCS assessments were 23 (14-42) minutes for prehospital, 58 (46-79) minutes for ED arrival, and 149 (120-180) minutes for early ED course assessments. From prehospital to early postarrival, ultra-early neurological deterioration (U-END) occurred in 200 of 1690 patients (11.8%), more often among patients with intracranial hemorrhage than among those with acute cerebral ischemia (119 of 386 [30.8%] vs 75 of 1237 [6.1%], P < .001). Patterns of U-END were prehospital U-END without early recovery in 30 of 965 patients (3.1%), stable prehospital course but early ED deterioration in 49 of 965 patients (5.1%), and continuous deterioration in both prehospital and early ED phases in 27 of 965 patients (2.8%). Ultra-early neurological deterioration was associated with worse 3-month outcomes, including increased global disability (mRS score, 4.6 vs 2.4; P < .001), reduced functional independence (mRS score 0-2, 32 of 200 [16.0%] vs 844 of 1490 [56.6%] P < .001), and increased mortality (87 of 200 [43.5%] vs 176 of 1490 [11.8%]; P < .001).CONCLUSIONS AND RELEVANCE Ultra-early neurological deterioration OCCUrs in 1 in 8 ambulance-transported patients with acute cerebrovascular disease, including 1 in 3 patients with intracranial hemorrhage and l in 16 patients with acute cerebral ischemia, and is associated with markedly reduced functional independence and increased mortality. Averting U-END may be a target for future prehospital therapeutics.