急性缺血性脑卒中急诊急救中国专家共识（2018）

doi:10.3969/j.issn.1002-1949.2018.07.001

摘要
图/表
参考文献(70)
相关文章 (15)

全文: PDF (1059 KB) HTML (1 KB)
输出: BibTeX | EndNote (RIS)

摘要急性脑卒中是一种发病率高、致残率高、病死率高、复发率高及并发症多的疾病。据统计，2013年中国卒中的年龄标准化患病率为1114.8/10万人，发病率为246.8/10万人，病死率为114.8/10万人。目前，急性缺血性卒中（acute ischemic stroke, AIS）最有效的治疗方法是时间窗内给予血管再通治疗，包括重组组织型纤溶酶原激活剂（recombinant tissue plasminogen activator, rt-PA）静脉溶栓和机械取栓，救治成功率与发病时间密切相关。由于我国群众对该疾病早期识别认知度低、院前救治能力不足、院内急诊延误等导致AIS救治延迟以及溶栓率较低，我国在发病3 h内到达急诊科的AIS患者只有21.5%，适合溶栓治疗者仅12.6%，而进行了溶栓治疗的患者只有2.4%；从患者进入急诊科到接受溶栓药物治疗的间隔时间平均是116 min，比发达国家显著延长。因此，我国缺血性卒中患者救治效率仍不理想，形势严峻。 AIS救治可以分为三个阶段：院前、急诊、住院治疗。2013年美国心脏病协会/美国卒中协会(AHA/ASA)《急性缺血性卒中患者的早期管理指南》中将卒中急救流程概括为8D生存链：Detection(发现)、Dispatch(派遣)、Delivery(转运)、Door(到院)、Data(检查资料)、Decision(临床决策)、Drug(药物治疗)、Disposition(安置)。首都医科大学附属北京天坛医院结合我国基本国情提出脑卒中治疗教育工程的概念，强调应该将院前、急诊、住院治疗有机地联系起来。本共识着重于前两个部分的内容，以期优化我国AIS急诊急救的流程，促进救治效率，改善患者预后，降低致残率和病死率。

	服务

	把本文推荐给朋友
	加入我的书架
	加入引用管理器
	E-mail Alert
	RSS
	作者相关文章
	中国老年医学学会急诊医学分会
	中华医学会急诊医学分会卒中学组
	中国卒中学会急救医学分会

通讯作者: 郭伟，E-mail:guowei1010@163.com；李斗，E-mail:lidou86@126.com；彭鹏，E-mail:pengpeng4949@126.com。

引用本文:

中国老年医学学会急诊医学分会，中华医学会急诊医学分会卒中学组，中国卒中学会急救医学分会. 急性缺血性脑卒中急诊急救中国专家共识（2018）[J]. 中国急救医学, 2018, 38(7): 557-564.

链接本文:

http://www.cnemergency.org.cn/CN/10.3969/j.issn.1002-1949.2018.07.001 或 http://www.cnemergency.org.cn/CN/Y2018/V38/I7/557

［1］Fonarow GC, Zhao X, Smith EE, et al. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative［J］. JAMA, 2014, 311(16): 1632-1640. ［2］Sturm JW, Dewey HM, Donnan GA, et al. Handicap after stroke: how does it relate to disability, perception of recovery, and stroke subtype: the north North East Melbourne Stroke Incidence Study (NEMESIS)［J］. Stroke, 2002, 33(3): 762-768. ［3］Wang W, Jiang B, Sun H, et al. Prevalence, Incidence, and Mortality of Stroke in China: Results from a Nationwide Population-〖JP〗Based Survey of 480 687 Adults［J］. Circulation, 2017, 135(8): 759-771. ［4］马玉宝，李成文，李卫东. 急性脑卒中患者院前时间延误的影响因素分析［J］. 中国全科医学， 2011， 14(29): 3380-3381. ［5］王素香，牛松涛，王拥军，等. 急性脑血管病患者到院延迟因素的调查［J］. 中华内科杂志， 2002， 41(11): 728-731. ［6］徐安定，丁燕，李牧. 中国缺血性卒中早期静脉溶栓的现状、阻碍因素及改进策略［J］. 中国卒中杂志， 2014， 9(6): 522-528. ［7］王文，朱曼璐，王拥军，等. 《中国心血管病报告2012》概要［J］. 中国循环杂志， 2013， 28(6): 408-412. ［8］Jauch EC, Saver JL, Adams HP, et al. Guidelines for the early management of patients with acute ischemic stroke:aguideline for healthcare professionals from the American Heart Association/American Stroke Association［J］. Stroke, 2013, 44(3): 870-947. ［9］王伊龙，王拥军，吴敌，等. 中国卒中防治研究现状［J］. 中国卒中杂志， 2007， 2(1): 20-37. ［10］Fassbender K, Balucani C, Walter S, et al. Streamlining of prehospital stroke management: the golden hour［J］. Lancet Neurology, 2013, 12(6): 585-596. ［11］O′Brien W, Crimmins D, Donaldson W, et al. FASTER (Face, Arm, Speech, Time, Emergency Response): experience of Central Coast Stroke Services implementation of a pre-hospital notification system for expedient management of acute stroke［J］. J Clin Neurosci, 2012, 19(2): 241-245. ［12］Song S, Saver J. Growth of regional acute stroke systems of care in the United States in the first decade of the 21st century［J］. Stroke, 2012, 43(7): 1975-1978. ［13］Schwamm LH, Pancioli A, Rd AJ, et al. Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association′s Task Force on the Development of Stroke Systems［J］. Circulation, 2005, 111(8): 1078-1091. ［14］朱鑫璞，王少石. 脑卒中一级预防与健康教育［J］. 中国现代神经疾病杂志， 2015， 15(2): 109-112. ［15］国家卫生和计划生育委员会神经内科医疗质量控制中心. 中国卒中中心建设指南［J］. 中国卒中杂志， 2015， 6: 499-507. ［16］马锐华，王拥军. 卒中中心的研究进展［J］. 中国康复医学杂志， 2005， 20(4): 307-309. ［17］Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association［J］. Stroke, 2018, 49(3): e46-e110. ［18］Nogueira RG, Smith WS. Emergency treatment of acute ischemic stroke: expanding the time window［J］. Curr Treat Options Neurol, 2009, 11(6): 433-443. ［19］Harris D, Hall C, Lobay K, et al. Canadian Association of Emergency Physicians position statement on acute ischemic stroke［J］. CJEM, 2015, 17(2): 217-226. ［20］Song S, Fonarow GC, Olson DM, et al. Association of Get With The Guidelines-Stroke Program Participation and Clinical Outcomes for Medicare Beneficiaries With Ischemic Stroke［J］. Stroke, 2016, 47(5): 1294-1302. ［21］Scott PA, Meurer WJ, Frederiksen SM, et al. A multilevel intervention to increase community hospital use of alteplase for acute stroke (INSTINCT): a cluster-randomised controlled trial［J］. Lancet Neurol, 2013, 12(2): 139-148. ［22］Group TNTSS. Generalized efficacy of t-PA for acute stroke［J］. Stroke, 1997, 28(11): 2119-2125. ［23］Adams HP, Davis PH, Leira EC, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST)［J］. Neurology, 1999, 53(1): 126-131. ［24］Frankel MR, Morgenstern LB, Kwiatkowski T, et al. Predicting prognosis after stroke:a placebo group analysis from the National Institute of Neurological Disorders and Stroke rt-PA Stroke Trial［J］. Neurology, 2000, 55(7): 952-959. ［25］Wahlgren N, Ahmed N, Eriksson N, et al. Multivariable analysis of outcome predictors and adjustment of main outcome results to baseline data profile in randomized controlled Trials: Safe Implementation of Thrombolysis in Stroke-MOnitoring STudy (SITS-MOST)［J］. Stroke, 2008, 39(12): 3316-3322. ［26］Ramanujam P, Guluma KZ, Castillo EM, et al. Accuracy of stroke recognition by emergency medical dispatchers and paramedics--San Diego experience［J］. Prehosp Emerg Care, 2008, 12(3): 307-313. ［27］Berglund A, Svensson L, Sjstrand C, et al. Higher prehospital priority level of stroke improves thrombolysis frequency and time to stroke unit:the Hyper Acute STroke Alarm (HASTA) Study［J］. Stroke, 2012, 43(10): 2666-2670. ［28］Abboud ME, Band R, Jia J, et al. Recognition of Stroke by EMS is Associated with Improvement in Emergency Department Quality Measures［J］. Prehosp Emerg Care, 2016, 20(6): 729-736. ［29］Kothari RU, Pancioli A, Liu T, et al. Cincinnati Prehospital Stroke Scale: reproducibility and validity［J］. Ann Emerg Med, 1999, 33(4): 373-378. ［30］Nor AM, McAllister C, Louw SJ,et al. Agreement between ambulance paramedic- and physician-recorded neurological signs with Face Arm Speech Test (FAST) in acute stroke patients［J］. Stroke, 2004, 35(6): 1355-1359. ［31］Kidwell CS, Starkman S, Eckstein M, et al. Identifying Stroke in the Field［J］. Stroke, 2000, 31(1): 71-76. ［32］Nazliel B, Starkman S, Liebeskind DS, et al. A brief prehospital stroke severity scale identifies ischemic stroke patients harboring persisting large arterial occlusions［J］. Stroke, 2008, 39(8): 2264-2267. ［33］Lima FO, Silva GS, Furie KL, et al. Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes［J］. Stroke, 2016, 47(8):1997-2002. ［34］Morris DL, Rosamond W, Madden K, et al. Prehospital and emergency department delays after acute stroke:the Genentech Stroke Presentation Survey［J］. Stroke, 2000, 31(1):2585-2590. ［35］中华医学会神经病学分会，中华医学会神经病学分会脑血管病学组. 中国急性缺血性脑卒中诊治指南2014［J］. 中华神经科杂志， 2015， 48(4): 246-257. ［36］康维为. 不同院前急救评价方法对急性脑卒中患者诊治效果的影响［J］. 中国全科医学， 2011， 14(2):208-209. ［37］Disorders NIoN, Group Sr-PSS. Tissue plasminogen activator for acute ischemic stroke［J］. New England Journal of Medicine, 1995, 333: 1581. ［38］Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke［J］. N Engl J Med, 2008, 359(13):1317-1329. ［39］Rinaldo L, Brinjikji W, McCutcheon BA, et al. Hospital transfer associated with increased mortality after endovascular revascularization for acute ischemic stroke［J］. J Neurointerv Surg, 2016, 9(12): 1166-1172. ［40］Gerschenfeld G, Muresan IP, Blanc R,et al. Two Paradigms for Endovascular Thrombectomy After Intravenous Thrombolysis for Acute Ischemic Stroke［J］. JAMA Neurol, 2017, 74(5): 549-556.〖JP〗 ［41］中国卒中学会急救医学分会. 脑卒中院前急救专家共识［J］. 中华急诊医学杂志， 2017， 26(10): 1107-1114. ［42］Ebinger M, Winter B, Wendt M, et al. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial［J］. JAMA, 2014, 311(16): 1622-1631. ［43］Walter S, Kostopoulos P, Haass A, et al. Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial［J］. Lancet Neurol, 2012, 11(5): 397-404. ［44］Kostopoulos P, Walter S, Haass A, et al. Mobile stroke unit for diagnosis-based triage of persons with suspected stroke［J］. Neurology, 2012, 78(23): 1849-1852. ［45］Lin CB, Peterson ED, Smith EE, et al. Emergency medical service hospital prenotification is associated with improved evaluation and treatment of acute ischemic stroke［J］. Circ Cardiovasc Qual Outcomes, 2012, 5(4): 514-522. ［46］Meretoja A, Strbian D, Mustanoja S, et al. Reducing in-hospital delay to 20 minutes in stroke thrombolysis［J］. Neurology, 2012, 79(4): 306-313. ［47］Meretoja A, Weir L, Ugalde M, et al. Helsinki model cut stroke thrombolysis delays to 25 minutes in Melbourne in only 4 months［J］. Neurology, 2013, 81(12): 1071-1076. ［48］Ford AL, Williams JA, Spencer M, et al. Reducing door-to-needle times using Toyota′s lean manufacturing principles and value stream analysis［J］. Stroke, 2012, 43(12): 3395-3398. ［49］王伊龙，吴敌，周永，等. 中国七城市卒中患者急诊溶栓情况分析［J］. 中国卒中杂志， 2009， 4(1): 23-28. ［50］中华医学会急诊医学分会卒中学组，中国卒中学会急救医学分会. 急性脑梗死溶栓治疗急诊绿色通道构建专家共识［J］. 中华急诊医学杂志， 2017， 26(9): 995-998. ［51］饶明俐. 中国脑血管病防治指南［M］. 人民卫生出版社， 2007. ［52］Cucchiara BL, Jackson B, Weiner M, et al. Usefulness of checkingplatelet count before thrombolysis in acute ischemic stroke［J］. Stroke, 2007, 38(5): 1639-1640.  ［53］Saposnik G, Fang J, Kapral MK, et al. The iScore predicts effectiveness of thrombolytic therapy foracute ischemic stroke［J］. Stroke, 2012, 43(5): 1315-1322.  ［54］Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group［J］. N Engl J Med, 1995, 333(15): 1581. ［55］Morris DC. Thrombolysis 3 to 4.5 hours after acute ischemic stroke［J］. N Engl J Med, 2008, 359(26): 2841. ［56］IST-3 collaborative group, Sandercock P, Wardlaw JM, et al. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial ［IST-3］): a randomised controlled trial［J］. Lancet, 2012,379(9834): 2352-2363. ［57］Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke［J］. N Engl J Med, 2015, 372(1): 11-20. ［58］Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke［J］. N Engl J Med, 2015, 372(24): 2285-2295. ［59］Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection［J］. N Engl J Med, 2015, 372(11): 1009-1018. ［60］Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke［J］. N Engl J Med, 2015, 372(11): 1019-1030. ［61］Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke［J］. N Engl J Med, 2015, 372(24): 2296-2306. ［62］Bracard S, Ducrocq X, Mas JL, et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial［J］. Lancet Neurol, 2016, 15(11): 1138-1147. ［63］Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct［J］. N Engl J Med, 2018, 378(1): 11-21. ［64］Albers GW, Marks MP, Kemp S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging［J］. N Engl J Med, 2018, 378(8): 708-718. ［65］Kim YS, Park SS, Bae HJ, et al. Stroke awareness decreases prehospital delay after acute ischemic stroke in Korea［J］. Bmc Neurol, 2011, 11: 2. ［66］Jin H, Zhu S, Wei JW, et al. Factors associated with prehospital delays in the presentation of acute stroke in urban China［J］. Stroke, 2012, 43(2): 362-370. ［67］王亚冰，焦力群，王亚东，等. 北京市三甲医院急性脑血管病患者发病至治疗延迟时间分布［J］. 中国神经精神疾病杂志， 2009， 35(1): 22-25. ［68］Zhao J, Liu R. Stroke 1-2-0: a rapid response programme for stroke in China［J］. Lancet Neurol, 2016, 16(1): 27-28. ［69］Schroeder EB, Rosamond WD, Morris DL, et al. Determinants of use of emergency medical services in a population with stroke symptoms:the Second Delay in Accessing Stroke Healthcare (DASH Ⅱ) Study［J］. Stroke, 2000, 31(11): 2591-2596. ［70］Ekundayo OJ, Saver JL, Fonarow GC, et al. Patterns of emergency medical services use and its association with timely stroke treatment: findings from Get With the Guidelines-Stroke［J］. Circ Cardiovasc Qual Outcomes, 2013, 6(3): 262-269.