JAMA Neurology-荟萃分析:大血管中风,及时取栓,时间就是生命

2021-07-24 Freeman MedSci原创

荟萃分析:大血管中风,及时取栓,时间就是生命

血管血栓切除术(EVT)对大血管闭塞引起的急性缺血性脑卒中的预后产生了很大的变化。多项随机临床试验的证据表明EVT有很大的益处,使血栓切除术成为一种标准的治疗方法,并鼓励人们努力改善其实施。

急性缺血性卒中后最重要的决定因素之一是通过静脉溶栓、EVT或两者快速再灌注,减少总的脑缺血时间。缺血性卒中是一种可以产生多种等级的功能障碍的疾病。

近十年来,绝大多数的时间效益研究都集中在二元功能结果上,只将残疾状态中的单一转变视为重要,而不是将患者、家属和医生所重视的所有转变视为重要。即使是多层次的结果分析,一般也是将残疾程度作为一个序数结果来分析,而忽略了使用健康效用对结果状态进行加权,以便以病人为中心的方式掌握健康相关的生活质量。

大多数对EVT时间效益的分析都强调了从发病/最后已知健康(last known well, LKW)的时间到最后已知健康/发病到穿刺(LKWTP)的时间间隔。使用LKWTP时间进行的时间-效益关联分析是不精确的,而且系统地偏向于无效。不精确的原因是,即使是在清醒状态下开始的中风患者,症状发生的确切时间也可能被错误地感知或报告,特别是对于那些在发病时没有目击者的患者,由于中风引起的缺陷,如忽视或失语,他们的症状可能被错误地感知。当分析中包括醒着发病或无意识发病的脑卒中患者时,就会出现系统性的偏向无效。
在这些患者中,LKW时间早于实际的卒中开始时间,产生了人为的较长的LKWTP值,导致系统地低估了治疗速度和治疗效果之间的联系。此外,只选择那些晚到的、影像学上缺血程度有限的患者进行EVT,导致梗死生长速度降低的患者比例过高,也偏向于低估时间-效益的关联。

藉此, 加拿大 University of Calgary的Mohammed A. Almekhlafi等人,评估大血管闭塞(LVO)导致的急性缺血性卒中患者的血管内血栓切除速度相关的终生结果。

他们在PubMed上搜索支架取栓器血栓切除术设备与前循环LVO患者在最后已知良好时间12小时内进行的随机临床试验,并且在2020年8月1日前发表一篇经同行评议的完整主要结果文章。

在781名EVT治疗的患者中,406名(52.0%)为早期治疗(LKWTP≤4小时),375名(48.0%)为后期治疗(LKWTP>4-12小时)。在早期治疗的患者中,LKWTD为188分钟,DTP为105分钟)。

在380名患者中的298名(78.4%)有大量再灌注的患者中,DTR时间的中位数是145.0分钟。在早期治疗的患者中,护理过程的延迟与LKW-干预间隔的临床结果较差有关,在早期治疗和晚期治疗的患者中,护理过程的延迟与LKWTD间隔无关。

例如,在早期治疗的患者中,每延迟10分钟,损失的健康生命年为DTP 1.8个月,LKWTD 0.0个月;P < .001。考虑到细化的时间增量,每延迟1秒所损失的健康寿命是DTP 2.2小时,DTR 2.4小时。

这个荟萃分析的重要意义在于发现了:护理延误与接受EVT治疗的急性缺血性卒中患者的健康生命年的损失有关,尤其是在到达后的时间段。每1秒的延迟与2.2小时的健康生命损失有关,这一发现可能会鼓励持续改善门到治疗时间的质量。


原文出处:
Almekhlafi MA, Goyal M, Dippel DWJ, Majoie CBLM, Campbell BCV, Muir KW, Demchuk AM, Bracard S, Guillemin F, Jovin TG, Mitchell P, White P, Hill MD, Brown S, Saver JL; HERMES Trialists Collaboration. Healthy Life-Year Costs of Treatment Speed From Arrival to Endovascular Thrombectomy in Patients With Ischemic Stroke: A Meta-analysis of Individual Patient Data From 7 Randomized Clinical Trials. JAMA Neurol. 2021 Jun 1;78(6):709-717. doi: 10.1001/jamaneurol.2021.1055. PMID: 33938914; PMCID: PMC8094030.

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    2021-10-26 kkunny
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    2021-08-01 yinhl1978
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    2021-09-25 venlin
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  5. [GetPortalCommentsPageByObjectIdResponse(id=1706180, encodeId=e3fb1e061807f, content=<a href='/topic/show?id=7f6443986ec' target=_blank style='color:#2F92EE;'>#大血管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=43986, encryptionId=7f6443986ec, topicName=大血管)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=caff31165455, createdName=kkunny, createdTime=Tue Oct 26 21:12:02 CST 2021, time=2021-10-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2001428, encodeId=54f220014282c, content=<a href='/topic/show?id=d5df12695e6' target=_blank style='color:#2F92EE;'>#Neurol#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12695, encryptionId=d5df12695e6, topicName=Neurol)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8217292, createdName=yinhl1978, createdTime=Sun Aug 01 02:12:02 CST 2021, time=2021-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1681423, encodeId=b5aa1681423fc, content=<a href='/topic/show?id=366b8e2299e' target=_blank style='color:#2F92EE;'>#荟萃#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=87229, encryptionId=366b8e2299e, topicName=荟萃)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c12d27855367, createdName=venlin, createdTime=Sat Sep 25 16:12:02 CST 2021, time=2021-09-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1836982, encodeId=60cf183698283, content=<a href='/topic/show?id=1f188e230c5' target=_blank style='color:#2F92EE;'>#荟萃分析#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=87230, encryptionId=1f188e230c5, topicName=荟萃分析)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b79433, createdName=fangcong, createdTime=Sun May 29 17:12:02 CST 2022, time=2022-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1479092, encodeId=f4f314e9092a5, content=<a href='/topic/show?id=b97f3800ee0' target=_blank style='color:#2F92EE;'>#取栓#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=38007, encryptionId=b97f3800ee0, topicName=取栓)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=99077483919, createdName=1249862am74(暂无昵称), createdTime=Sun Jul 25 20:12:02 CST 2021, time=2021-07-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1002375, encodeId=28c510023e58c, content=非常受用, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210724/725901dc0ed249ebba9d096aacddde3f/a89b874e17434adb82b0c2dff5f374f1.jpg, createdBy=c0225555986, createdName=@gxl, createdTime=Sat Jul 24 19:44:00 CST 2021, time=2021-07-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1036757, encodeId=f5f91036e5701, content=顶刊就是顶刊,谢谢梅斯带来这么高水平的研究报道,我们科里同事经常看梅斯,分享梅斯上的信息, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=旺医, createdTime=Sat Jul 24 08:12:02 CST 2021, time=2021-07-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1046096, encodeId=407710460962b, content=中风是俗称,应该称为缺血性卒中吧, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=guging, createdTime=Sat Jul 24 08:12:02 CST 2021, time=2021-07-24, status=1, ipAttribution=)]
  6. [GetPortalCommentsPageByObjectIdResponse(id=1706180, encodeId=e3fb1e061807f, content=<a href='/topic/show?id=7f6443986ec' target=_blank style='color:#2F92EE;'>#大血管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=43986, encryptionId=7f6443986ec, topicName=大血管)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=caff31165455, createdName=kkunny, createdTime=Tue Oct 26 21:12:02 CST 2021, time=2021-10-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2001428, encodeId=54f220014282c, content=<a href='/topic/show?id=d5df12695e6' target=_blank style='color:#2F92EE;'>#Neurol#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12695, encryptionId=d5df12695e6, topicName=Neurol)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8217292, createdName=yinhl1978, createdTime=Sun Aug 01 02:12:02 CST 2021, time=2021-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1681423, encodeId=b5aa1681423fc, content=<a href='/topic/show?id=366b8e2299e' target=_blank style='color:#2F92EE;'>#荟萃#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=87229, encryptionId=366b8e2299e, topicName=荟萃)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c12d27855367, createdName=venlin, createdTime=Sat Sep 25 16:12:02 CST 2021, time=2021-09-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1836982, encodeId=60cf183698283, content=<a href='/topic/show?id=1f188e230c5' target=_blank style='color:#2F92EE;'>#荟萃分析#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=87230, encryptionId=1f188e230c5, topicName=荟萃分析)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b79433, createdName=fangcong, createdTime=Sun May 29 17:12:02 CST 2022, time=2022-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1479092, encodeId=f4f314e9092a5, content=<a href='/topic/show?id=b97f3800ee0' target=_blank style='color:#2F92EE;'>#取栓#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=38007, encryptionId=b97f3800ee0, topicName=取栓)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=99077483919, createdName=1249862am74(暂无昵称), createdTime=Sun Jul 25 20:12:02 CST 2021, time=2021-07-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1002375, encodeId=28c510023e58c, content=非常受用, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210724/725901dc0ed249ebba9d096aacddde3f/a89b874e17434adb82b0c2dff5f374f1.jpg, createdBy=c0225555986, createdName=@gxl, createdTime=Sat Jul 24 19:44:00 CST 2021, time=2021-07-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1036757, encodeId=f5f91036e5701, content=顶刊就是顶刊,谢谢梅斯带来这么高水平的研究报道,我们科里同事经常看梅斯,分享梅斯上的信息, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=旺医, createdTime=Sat Jul 24 08:12:02 CST 2021, time=2021-07-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1046096, encodeId=407710460962b, content=中风是俗称,应该称为缺血性卒中吧, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=guging, createdTime=Sat Jul 24 08:12:02 CST 2021, time=2021-07-24, status=1, ipAttribution=)]
    2021-07-24 @gxl

    非常受用

    0

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    2021-07-24 旺医

    顶刊就是顶刊,谢谢梅斯带来这么高水平的研究报道,我们科里同事经常看梅斯,分享梅斯上的信息

    0

  8. [GetPortalCommentsPageByObjectIdResponse(id=1706180, encodeId=e3fb1e061807f, content=<a href='/topic/show?id=7f6443986ec' target=_blank style='color:#2F92EE;'>#大血管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=43986, encryptionId=7f6443986ec, topicName=大血管)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=caff31165455, createdName=kkunny, createdTime=Tue Oct 26 21:12:02 CST 2021, time=2021-10-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2001428, encodeId=54f220014282c, content=<a href='/topic/show?id=d5df12695e6' target=_blank style='color:#2F92EE;'>#Neurol#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12695, encryptionId=d5df12695e6, topicName=Neurol)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8217292, createdName=yinhl1978, createdTime=Sun Aug 01 02:12:02 CST 2021, time=2021-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1681423, encodeId=b5aa1681423fc, content=<a href='/topic/show?id=366b8e2299e' target=_blank style='color:#2F92EE;'>#荟萃#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=87229, encryptionId=366b8e2299e, topicName=荟萃)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c12d27855367, createdName=venlin, createdTime=Sat Sep 25 16:12:02 CST 2021, time=2021-09-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1836982, encodeId=60cf183698283, content=<a href='/topic/show?id=1f188e230c5' target=_blank style='color:#2F92EE;'>#荟萃分析#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=87230, encryptionId=1f188e230c5, topicName=荟萃分析)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b79433, createdName=fangcong, createdTime=Sun May 29 17:12:02 CST 2022, time=2022-05-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1479092, encodeId=f4f314e9092a5, content=<a href='/topic/show?id=b97f3800ee0' target=_blank style='color:#2F92EE;'>#取栓#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=38007, encryptionId=b97f3800ee0, topicName=取栓)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=99077483919, createdName=1249862am74(暂无昵称), createdTime=Sun Jul 25 20:12:02 CST 2021, time=2021-07-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1002375, encodeId=28c510023e58c, content=非常受用, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210724/725901dc0ed249ebba9d096aacddde3f/a89b874e17434adb82b0c2dff5f374f1.jpg, createdBy=c0225555986, createdName=@gxl, createdTime=Sat Jul 24 19:44:00 CST 2021, time=2021-07-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1036757, encodeId=f5f91036e5701, content=顶刊就是顶刊,谢谢梅斯带来这么高水平的研究报道,我们科里同事经常看梅斯,分享梅斯上的信息, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=旺医, createdTime=Sat Jul 24 08:12:02 CST 2021, time=2021-07-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1046096, encodeId=407710460962b, content=中风是俗称,应该称为缺血性卒中吧, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=guging, createdTime=Sat Jul 24 08:12:02 CST 2021, time=2021-07-24, status=1, ipAttribution=)]
    2021-07-24 guging

    中风是俗称,应该称为缺血性卒中吧

    0

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