作者没有致谢。

本议定书所述的程序计时、介入性特征和临床数据是从一个综合的观察数据库中获得的, 这是由地方道德委员会批准的 (核准号 4/11/08 和 15/7/13)。病人同意接受治疗是根据共同的临床指南;道德委员会放弃了关于在数据库中列入的单独同意的必要性。
1. 急诊室病人管理 (ER)-目标时间:10 分钟
注意: 以下步骤必须由中风神经学家执行。
<ol><li>
通知 neuroradiologist, 在病人到来之前, 有迹象提示有急性中风的患者。状态年龄和症状发作, 如果知道。
	<ol>
<li>此外, 通知麻醉师可能即将到来的 EVT (第一次呼叫)。</li>
		<li>有 neuroradiologist 通知介入 neuroradiologist 关于疑似即将到来的急性中风患者。</li>
	</ol>
</li>
	<li>在到达时对病人进行快速的临床评估, 包括根据 NIHSS 的功能损伤的量化。因此, 测试的意识水平, 视觉, 运动和感官功能, 语言和言语, 以及灭绝和漫不经心。</li>
	<li>同时, 让 ER 护士放置两个大的外周静脉导管, 并采取血液样本立即进行实验室分析。</li>
	<li>让 ER 护士将心电图、血压、血氧饱和流动监测系统与患者连接起来。</li>
	<li>
如果怀疑中风, 护送病人到血管造影套件 (方案 a) 或与血管造影套件 (场景 B) 相邻的 CT 成像部位, 视 NIHSS 评分和症状开始到入院的时间而定。
	<ol>
<li>带一个装有急救设备的背包和一套完整的静脉溶栓装置。包括90毫克 rtPA, 注射器, 静脉注射线, 和注射器泵在这一套。</li>
	</ol>
</li>
	<li>如果患者的临床情况与中风不一致, 根据各自的神经学准则治疗患者。</li>
</ol>2. 方案 A = NIHSS 7 或以上的诊断成像, 自症状发生以来已过6小时, 目标时间为成像:15 分钟
注意: 以下步骤必须由 neuroradiologist 执行。
<ol><li>让神经科医师直接护送病人到血管造影套件</li>
	<li>
将病人放在造影台上, 与神经学家和学技术员一起。
	<ol>
<li>将患者的头部置于 headholder, 使 orbitomeatal 线与旋转窗格平行。遮住眼睛, 用两条带子缠住头部以防止运动。</li>
	</ol>
</li>
	<li>
执行一个标准的二十年代非增强旋转 FDCT 和标准双相 FDCTA。
	<ol>
<li>使用下列参数对血管造影系统进行 FDCT: 二十年代旋转;200总角与 ~ 500 投射;109 kV;1.8 µGy/架;有效剂量〜 2.5 mSv。</li>
		<li>对于血管造影系统的 FDCTA, 在注射率为5毫升/秒的情况下, 静脉注射60毫升造影剂, 然后在5毫升/秒相同的注射速率下, 60 毫升盐水追逐。</li>
		<li>使用右臂的 antecubital 静脉以优化丸浓度。使用注入电源的注射器。</li>
		<li>使用以下规格的 FDCTA: 2 x 十年代轮换;200总角 (每帧 0.8°);70 kV;1.2 µGy/架;有效剂量〜 2.5 mSv。 注: 第一次旋转是定时的, 在一个弹丸观看数字减影血管造影, 以捕捉峰值动脉阶段, 而第二阶段是自动获取后, 5 s 相关的静脉阶段。原始数据自动转移和自动重建在一个商业可用的工作站。</li>
	</ol>
</li>
	<li>回顾所获得的图像与介入 neuroradiologist, 以排除颅内出血使用 FDCT 和检测 LVO 使用早期阶段的 FDCTA。使用 FDCTA 的晚期静脉期来评估其侧枝状态。</li>
	<li>在排除颅内出血和确认患者的资格后, 有神经学家开始静脉注射 rtPA (剂量: 0.9 毫克/千克, 注入超过60分钟, 10% 的总剂量作为初始丸)。 注: 从入院到开始 rtPA 治疗的总目标时间:20 分钟</li>
	<li>打电话给麻醉师 (第二次打电话), 确认即将到来的 EVT。</li>
	<li>将移动监控设备替换为在血管造影套件中存在的固定设备, 并立即开始准备 EVT, 如本协议步骤3所述 (参见步骤3。"EVT 的准备")。</li>
	<li>如果 FDCT 和 FDCTA 不符合急性缺血性中风, 症状维持, 病人有资格进行 mri 扫描, 让神经科医生护送病人到 mri 套件。进行 MRI 检查以进一步调查患者的神经状况。</li>
</ol>3. 方案 B = NIHSS 低于7和/或自症状发生以来超过6小时的诊断成像-目标时间:25 分钟
注意: 以下步骤必须由 neuroradiologist 执行。
<ol><li>让神经科医生护送病人到 CT 套房</li>
	<li>让学技术员在影像学现场的病人到达后立即进行非增强 CT 扫描。 注: 只有当 ct 不能或其他因素有利于 mri 扫描时, 你才能决定进行 mri 而不是 ct。</li>
	<li>快速阅读 CT 图像, 以排除颅内出血和大的分界梗塞。</li>
	<li>
排除两者后, 确认患者的资格。如果症状发生后少于4.5 小时, 有神经病学家开始静脉注射 rtPA (剂量: 0.9 毫克/千克, 注入超过60分钟, 10% 的总剂量作为初始丸)。
	<ol>
<li>当病人躺在 CT 桌上时, 给出初始的丸在现场。 注: 从入院到开始 rtPA 治疗的总目标时间:20 分钟</li>
	</ol>
</li>
	<li>让学技术员进行 CT 血管造影 (CTA) 和灌注 (CTP) 扫描。</li>
	<li>
完成 CTA 和 CTP 后, 评估患者是否符合 EVT。 注: 资格标准是: 存在 LVO 的 CTA 检测到缺乏混浊和没有一个大的分界梗塞确定使用艾伯塔省中风计划早期 ct 评分 (方面)12的非增强 ct. 方面的价值4及以下指示大梗塞分界。<ol>
<li>使用 CTP 来确定仍然可以组织的数量。为这个决心, 评估方面在脑血容量地图 (CBV);患者有资格 EVT 与 CBV 4 以上的方面。</li>
	</ol>
</li>
	<li>
如果病人有资格 EVT, 打电话给麻醉师, 确认即将到来的 EVT。
	<ol>
<li>让神经学家立即将病人转移到相邻的血管造影室, 病人定位在血管造影台上, 移动监控装置被在造影套件中出现的固定装置所取代。</li>
	</ol>
</li>
</ol>4. EVT 的制备-目标时间:10 分钟
注意: 以下步骤必须由 neuroradiologist 执行。
<ol><li>
与学技术员一起准备 EVT 的病人。
	<ol>
<li>让学技术员设置 EVT 所需的材料,即导管、冲洗输液、注射器、等
</li>
		<li>用皮肤防腐剂 (例如, kodan 酊) 和消毒的窗帘, 为病人的腹股沟进行剃须, 并为 EVT 提供无菌条件。</li>
	</ol>
</li>
	<li>
让麻醉师开始有意识的镇静: 用氯胺酮 (1 毫克/千克) 与异丙酚 (1 毫克/千克) 结合静脉注射, 并维持连续输注异丙酚 (1-2 毫克/千克/小时), 以确保足够的自发呼吸和病人合作. 注意: 有意识镇静是 EVT 的首选方法。<ol>
<li>如果有意识的镇静似乎不适当, 由于持续的躁动或病人的运动, 让麻醉师插管病人, 使 EVT 在全身麻醉下进行。<ol>
<li>静脉注射舒芬丸 (0.2-0.4 µg/千克) 和异丙酚丸 (1.5-2 毫克/千克)。使用罗库 (0.6 毫克/千克) 的肌肉松弛改善插管条件。如有必要, 保持全身麻醉与七氟醚 (0.5-1.5 MAC) 和额外的重复舒芬 (0.2-0.5 µg/千克)。为了便于插管, 将血管造影表摇摆到通气机上。</li>
		</ol>
</li>
	</ol>
</li>
</ol>5. EVT 的表现
注意: 以下步骤必须由介入 neuroradiologist。
<ol><li>用18克穿刺针刺穿腹股沟的右股动脉, 并引入外周8F 引导鞘。然后开始 EVT;从患者入院到腹股沟穿刺的总目标时间为方案 a 和方案 B 中的45分钟30分钟。</li>
	<li>
执行 EVT。
	<ol>
<li>选择支架式检索器辅助真空锁定提取 (保存)13技术作为主要处理方法。如有需要, 可根据个别情况调整程序。在串联闭塞的情况下, 使用 ReWiSed 护理技术同时栓颅内病变和治疗颈椎狭窄14。</li>
	</ol>
</li>
	<li>让麻醉师在整个手术过程中密切监测病人的生命体征。特别是, 让麻醉师立即采取行动, 以防止低血压。</li>
	<li>在控制血管造影证实了成功的再灌注后, 定义为脑梗塞 (mTICI) 评分为 2b-3 的改良溶栓, 进行了平板探测器造影 CT 检查. 阅读图像, 以排除治疗的并发症,例如颅内出血。</li>
	<li>取出所有的材料, 在腹股沟处包扎伤口。使用血管闭合装置闭合并封闭股动脉的穿刺。</li>
</ol>6. 后 EVT 程序和后续
注意: 以下步骤必须由 neuroradiologist 执行。
<ol><li>卸下所有窗帘, 将病人放在床上, 并让病人准备好运送到重症监护病房 (ICU) 或卒中单位与学技术员一起。</li>
	<li>让麻醉师护送病人到 ICU 或卒中单位, 在那里病人根据神经系统的指导方针治疗。</li>
	<li>在24小时后或在患者临床病情恶化后进行随访非增强 CT。</li>
	<li>所有临床数据, 成像评分, 并取得的时间是前瞻记录在一个全面的数据库批准的地方伦理委员会。</li>
</ol>

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R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Latest+generation+of+flat+detector+CT+as+a+peri-interventional+diagnostic+tool:+a+comparative+study+with+multidetector+CT.">Latest generation of flat detector CT as a peri-interventional diagnostic tool: a comparative study with multidetector CT.</a> J Neurointerv Surg. , (2016).</li><li>Eckert, M., G&#246;litz, P., L&#252;cking, H., Struffert, T., Knossalla, F., Doerfler, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Optimized+Flat-Detector+CT+in+Stroke+Imaging:+Ready+for+First-Line+Use?.">Optimized Flat-Detector CT in Stroke Imaging: Ready for First-Line Use?.</a> Cerebrovasc Dis. 43 (1-2), 9-16 (2017).</li><li>Khatri, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Time+to+angiographic+reperfusion+and+clinical+outcome+after+acute+ischaemic+stroke:+an+analysis+of+data+from+the+Interventional+Management+of+Stroke+(IMS+III)+phase+3+trial.">Time to angiographic reperfusion and clinical outcome after acute ischaemic stroke: an analysis of data from the Interventional Management of Stroke (IMS III) phase 3 trial.</a> The Lancet. Neurology. 13 (6), 567-574 (2014).</li><li>Jovin, T. G., Albers, G. W., Liebeskind, D. S., STAIR IX Consortium, <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stroke+Treatment+Academic+Industry+Roundtable:+The+Next+Generation+of+Endovascular+Trials.">Stroke Treatment Academic Industry Roundtable: The Next Generation of Endovascular Trials.</a> Stroke. 47 (10), 2656-2665 (2016).</li><li>McTaggart, R. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Initial+hospital+management+of+patients+with+emergent+large+vessel+occlusion+(ELVO):+report+of+the+standards+and+guidelines+committee+of+the+Society+of+NeuroInterventional+Surgery.">Initial hospital management of patients with emergent large vessel occlusion (ELVO): report of the standards and guidelines committee of the Society of NeuroInterventional Surgery.</a> J Neurointerv Surg. 9 (3), 316-323 (2017).</li></ol>

神经大学医学研究所与西门子医疗机构有研究协议。m. Psychogios 和 m. Knauth 已收到西门子医疗保健的旅费赠款。

该协议有效地简化了急性缺血性中风患者的管理, 从而大大缩短了治疗时间。跨学科的团队合作和沟通是这个过程成功的关键。定期的团队会议, 包括对已完成的过程时间的审查, 以及对问题和潜在解决方案的讨论都很重要。所有 neuroradiologists、技术员、神经科医师、麻醉和护士都必须定期接受培训, 以保持良好的表现。定期的会议和培训也应侧重于保持对迅速再灌注的重要性的认识。可以想象, 增加的紧迫感也可能影响 EVT 本身, 因为在执行 SOP 的第一个版本之后, EVT 的持续时间较短, 独立于使用8的设备。潜在的是, 对快速再灌注对临床结果的重要性的认识的提高促使所有参与 EVT 的工作人员更快地执行必要的步骤。然而, 提高认识的效果难以衡量。
初步成像模式用于检测早期缺血性变化和排除颅内出血在拟议的议定书分别是, FDCT 和常规 CT. FDCTA 和 CTA 分别用于识别 LVO 和评估抵押品地位。但是, 该协议可以修改, 使不符合一站式管理方法的患者接受脑 MRI 扫描诊断。除此之外, 一站式管理方法的 6 h 值可以扩展到未来。初步结果从 "扩散加权成像 (DWI) 或计算机断层扫描灌注 (CTP) 评估与临床不匹配的诊断和晚呈现中风的 Neurointervention" (黎明) 试验19建议选择中风患者可以受益于 EVT, 即使他们被送入医院超过6小时后症状发作20。结果从目前正在进行的 "血管内治疗后, 缺血性中风 3" (缓解 3) 试验, 调查 EVT 执行的病人中风后 6–16 h, 可以提供进一步的洞察这个问题。
SOP 设计为一个全面的中风中心配备了最新的新一代血管造影系统, 允许高质量的 FDCT 成像和 EVT。没有执行 EVT 能力的主笔划中心可以按照方案 B 的规定遵循协议。如果颅内出血已被排除在常规非增强 CT, rtPA 的管理应开始在初级中风中心。然后, 病人应转移到一个全面的中风中心立即在持续的 rtPA 治疗 ("滴水和船") EVT。
建议的协议有一些局限性。首先, 在实施一站式管理的方法时, 需要对出血性卒中的 FDCT 进行可靠的排除。在过去, 不准确的检测颅内出血是最大的障碍, 使用 FDCT 中风诊断21,22。这一情况似乎得到改善, 当 FDCT 是执行与最新一代的血管造影系统23。Leyhe et al.不仅报告了检测颅内出血的高灵敏度和特异性, 而且还显示了幕地区的灰白色分化与最新一代 FDCT 的可行性24.然而, 由于束硬化伪影和 FDCT25的低软组织分辨率, FDCT 下出血或 perimesencephalic subarachnoidal 出血的可能性仍然有限。因此, 一个 neuroradiologist 的经验, 评估 FDCT 图像应仔细审查的图像, 没有颅内出血, 并最终清除病人 rtPA 治疗。考虑到这些方面, 建议的一站式管理仅限于配备了最新的新一代血管造影系统的医院, 以及在解释 FDCT 和 FDCTA 方面有经验的工作人员。否则, FDCT 和 FDCTA 的唯一使用, 以可靠排除出血和确定大动脉闭塞有误诊的风险。与传统 CTA 相比, FDCTA 的另一个局限性是它在较小程度上覆盖了颅外血管。当颅外颈动脉和颈动脉分支被覆盖, 并可以评估, 主动脉弓是不包括在目前, 但将在未来。我们观察到的再灌注时间的减少表明, 这个潜在的问题不会导致在干预期间出现任何重大的延误。最后, 该协议是根据我们医院的情况量身定做的, 可能在不同的环境下工作得不太好。不过, 我们认为类似的一站式方法, 可以在其他医院实施, 尽管有结构性差异。
快速再灌注对急性缺血性中风患者的预后至关重要。每隔30分钟延迟再灌注, 就能减少 10%26实现独立工作水平的可能性。最近的五项随机试验的 meta 分析显示, EVT 的好处表明, 较早的治疗与医疗治疗相比, 单独的6, EVT 加医疗治疗有更好的结果。因此, 中风治疗学术行业圆桌会议包括优化病人管理, 以减少时间从入院到再灌注作为一个优先事项, 未来的研究在 EVT27。此外, Neurointerventional 外科学会建议了中风过程的理想时间指标28。从入院到腹股沟穿刺的时间中位数与上面所述的修订 SOP 符合建议的 < 60 分钟的理想. 此外, 一站式管理的病人入院后的中位时间是主要在 < 90 分钟的理想。然而, 这一理想的过程时间是不满足的病人的初步方法, 包括常规 CT, CTA 和 CTP, 因为从入院到再灌注的中位时间是106分钟这个分组。
由于初步观察到从入院到再灌注的时间大大缩短, 而上述简化的议定书是有希望的, 因此目前正在计划进一步评估这一方法的更大的前瞻性试验。

EVT 是治疗急性缺血性中风患者的护理标准, LVO1,2,3,4,5。良好的侧枝状态和早期恢复血流在受影响的脑区确定临床结局在这些患者中6,7。因此, 重要的是要避免任何延误的治疗。从症状开始到入院的时间取决于每个病人的个别情况, 几乎不能受治疗中风医生的影响。因此, 所有医院固有的潜在治疗-延迟因素应小心避免。为此, 我们的医院在2014年2月开发了一个跨学科 SOP, 它简化了从病人入院到 EVT8的过程。中风神经学家, 诊断以及介入 neuroradiologists, 和麻醉建立了详细的工作流程和定义的每一个步骤的目标时间。实际取得的时间是前瞻记录与临床数据和成像评分的所有瘤治疗中风患者在一个全面的数据库批准的地方伦理委员会。这些数据在跨学科小组会议上定期进行分析和讨论。对潜在问题进行了评估, 所有参与的工作人员都接受了遵守 SOP 的培训。
对记录数据的分析显示, 从病人入院到再灌注的时间明显缩短。此外, 对临床结局的有益影响也观察到了8。根据这些发现, 以及在充分利用诸如增强紧迫感和团队精神等措施的潜力之后, 我们无法进一步减少时间, 因此改进了 SOP, 通过结合成像技术, 进一步缩短住院时间和治疗在血管造影套件9。
这种精致的 SOP 于2016年生效。有疑似中风的患者, 症状持续时间少于6小时, 并有显著的功能损害, 确定有7或更多点的国家卫生研究院中风规模 (NIHSS), 并接受这一停止管理的方法。之所以选择这个7点的切除值, 是因为最近的一份出版物确定了 NIHSS 分数7作为 LVO10的最佳预测器。符合上述标准的患者直接转移到造影套件, 在那里, 平板探测器 CT (FDCT) 是用来描述急性缺血性症状和排除颅内出血。进行双相 FDCT 血管造影 (FDCTA), 以确定 LVO。然后, 重组组织型纤溶酶原激活剂 (rtPA) 是静脉注射在符合条件的病人和 EVT 是执行后, 立即评估后的图像在同一房间。
初步数据显示, 比起其他研究建议简化的患者管理11, 从入院到再灌注的时间有了进一步的显著减少。不符合一站式管理方法所需的标准的患者,即症状发生后的较轻程度 (NIHSS 低于 7) 和/或超过6小时, 将按照初始例程 (包括诊断成像) 进行管理常规多探头 ct、ct 血管造影 (CTA) 和 ct 灌注 (CTP)。
在此, 详细介绍了快速治疗急性缺血性中风患者的跨学科优化工作流程。该协议是量身定做的一个全面的中风中心配备了最新的新一代血管造影系统。

<table><tbody><tr><td>Actilyse (recombinant tissue plasminogen activator)</td><td>Boehringer Ingelheim, Ingelheim am Rhein, Germany</td><td>n/a</td><td>generic products from other pharmaceutical companies can be used</td></tr><tr><td>Imeron 400 (contrast agent)</td><td>Bracco Imaging GmbH, Konstanz, Germany</td><td>n/a</td><td>generic products from other companies can be used</td></tr><tr><td>Siemens ArtisQ angiography system</td><td>Siemens Healthcare, Forchheim, Germany</td><td>n/a</td><td>an angiography system of another manufacturer can be used; specifications of FDCT and FDCTA described in protocol are valid for ArtisQ&amp;nbsp;</td></tr><tr><td>Siemens syngo X worklplace</td><td>Siemens Healthcare, Forchheim, Germany</td><td>n/a</td><td>a workstation from another manufacturer can be used</td></tr><tr><td>ketamine (e.g. Ketanest)</td><td>Pfizer Pharma PFE GmbH, Berlin, Germany</td><td>n/a</td><td>generic products from other pharmaceutical companies can be used</td></tr><tr><td>propofol (e.g. Propofol-Lipuro)</td><td>B. Braun Melsungen AG, Melsungen, Germany</td><td>n/a</td><td>generic products from other pharmaceutical companies can be used</td></tr><tr><td>sufentanil (e.g. Sufenta)</td><td>Janssen-Cilag GmbH, Neuss, Germany</td><td>n/a</td><td>generic products from other pharmaceutical companies can be used</td></tr><tr><td>rocuroniumbromid</td><td>B. Braun Melsungen AG, Melsungen, Germany</td><td>n/a</td><td>generic products from other pharmaceutical companies can be used</td></tr><tr><td>sevoflurane (e.g. Sevofluran)</td><td>Baxter Deutschland GmbH Medication Delivery, Unterschleissheim, Germany</td><td>n/a</td><td>generic products from other pharmaceutical companies can be used</td></tr><tr><td>vascular closure device (e.g. Angio-Seal)</td><td>Terumo Interventional Systems, Eschborn, Germany</td><td>n/a</td><td>generic products from other companies can be used</td></tr><tr><td>peripheral 8F guiding sheath</td><td>Terumo Interventional Systems, Eschborn, Germany</td><td>n/a</td><td>generic products from other companies can be used</td></tr><tr><td>skin antiseptic (e.g. kodan tincture forte, coloured)</td><td>Schuelke &amp;amp; Mayr GmbH, Norderstedt, Germany</td><td>n/a</td><td>generic products from other companies can be used</td></tr><tr><td>18 G intradyn puncture needle</td><td>B. Braun Melsungen AG, Melsungen, Germany</td><td>n/a</td><td>generic products from other companies can be used</td></tr></tbody></table>

optimized management of endovascular treatment for acute ischemic stroke

这篇手稿描述了一个简化的治疗急性缺血性中风患者的协议, 其目的是尽量减少住院时间再灌注。脑血流的快速恢复对于急性缺血性中风患者的预后至关重要。血管内治疗 (EVT) 已成为护理的标准, 以完成这一急性中风患者由于大血管闭塞 (LVO)。为了尽快实现缺血性脑区的再灌注, 所有住院时间延误都必须小心避免。因此, 对急性缺血性脑卒中患者的管理进行了优化, 采用了多学科标准操作程序 (SOP)。中风神经学家, 诊断以及介入 neuroradiologists, 麻醉简化所有必要的过程从病人入院和诊断到 EVT 的合格患者。每个步骤的目标时间都已确定。实际取得的时间是前瞻记录与临床数据和成像评分的所有瘤治疗中风患者。这些数据在跨学科小组会议上定期进行分析和讨论。对潜在问题进行了评估, 所有参与的工作人员都接受了遵守 SOP 的培训。这种简化的病人管理方法和加强的跨学科协作减少了病人入院到再灌注的时间, 并伴有对临床结果的有益影响。

对急性缺血性中风患者的简化管理如上文所述并在图 1中显示, 伴随着我院围手术期的改善。从入院到腹股沟穿刺的平均时间减少了约半小时, 比较前一年的实施后的第一版 SOP (94 分钟在2013年和65分钟在 2014年)。修订 SOP, 包括2016年实施的一站式管理方法, 进一步减少了从入场到腹股沟穿刺的中位时间 (2014年为65分钟, 2016年45分钟;图 2)。对那些接受过 EVT 治疗的患者采用一站式方法 (方案 A) 对那些在最初的方法 (包括常规的 CT 成像 (类似于场景 B) 后被瘤处理的病人进行比较, 显示中位时间从如果患者直接转移到血管造影套件 (场景 a 和场景 B 中的20.5 分钟,表 1), 则腹股沟穿刺的入场量减少了一半以上。此外, 当采用一站式管理方法时, 从入院到再灌注的总时间明显缩短 (方案 a 和方案 B 中的65分钟,表 1)。
正如预期的那样, sop 对从症状开始到入院的时间没有影响 (sop 实施后77分钟和80分钟), 因为治疗中风的团队不能影响这一时期。分析和比较了在入院前和治疗后再灌注的个体步骤的实现时间 (图 2)。较快的影像供应 (平均入院时间和影像31分钟前, 19 分钟后的初始, 9.5 分钟后修订 SOP), 特别是迅速转移的病人有资格 EVT 到血管造影套件贡献最在初始化和 SOP 的修订版本 (图 2) 执行后观察到的减少时间的方法。EVT 本身的持续时间也较短, 在2014年初 sop 的介绍 (中位数58分钟之前, 和42分钟后实施初步 sop)。这与 EVT8期间使用的设备无关。经修订的 SOP 生效后, 从腹股沟穿刺到再灌注的时间没有改变 (图 2)。在2014年实施 SOP 的第一版后, 患者的功能效果明显好转 (数据已在别处详细公布)8。无论是增加的病人没有残留功能损害, 确定了一个值为0的修改排名比额表 (mRS) (1.5% 之前和9.1% 后, SOP), 以及普遍转向较低程度的残障后观察工作流优化 (有序逻辑回归分析: 或 0.56; 95% CI 0.32-0. 98;p = 0.038)8。
即使7点或以上的 NIHSS 评分提供了 LVO10存在的粗略估计, 患者的症状也可以明显来源于其他病症。对前30名患者进行的一站式治疗的观察分析提供了一个迹象表明, 除了缺血性中风, 由于 LVO 在 FDCT 和 FDCTA 的结果的频率。在 13% (4/30) 患者中发现了颅内出血, 在 7% (2/30) 患者中有一个外周血管闭塞。另外 13% (4/30) 的病人既没有出血, 血管闭塞, 也没有其他病症, 并被诊断为托德的麻痹15。
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/56397/56397fig1.jpg"> 图 1: 方案 A 和方案 B 的时间轴.当一个疑似急性中风患者被送往医院时, 这些时间线提供了所执行步骤的概览。地点由更大的箱子指示, 并且对每个步主要责任的人在底部被表明。更小的入的箱子列出行动重要在每个步。详细信息可以在协议中找到。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56397/56397fig1large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/56397/56397fig2.jpg"> 图 2: 流程优化所达到的代表性的围程序时间.中位数 (分钟) 为个别步骤之间的症状开始和再灌注前和后介绍的初步以及修订 SOP 显示。误差线表示分范围。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56397/56397fig2large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always"><tbody>
<tr>
<td></td>
			<td>腹股沟门 (分钟)</td>
			<td></td>
			<td colspan="2">再灌注门 (分钟)</td>
		</tr>
<tr>
<td></td>
			<td>一站式方法 (方案 A)</td>
			<td>常规方法 (类似于场景 B)</td>
			<td>一站式方法 (方案 A)</td>
			<td>常规方法 (类似于场景 B)</td>
		</tr>
<tr>
<td>n</td>
			<td>30</td>
			<td>44</td>
			<td>30</td>
			<td>44</td>
		</tr>
<tr>
<td>中</td>
			<td>20。5</td>
			<td>54。5</td>
			<td>65</td>
			<td>106</td>
		</tr>
<tr>
<td>iqr</td>
			<td>17–27</td>
			<td>44–66</td>
			<td>53–96。5</td>
			<td>88.5–121。5</td>
		</tr>
<tr>
<td>p-值</td>
			<td colspan="2">< 0.001</td>
			<td colspan="2">< 0.001</td>
		</tr>
</tbody></table>表 1: 2016年从入院到腹股沟穿刺再灌注的中位时间.方案 a 由一站式管理方法组成, 其中符合资格的患者 (严重症状, NIHSS 评分7及以上, 并入院6小时内症状发作) 直接转移到血管造影套件。成像和 EVT 在同一个地方执行。这些患者与其他匹配 (关于 NIHSS, 症状-门时间, 血管造影套件的可用性) 的病人, 是管理后的工作流程实施的第一版 SOP。此管理类似于场景 B, 包括非增强 CT、CTA 和 CTP 的诊断成像。IQR, 分范围。统计的重要性被测试了以曼-惠特尼 U 测试和意义水平被设置了α = 0.05。

Watch this Scientific Journal Video about Optimized Management of Endovascular Treatment for Acute Ischemic Stroke at JoVE.com

Optimized Management of Endovascular Treatment for Acute Ischemic Stroke

急性缺血性中风血管内治疗的优化管理

急性缺血性脑卒中患者的预后取决于脑血流的快速恢复。本议定书的目的是通过尽量缩短围手术期的时间, 并使医院入院时尽可能短, 以优化对这些病人的管理。

This manuscript describes a streamlined protocol for the management of patients with acute ischemic stroke, which aims at the minimization of time from ...

optimized-management-endovascular-treatment-for-acute-ischemic

Nanyang Technological University

Research

JoVE Journal

Neuroscience

11.8K 次观看.  University Medical Center Goettingen. 急性缺血性脑卒中患者的预后取决于脑血流的快速恢复。本议定书的目的是通过尽量缩短围手术期的时间, 并使医院入院时尽可能短, 以优化对这些病人的管理。

视频: Optimized Management of Endovascular Treatment for Acute Ischemic Stroke

Prehospital Thrombolysis: A Manual from Berlin

In acute ischemic stroke, time from symptom onset to intervention is a decisive prognostic factor. In order to reduce this time, prehospital thrombolysis at the emergency site would be preferable. However, apart from neurological expertise and laboratory investigations a computed tomography (CT) scan is necessary to exclude hemorrhagic stroke prior to thrombolysis. Therefore, a specialized ambulance equipped with a CT scanner and point-of-care laboratory was designed and constructed. Further, a new stroke identifying interview algorithm was developed and implemented in the Berlin emergency medical services. Since February 2011 the identification of suspected stroke in the dispatch center of the Berlin Fire Brigade prompts the deployment of this ambulance, a stroke emergency mobile (STEMO). On arrival, a neurologist, experienced in stroke care and with additional training in emergency medicine, takes a neurological examination. If stroke is suspected a CT scan excludes intracranial hemorrhage. The CT-scans are telemetrically transmitted to the neuroradiologist on-call. If coagulation status of the patient is normal and patient&#39;s medical history reveals no contraindication, prehospital thrombolysis is applied according to current guidelines (intravenous recombinant tissue plasminogen activator, iv rtPA, alteplase, Actilyse).
Thereafter patients are transported to the nearest hospital with a certified stroke unit for further treatment and assessment of strokeaetiology. After a pilot-phase, weeks were randomized into blocks either with or without STEMO care. Primary end-point of this study is time from alarm to the initiation of thrombolysis. We hypothesized that alarm-to-treatment time can be reduced by at least 20 min compared to regular care.

Identification of suspected stroke in the dispatch center of the Berlin Fire Brigade prompts the deployment of a CT-equipped ambulance. If ischemic stroke is confirmed and contraindications are excluded prehospital thrombolysis is applied.

院前溶栓治疗:从柏林手册

In acute ischemic stroke, time from symptom onset to intervention is a decisive prognostic factor. In order to reduce this time, prehospital thrombolysis ...

科研

医学

A Thrombotic Stroke Model Based On Transient Cerebral Hypoxia-ischemia

Stroke research has endured many setbacks in translating neuroprotective therapies into clinical practice. In contrast, the real-world therapy (tPA thrombolysis) rarely produces benefits in mechanical occlusion-based experimental models, which dominate preclinical stroke research. This split between the bench and bedside suggests the need to employ tPA-responsive models in preclinical stroke research. To this end, a simple and tPA-reactive thrombotic stroke model is invented and described here. This model consists of transient occlusion of the unilateral common carotid artery and delivery of 7.5% oxygen through a face mask in adult mice for 30 min, while maintaining the animal rectal temperature at 37.5 &#177; 0.5 &#176;C. Although reversible ligation of the unilateral carotid artery or hypoxia each suppressed cerebral blood flow only transiently, the combination of both insults caused lasting reperfusion deficits, fibrin and platelet deposition, and large infarct in the middle cerebral artery-supplied territory. Importantly, tail-vein injection of recombinant tPA at 0.5, 1, or 4 hr post-tHI (10 mg/kg) provided time-dependent reduction of the mortality rate and infarct size. This new stroke model is simple and can be standardized across laboratories to compare experimental results. Further, it induces thrombosis without craniectomy or introducing pre-formed emboli. Given these unique merits, the tHI model is a useful addition to the repertoire of preclinical stroke research.

Thromboembolic stroke models are vital tools for optimizing the recanalization therapy. Here we report a murine thrombotic stroke model based on transient cerebral hypoxic-ischemic (tHI) insult, which triggers thrombosis and infarction, and responds favorably to tissue plasminogen activator (tPA)-mediated fibrinolysis in a therapeutic window similar to those in stroke patients.

基于短暂性脑缺氧缺血性血栓性中风模型

Stroke research has endured many setbacks in translating neuroprotective therapies into clinical practice. In contrast, the real-world therapy (tPA ...

Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations

Arteriovenious malformations (AVMs) are associated with significant morbidity and mortality, and have a rupture risk of ~3% per year. Treatment of AVMs must be tailored specifically to the lesion, with surgical resection being the gold standard for small, accessible lesions. Pre-operative embolization of AVMs can reduce nidal blood flow and remove high-risk AVM features such as intranidal or venous aneurysms, thereby simplifying a challenging neurosurgical procedure. Herein, we describe our approach for the staged endovascular embolization and open resection of AVMs, and highlight the advantages of having a comprehensively trained neurovascular surgeon leading a multi-disciplinary clinical team. This includes planning the craniotomy and resection to immediately follow the final embolization stage, thereby using a single session of anesthesia for aggressive embolization, and rapid resection. Finally, we provide a representative case of a 22-year-old female with an unruptured right frontal AVM diagnosed during a seizure workup, who was successfully treated via staged embolizations followed by open surgical resection.

Surgery is the gold standard for accessible arteriovenious malformations (AVMs), and pre-operative embolization can simplify this procedure. We describe our approach for staged endovascular embolization and open resection of AVMs, and provide a representative clinical example highlighting the advantages of a comprehensively trained neurovascular surgeon leading a multi-disciplinary clinical team.

脑动静脉畸形的综合血管内和开放性手术治疗

Arteriovenious malformations (AVMs) are associated with significant morbidity and mortality, and have a rupture risk of ~3% per year. Treatment of AVMs ...

神经科学

Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide

Time is of the essence when caring for an acute stroke patient. The ultimate goal is to restore blood flow to the ischemic brain. This can be&#160;achieved by either&#160;thrombolysis with recombinant tissue-plasminogen activator (rt-PA), the standard therapy for stroke patients who present within the first hours of symptom onset without contraindications, or by an endovascular approach, if a proximal brain vessel occlusion is detected. As the efficacy of both therapies declines over time, every minute saved along the way will improve the patient&#39;s outcome.
This critical situation requires thorough work and precise communication with the patient, the family and colleagues from different professions to acquire all relevant information and reach the right decision while carefully monitoring the patient. This is a high fidelity situation. In nonmedical high-fidelity environments such as aviation, Crew Resource Management (CRM) is used to enhance safety and team efficiency.
This guide shows how a Stroke Team algorithm, which is transferable to other hospital settings, was established and how regular simulation-based trainings were performed. It requires determination and endurance to maintain these time-consuming simulation trainings on a regular basis over the course of time. However, the resulting improvement of team spirit and excellent door-to-needle times will benefit both the patients and the work environment in any hospital.
A dedicated Stroke Team of 7 persons who are notified 24/7 by a collective call via speed dial and run a binding algorithm that takes approximately 20 min, was established. To train everybody involved in this algorithm, a simulation-based team training for all new Stroke Team members was conceived and conducted at monthly intervals. This led to a relevant and sustained reduction of the mean door-to-needle time to 25 min, and enhanced the feeling of stroke readiness especially in junior doctors and nurses.

Every min counts in acute stroke care. This guide shows how to establish a Stroke Team algorithm and enhance its performance with regular simulation training. The principles of Crew Resource Management (CRM) facilitate a straight workflow, reduce door-to-needle times and increase staff satisfaction.

建立中风病研究小组算法并进行急诊科基于仿真的培训 - 实用指南

Time is of the essence when caring for an acute stroke patient. The ultimate goal is to restore blood flow to the ischemic brain. This can ...

Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation

Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and poor functional outcomes, largely because there are no evidence-based treatment options for this devastating disease process. In the past decade, a number of minimally invasive surgeries have emerged to address this issue, one of which is endoscopic evacuation. Stereotactic ICH Underwater Blood Aspiration (SCUBA) is a novel endoscopic evacuation technique performed in a fluid-filled cavity using an aspiration system to provide an additional degree of freedom during the procedure. The SCUBA procedure utilizes a suction device, endoscope, and sheath and is divided into two phases. The first phase involves maximal aspiration and minimal irrigation to decrease clot burden. The second phase involves increasing irrigation for visibility, decreasing aspiration strength for targeted aspiration without disturbing the cavity wall, and cauterizing any bleeding vessels. Using the endoscope and aspiration wand, this technique aims to maximize hematoma evacuation while minimizing collateral damage to the surrounding brain. Advantages of the SCUBA technique include the use of a low-profile endoscopic sheath minimizing brain disruption and improved visualization with a fluid-filled cavity rather than an air-filled one.

This paper details the surgical protocol for minimally invasive endoscopic intracerebral hemorrhage evacuation using the SCUBA technique.

微创内窥镜内腹出血疏散

Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and poor functional outcomes, largely because there are no evidence-based ...

Simulator Training for Endovascular Neurosurgery

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk environments. In the field of endovascular neurosurgery, the demand for consequence- and risk-free learning environments led to the development of simulation devices valuable for medical trainees. The goal of this protocol is to provide instructive guidelines for the use of an endovascular neurosurgery simulator in an academic setting. The simulator provides trainees with the opportunity to receive realistic feedback on their knowledge of anatomy, as well as haptic feedback indicative of their success in handling the catheter-based systems without negative consequences. The utility of this specific protocol in relation to other neuroendovascular training modalities is also discussed.

Simulation of complex, high-risk procedures is critical to the education of medical trainees. A protocol for simulator-based endovascular neurosurgery training in a controlled academic environment is described. The protocol includes stepwise guidelines for trainees of varying levels, with a discussion of the advantages and limitations of this model.

血管内神经外科模拟器培训

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk ...

A Fibrin-Enriched and tPA-Sensitive Photothrombotic Stroke Model

An ideal thromboembolic stroke model requires certain properties, including relatively simple surgical procedures with low mortality, a consistent infarction size and location, precipitation of platelet:fibrin intermixed blood clots similar to those in patients, and an adequate sensitivity to fibrinolytic treatment. The rose bengal (RB) dye-based photothrombotic stroke model meets the first two requirements but is highly refractory to tPA-mediated lytic treatment, presumably due to its platelet-rich, but fibrin-poor clot composition. We reason that combination of RB dye (50 mg/kg) and a sub-thrombotic dose of thrombin (80 U/kg) for photoactivation aimed at the proximal branch of middle cerebral artery (MCA) may produce fibrin-enriched and tPA-sensitive clots. Indeed, the thrombin and RB (T+RB)-combined photothrombosis model triggered mixed platelet:fibrin blood clots, as shown by immunostaining and immunoblots, and maintained consistent infarct sizes and locations plus low mortality. Moreover, intravenous injection of tPA (Alteplase, 10 mg/kg) within 2 h post-photoactivation significantly decreased the infarct size in T+RB photothrombosis. Thus, the thrombin-enhanced photothrombotic stroke model may be a useful experimental model to test novel thrombolytic therapies.

Traditional photothrombotic stroke (PTS) models mainly induce dense platelet aggregates of a high resistance to tissue plasminogen activator (tPA)-lytic treatment. Here a modified murine PTS model is introduced by co-injecting thrombin and photosensitive dye for photoactivation. The thrombin-enhanced PTS model produces mixed platelet:fibrin clots and is highly sensitive to tPA-thrombolysis.

纤维蛋白富集和 tPA 敏感的光血栓形成卒中模型

An ideal thromboembolic stroke model requires certain properties, including relatively simple surgical procedures with low mortality, a consistent ...

A Model for Encephalomyosynangiosis Treatment after Middle Cerebral Artery Occlusion-Induced Stroke in Mice

There is no effective treatment available for most patients suffering with ischemic stroke, making development of novel therapeutics imperative. The brain's ability to self-heal after ischemic stroke is limited by inadequate blood supply in the impacted area. Encephalomyosynangiosis (EMS) is a neurosurgical procedure that achieves angiogenesis in patients with moyamoya disease. It involves craniotomy with placement of a vascular temporalis muscle graft on the ischemic brain surface. EMS has never been studied in the setting of acute ischemic stroke in mice. The hypothesis driving this study is that EMS enhances cerebral angiogenesis at the cortical surface surrounding the muscle graft. The protocol shown here describes the procedure and provides initial data supporting the feasibility and efficacy of the EMS approach. In this protocol, after 60 min of transient middle cerebral artery occlusion (MCAo), mice were randomized to either MCAo or MCAo + EMS treatment. The EMS was performed 3-4 h after occlusion. The mice were sacrificed 7 or 21 days after MCAo or MCAo + EMS treatment. Temporalis graft viability was measured using nicotinamide adenine dinucleotide reduced-tetrazolium reductase assay. A mouse angiogenesis array quantified angiogenic and neuromodulating protein expression. Immunohistochemistry was used to visualize graft bonding with brain cortex and change in vessel density. The preliminary data here suggest that grafted muscle remained viable 21 days after EMS. Immunostaining showed successful graft implantation and increase in vessel density near the muscle graft, indicating increased angiogenesis. Data show that EMS increases fibroblast growth factor (FGF) and decreases osteopontin levels after stroke. Additionally, EMS after stroke did not increase mortality suggesting that protocol is safe and reliable. This novel procedure is effective and well-tolerated and has the potential to provide information of novel interventions for enhanced angiogenesis after acute ischemic stroke.

The protocol aims to provide methods for encephalomyosynangiosis-grafting of a vascular temporalis muscle flap on the pial surface of ischemic brain tissue-for the treatment of non-moyamoya acute ischemic stroke. The approach's efficacy in increasing angiogenesis is evaluated using a transient middle cerebral artery occlusion model in mice.

小鼠脑中动脉闭塞诱导脑卒中后脑肌粘连血管病治疗模型

There is no effective treatment available for most patients suffering with ischemic stroke, making development of novel therapeutics imperative. The ...

远端中动脉闭塞开发缺血性卒中小鼠模型

Induction of Acute Ischemic Stroke in Mice Using the Distal Middle Artery Occlusion Technique

Ischemic stroke remains the predominant cause of mortality and functional impairment among the adult populations globally. Only a minority of ischemic stroke patients are eligible to receive intravascular thrombolysis or mechanical thrombectomy therapy within the optimal time window. Among those stroke survivors, around two-thirds suffer neurological dysfunctions over an extended period. Establishing a stable and repeatable experimental ischemic stroke model is extremely significant for further investigating the pathophysiological mechanisms and developing effective therapeutic strategies for ischemic stroke. The middle cerebral artery (MCA) represents the predominant location of ischemic stroke in humans, with the MCA occlusion serving as the frequently employed model of focal cerebral ischemia. In this protocol, we describe the methodology of establishing the distal MCA occlusion (dMCAO) model through transcranial electrocoagulation in C57BL/6 mice. Since the occlusion site is located at the cortical branch of MCA, this model generates a moderate infarcted lesion restricted to the cortex. Neurological behavioral and histopathological characterization have demonstrated visible motor dysfunction, neuron degeneration, and pronounced activation of microglia and astrocytes in this model. Thus, this dMCAO mouse model provides a valuable tool for investigating the ischemiastroke and worth of popularization.

作者聚焦：在小鼠中建立可靠的远端 MCA 闭塞模型用于中风研究

Here, we present a protocol to establish a distal middle cerebral artery occlusion (dMCAO) model through transcranial electrocoagulation in C57BL/6J mice and evaluate the subsequent neurological behavior and histopathological features.

使用远端中动脉闭塞技术诱导小鼠急性缺血性卒中

Ischemic stroke remains the predominant cause of mortality and functional impairment among the adult populations globally. Only a minority of ischemic ...

急性缺血性中风血管内治疗的优化管理

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此视频中的章节

院前溶栓治疗:从柏林手册

基于短暂性脑缺氧缺血性血栓性中风模型

脑动静脉畸形的综合血管内和开放性手术治疗

建立中风病研究小组算法并进行急诊科基于仿真的培训 - 实用指南

微创内窥镜内腹出血疏散

血管内神经外科模拟器培训

纤维蛋白富集和 tPA 敏感的光血栓形成卒中模型

小鼠脑中动脉闭塞诱导脑卒中后脑肌粘连血管病治疗模型

使用远端中动脉闭塞技术诱导小鼠急性缺血性卒中

使用远端中动脉闭塞技术诱导小鼠急性缺血性卒中