Chinese Journal of Stroke

A Relay Race

WANG Yong-Jun

2018, 13(02): 99-101. DOI: 10.3969/j.issn.1673-5765.2018.02.001

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Accelerating Construction of Regional Stroke Rescue Network

ZHANG Yu-Sheng, XU An-Ding

2018, 13(02): 102-105. DOI: 10.3969/j.issn.1673-5765.2018.02.002

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The Impact of Prehospital Notification on Door-to-reperfusion Time and Clinical Outcome after Thrombectomy

ZHANG Sheng, SHI Zong-Jie, WANG Zhen, LIU Fang, CHEN Bo, ZHANG Ning-Yuan, XU Tian-Bo, GENG Yu

2018, 13(02): 106-113. DOI: 10.3969/j.issn.1673-5765.2018.02.003

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Objective To investigate the impact of prehospital notification (PN) on the door-to-reperfusion time (DRT) and outcome of patients who underwent thrombectomy. Methods A retrospective analysis was made upon clinical and imaging data of patients who underwent thrombectomy in Zhejiang Provincial People's Hospital from January 2015 to December 2016. PN was defined as a local hospital informing our stroke team prior to the transfer of thrombectomy candidates. The baseline characteristics, DRT and outcome between patients with and without PN were compared. Good outcome was defined as modified Rankin Scale score ≤3 at 3 months. Results A total of 123 patients underwent thrombectomy were enrolled, including 57 (46.3%) patients that was identified as PN group. Among patients who achieved reperfusion after thrombectomy (n =100), the DRT of PN group was significantly shorter than that of non-PN group (P <0.001). Implementing intravenous thrombolysis before thrombectomy [odds ratio (OR)=2.774, P =0.023] was an independent factor for good outcome, while PN was not (OR=2.586, P =0.058).Nevertheless, PN combined with preoperative intravenous thrombolysis was an independent factor for good outcome (OR =7.662, P =0.006).

Conclusion PN can shorten DRT. Patients who achieved reperfusion after thrombectomy could benefit from preoperative intravenous thrombolysis. PN combined with preoperative intravenous thrombolysis would increase the beneficial rate by 2.7 times.

Prehospital Notification Procedure Improves Endovascular Treatment Outcome in Patients with Acute Ischemic Stroke

ZHANG Mei-Xia, CHEN Zhi-Cai, ZHANG Rui-Ting, SHI Fei-Na, LOU Min

2018, 13(02): 114-121. DOI: 10.3969/j.issn.1673-5765.2018.02.004

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was strongly time-dependent. Emergency medical service (EMS) prehospital notification procedure (PNP) may reduce door to reperfusion time (DRT). This study was aimed to examine whether PNP by EMS providers could reduce DRT and improve neurological outcome in LVO patients who received EVT. Methods A retrospective analysis was made upon clinical and imaging data of LVO patients who received EVT and were enrolled consecutively. The effect of EMS with PNP (PNP group), EMS without PNP (Non-PNP group) and non-EMS group on DRT, and the subsequent neurological outcome were compared. Good outcome was defined as modified Rankin Scale (mRS) ≤2 at 3 month. The difference in DRT and clinical outcome were compared among PNP group, Non- PNP group and Non-EMS group. Results Finally, 110 patients were included (average age: 68±12 years, female: 49, 44.5%). Among which, 91 (82.7%) patients were transferred by EMS, of whom 21 (19.1%) patients were PNP. There was no difference in DRT between EMS without PNP group and non-EMS group (180 min vs 194 min, t =0.663, P =0.510), while EMS with PNP group tended to have shorter DRT than non- EMS group (145 min vs 194 min, t =2.260, P =0.055) and EMS with PNP group had shorter DRT than Non-PNP group (145 min vs 180 min, t =-2.065, P =0.043). Multivariate analysis showed that EMS with PNP was independently associated with good outcome after adjusting for hypertension, baseline systolic blood pressure and baseline National Institute of Health Stroke Scale (NIHSS) [odds ratio (OR) 3.653, 95% confidence interval (CI) 1.085-12.301, P =0.037]. When DRT was included in the regression model, DRT was independently associated with good outcome (OR=0.981, 95%CI 0.968-0.994, P =0.005). Conclusion PNP can improve neurological outcome by shortening door to reperfusion time in patients with endovascular treatment and improve the clinical outcome.

Regional Stroke Rescue Network Improves Clinical Outcome of Endovascular Treated Patients with Acute Ischemic Stroke

LIAO Yu, QIAO Hong-Yu, GUAN Min, YANG Bing, ZHANG Yu-Sheng, HUANG Li-An, XU An-Ding

2018, 13(02): 122-126. DOI: 10.3969/j.issn.1673-5765.2018.02.005

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Objective To investigate the clinical outcome of regional stroke rescue network in improving endovascular treated patients with acute ischemic stroke (AIS). Methods A retrospective analysis was made upon regional AIS rescue network in Tianhe District, Guangzhou, which was established by Jinan University First Affiliated Hospital. All patients were divided into directly admitted group (Direct group), network hospital transferred group (Network group) and non-network hospital transferred group (Non-network group). The onset to arrive comprehensive stroke center (CSC) time, the onset to puncture time, the onset to recanalization time and the clinical outcome 3 months after treatment were compared. Results From October 2015 to July 2017, 93 patients who underwent endovascular therapy was enrolled. Among which, 37 patients were in Direct group; 31 patients were in Network group and 25 patients were in Non-network group. There were significant differences in the onset to arrive CSC time, the onset to puncture time and the onset to recanalization time among three groups, with much longer time in Non-network group (P <0.05), respectively. The non-disable rate (modified Rankin scale ≤2) at 3 months was 60.0%, 45.16%, and 28.0%, in Direct group, Network group and Non-network group, respectively, with no difference between Direct and Network group (P =0.244), but significantly worse outcome in Non-network group than in direct group (P =0.039).

Conclusion Regional stroke rescue network can shorten the treatment time and improve the outcome of patients with AIS.

Construction and Optimization of In-hospital Stroke Fast Channel and Construction of Regional Stroke Rescue Network

LI Guang-Jian, SHI Shu-Gui, ZHOU Zhen-Hua, CHEN Lin, GUI Li, ZHAI Hong, XIAO Li, WU Yi-Hong, CHEN Zhen-Fang, WU Min, LIU Lu, CHEN Kang-Ning

2018, 13(02): 127-131. DOI: 10.3969/j.issn.1673-5765.2018.02.006

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Objective In the context of current era of mechanical thrombectomy, this study is to explore how to establish acute stroke emergency system suited for local condition, make more stroke patients arrive at the qualified hospitals within the therapy time window, and increase the overall level of regional stroke rescue treatment. Methods Since 2014, the hospital and regional health administrative departments began to assist the local hospitals to make the policy and regulation of stroke rescue. The Department of Neurology of the Third Military University Affiliated First Hospital took the lead in aspect of technique, developed the training of diagnosis and treatment of stroke, provided assistance in establishing rescue workflow and assisted the collaborative hospitals to establish stroke emergency workflow and criterion. The improvement of key performance indicator (KPI) of acute ischemic stroke (AIS) care of our hospital, and change of stroke rescue level of collaborative hospitals were observed. Results (1) Establishment of stroke fast channel: the hospital director participated in the work. The department of medical affairs carried out the monitoring and coordination work. Many departme

actively participated in the work, including Emergency, Neurology, Neurosurgery, Neuroimaging, Laboratory Medicine, ECG, and Nursing Security. The door-to-needle time (DNT) was shortened from 71 minutes before to 53 minutes now; the door-to-puncture time (DPT) was shortened from 104 minutes before to 82 minutes now; the door-to-revascularization time (DRT) was shortened from 144 minutes before to 117 minutes now. (2) Establishment of regional stroke rescue network: the level of AIS emergency care of our hospital got greatly improved. The total number of patients treated with IV thrombolysis and endovascular treatment increased from 7 in 2014 to 112 in 2016; the KPIs of stroke care in primary stroke center in this region also got improved significantly. Conclusion The establishment of in-hospital stroke fast channel and regional stroke rescue network can increase the level of stroke emergency care and regional stroke cure rate. It’s worthwhile to be further improved and widely promoted.

Study of the Relationship between DSA Collateral Circulation Feature and Clinical Symptom for Patients with#br# Severe Internal Carotid Artery Stenosis or Occlusion

WANG Zheng-Yang, SUN Zhong-Liang, WANG Dong-Mei, LI Yao, MIAO Zhong-Rong

2018, 13(02): 132-138. DOI: 10.3969/j.issn.1673-5765.2018.02.007

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Objective To evaluate collateral circulation features for patients with severe internal carotid artery (ICA) stenosis or occlusion by Digital Subtraction Angiography (DSA), and study the relationship between collateral circulation feature and clinical symptom. Methods It was a retrospective study. A total of 137 patients with ICA severe stenosis (≥70%) or occlusion confirmed by DSA were consecutively enrolled during June 2014 to September 2015 in Dept. of Neurology Intervention, Beijing Tiantan Hospital, Capital Medical University. Patients were divided into asymptomatic group (n =39) and symptomatic group (n =98) according to clinical symptoms, neurological signs and imaging appearance. The DSA results of all patients were collected and collateral circulation compensation status were recorded. Patients’ collateral circulation status were classified by following situation: 1. Numbers of collaterals: Patients were classified to with or without collateral circulation by collateral numbers and less than 2 or 2 and more. 2. Collateral circulation status: anteriorcommunicating anastomoses (ACoA), posterior communicating arteries (PCoA), ophthalmic artery (OA), and leptomeningeal anastomoses (LMA). 3. Collateral composition: collaterals were classified according to Willis status and whether have secondary collaterals. The relationship between collateral circulation feature and clinical symptoms was analyzed. Results Among 137 patients, the mean age of patients was (59.7±10.5) years, 97 patients were male, and 94 patients (68.6%) had collaterals. The rate of complete Willis, ACoA, PCoA, OA, and LMA were 14.6%, 58.5%, 46.8%, 43.6%, and 48.9%, respectively. In asymptomatic group (n =39), 33 patients (84.6%) had collateral circulation. In symptomatic group (n =98), 61 patients (62.2%) had collateral circulation. The rate of circulation was significantly higher in asymptomatic group [84.6% vs 62.2%, P =0.011, odds ratio (OR) 3.336]. Patients in asymptomatic group had more patients with 2 or more collaterals than patients in symptomatic group (64.1% vs 38.3%, P =0.007, OR 2.820). Asymptomatic group had more complete functional Willis (36.4% vs 13.1%, P =0.009, OR 3.786). Conclusion For patients with severe internal carotid artery (ICA) stenosis or occlusion, collateral circulation feature has close relationship with clinical symptom. Asymptomatic patients have more collateral circulation compensatory and more complete circle of Willis. The circle of Willis plays an important role in the compensation of collateral circulation.

Clinic Study on the Pathogenesis of Pontine Infarction

WANG Hong-Xia, LIU Xin, WANG Li-Juan, LIU Ying, LI Xiao-Gang

2018, 13(02): 139-143. DOI: 10.3969/j.issn.1673-5765.2018.02.008

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Objective To compare the clinical features and the pathogenesis of different types of pontine infarction. Methods A total of 75 patients with pontine infarction were divided into basilar artery stenosis group (n =9) and basilar artery non-stenosis group (n =66). Among which , basilar artery nonstenosis group were divided into perforating disease group (n =33) and small artery disease group (n =33). The clinical features and imaging changes of each group were compared. Results The incidence of diabetes mellitus, coronary heart disease, intracranial artery atherosclerotic stenosis, admission National Institutes of Health Stroke Scale (NIHSS) score, discharged NIHSS score and modified Rankin Scale (mRS) score ≥3 were significantly higher in BA stenosis group (P <0.05). The incidence of fasting and 2 h postprandial plasma glucose, glycosylated hemoglobin, admission systolic pressure, the infarct size, admission NIHSS and discharged NIHSS score, and mRS score were significantly higher in basilar branch disease group than in small vascular disease group (P <0.05). Conclusion There are different causes and pathogenesis of pontine infarction. The lesions of paramedian pontine infarction with basilar artery stenosis are characterized by atherosclerosis, large lesion, severe symptoms, easy progression and poor prognosis.

An Indirect Comparison and Meta-analysis on the Diagnostic Value of CE-MRA vs 3D-TOF MRA for Vertebrobasilar#br# Artery Stenosis

ZHANG Jing, CHEN Xiao-Li, LIU Hai-Feng, XU Kai, ZHANG Hong-Xia, ZHANG Yan-Li, DOU Yu, LEI Jun-Qiang

2018, 13(02): 144-150. DOI: 10.3969/j.issn.1673-5765.2018.02.009

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Objective Taking digital subtraction angiography (DSA) as the golden standard, the diagnostic value of contrast enhanced magnetic resonance angiography (CE-MRA) and three dimensional time of flight magnetic resonance angiography (3D-TOF MRA) were indirectly compared by Metaanalysis on vertebrobasilar artery stenosis. Methods PubMed, Web of Science, Embase, the Cochrane Library, CNKI, CBM and WanFang Data databases were searched for studies about CE-MRA and 3D-TOF MRA in the diagnosis of fracture of vertebrobasilar artery stenosis from inception to MAY, 2017. Two reviewers independently screened literatures according to inclusion and exclusion criteria, extracted data, and assessed the risk of bias of included studies by using the QUADAS-2. Stata 12.1 software was used to pooled sensitivity (Sen), specificity (Spe), positive likelihood ratio (+LR), negative likelihood ratio (-LR) and diagnostic odds ratio (DOR). Then the summary receiver operating characteristic curve (SROC) was drawn; the area under curve (AUC) was calculated. The results of indirect comparison were compared by relative ratio. Results There were 10 studies out of 1418 records. The results of meta-analysis showed that the pooled Sen, Spe, +LR, -LR, DOR and AUC of CE-MRA and 3D-TOF MRA for vertebrobasilar artery which stenosis more than 50% were 0.89 [95% confidence interval (CI) 0.75-0.95], 0.98 (95%CI 0.91- 0.99), 36.1 (95%CI 10.3-126.2), 0.12 (95%CI 0.05-0.27), 307 (95%CI 102-922), 0.97 (95%CI 0.96- 0.98), and 0.94 (95%CI 0.86-0.98), 0.93 (95%CI 0.87-0.97), 14.4 (95%CI 7.1-29.1), 0.06 (95%CI 0.03-0.15), 226 (95%CI 57-902), and 0.98 (95%CI 0.96-0.99), respectively. The result of indirect comparison were 1.36 (95%CI 0.23-7.94). Conclusion CE-MRA could be more accurate than 3D-TOF-MRA on the diagnosis of vertebrobasilar artery stenosis.assessed the risk of bias of included studies by using the QUADAS-2. Stata 12.1 software was used to pooled sensitivity (Sen), specificity (Spe), positive likelihood ratio (+LR), negative likelihood ratio (-LR) and diagnostic odds ratio (DOR). Then the summary receiver operating characteristic curve (SROC) was drawn; the area under curve (AUC) was calculated. The results of indirect comparison were compared by relative ratio. Results There were 10 studies out of 1418 records. The results of meta-analysis showed that the pooled Sen, Spe, +LR, -LR, DOR and AUC of CE-MRA and 3D-TOF MRA for vertebrobasilar artery which stenosis more than 50% were 0.89 [95% confidence interval (CI) 0.75-0.95], 0.98 (95%CI 0.91- 0.99), 36.1 (95%CI 10.3-126.2), 0.12 (95%CI 0.05-0.27), 307 (95%CI 102-922), 0.97 (95%CI 0.96- 0.98), and 0.94 (95%CI 0.86-0.98), 0.93 (95%CI 0.87-0.97), 14.4 (95%CI 7.1-29.1), 0.06 (95%CI 0.03-0.15), 226 (95%CI 57-902), and 0.98 (95%CI 0.96-0.99), respectively. The result of indirect comparison were 1.36 (95%CI 0.23-7.94). Conclusion CE-MRA could be more accurate than 3D-TOF-MRA on the diagnosis of vertebrobasilar artery stenosis.

The Application Study of Six Sigma in Improving the Chronergy of CT Examination in Patients with Stroke

DONG Xin, HU Bi-Fu, JIANG Guang-Bin, WANG Jun, XIE Peng, YANG Yong-Gang, XIE Xing-Jia

2018, 13(02): 151-154. DOI: 10.3969/j.issn.1673-5765.2018.02.010

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Objective To investigate the time limit of six sigma approach in optimizing the chronergy of green channel for image examination. Methods A total of 600 patients with suspected acute ischemic stroke and examined by computed tomography (CT) during January-May 2015 were selected into control group, and the time of each stage was analyzed to find out the key factors to prolong the time of the patient's waiting time. The improvement measures were put forward for shortening the whole time of CT examination. After the improvement measures were implemented, another 600 patients who were diagnosed as suspected acute ischemic stroke by CT during Jan-May 2016 were selected into experimental group. Residence time in the green channel of CT examination (CT scanning, the end of CT scanning-CT report, total residence time of target<30 min) was improved by applying the 5 step method in the six sigma management system. The qualified rate of residence time was compared between two groups. Results Before improvement, the average time of the whole imaging examination was (40±7) min; after improvement, the average time of the whole imaging examination was (28±2) min (P =0.001). The duration of CT scanning was shortened from (15±4) min to (10±2) min (P =0.006); the duration of the end of CT scanning-CT report was shortened from (25±5) min to (23±3) min (P =0.006). The qualified rate of residence time in the green channel of image examination was improved by 13.67%. Conclusion The six sigma management system can significantly shorten the residence time in the green channel of image examination and effectively improve rescue efficiency in emergency patients with stroke.

Clinical Observation of Gastrointestinal Dysfunction after Stroke by Eletroacupuncture at Zusanli

REN Xia-Qi, WANG Ming-Chi, WANG Hui-Min

2018, 13(02): 155-158. DOI: 10.3969/j.issn.1673-5765.2018.02.011

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Objective To explore the clinical effect of electroacupuncture at Zusanli in patients with gastrointestinal dysfunction after stroke, so as to provide clinical evidence for stroke treated with combination of TCM and Western medicine by taking advantage of traditional Chinese medicine. Methods A total of 80 patients who were admitted in neurology department of our hospital during October 2014 and December 2015and diagnosed as gastrointestinal dysfunction after stroke with more than 2 months were selected and randomly divided into observation group and control group, with 40 cases in each group. The control group was given conventional western medicine treatment and nursing, while the observation group was treated by Zusanli electroacupuncture on the basis of control treatment. Results The total effective rate was 92.5% in observation group, better than the 75% in control group (P <0.05). The recovery time for borborygmus, as well as time for anal evacuation and defecation in observation group were shorter than that in control group (P <0.05). After treatment, Blood gastrin and motilin levels in two groups were higher than that before treatment (P <0.05), and the blood gastrin and motilin levels of the observation group were obviously higher than the control group, which had statistically significant difference (P <0.05). Conclusion Conventional treatment combined with Zusanli electroacupuncture can effectively promote recovery of gastrointestinal function in patients with stroke, improve gastrointestinal motility and regulate the secretions of gastrointestinal hormones, which has significant the clinical effect.

Endovascular Therapy in Acute Ischemic Stroke: Time is Brain

WANG An-Li, CHEN Zhi-Cai, SHI Fei-Na, LOU Min

2018, 13(02): 160-166. DOI: 10.3969/j.issn.1673-5765.2018.02.012

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Endovascular therapy brings a breakthrough progress in treatment of ischemic patients with acute large artery occlusion. Recent years studies have shown that endovascular therapy is more highly time-dependent than intravenous thrombolysis in terms of clinical outcome. To reduce reperfusion time delay is important for the management and development of endovascular therapy. Optimization of emergency rescue work flow, utilization of rapid and effective imaging evaluation system and development of fast recanalization method of thrombectomy will be helpful in clinical promotion and application of endovascular therapy in treatment of acute ischemic stroke.

JAMA N: Association of a Primary Stroke Center Protocol for Suspected Stroke by Large-Vessel Occlusion with Efficiency of Care and Patient Outcomes

YANG Zhong-Hua

2018, 13(02): 167-168. DOI: 10.3969/j.issn.1673-5765.2018.02.013

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Stroke: Mobile Interventional Stroke Teams Lead to Faster Treatment Times for Thrombectomy in Large Vessel Occlusion

YANG Zhong-Hua

2018, 13(02): 169-170. DOI: 10.3969/j.issn.1673-5765.2018.02.014

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