Abstract:

Objective  Based on the optimized in-hospital stroke emergency system of Peking Union Medical College Hospital established since 2021, this study analyzed the impact of optimized in-hospital stroke emergency system on the reperfusion therapy and outcome of patients with in-hospital ischemic stroke.

Methods  This retrospective study included the consecutive patients with in-hospital ischemic stroke during hospitalization for non-stroke disease in Peking Union Medical College Hospital from March 2013 to January 2022. Demographic data, vascular risk factors, clinical and imaging data of new-onset stroke, reperfusion therapy, reasons for not receiving reperfusion therapy, and neurological outcome at discharge were collected. NIHSS was used to assess neurological impairment in acute phase (mild stroke for NIHSS 0-5, moderate-severe stroke for NIHSS 6-42), and mRS for assessing functional outcome at discharge. Patients were classified into two groups according to whether the optimized in-hospital stroke emergency system were applied. The differences in proportion of reperfusion therapy and good functional outcome at discharge (mRS 0-2) were compared between the two groups. Binary logistic regression was used to analyze the independent risk factors of poor outcome for patients with in-hospital ischemic stroke.

Results  A total of 203 eligible patients were included. The median age was 64 (52-72) years and 126 patients (62.1%) were males. The median score of NIHSS at baseline was 5 (2-10), and there were 100 cases (49.3%) with moderate-severe stroke. Of the 23 patients (11.3%) who received reperfusion therapy, 2 patients (1.0%) received intravenous thrombolysis, 20 patients (9.9%) received endovascular therapy, and 1 patient (0.5%) received intravenous thrombolysis combined with endovascular therapy. The main reasons for not receiving reperfusion therapy included the following factors: contraindications in 104 patients (51.2%), beyond the time window of intravenous thrombolysis in 67 patients (33.0%), and other reasons in 9 ones (4.4%). The median mRS score at discharge was 3 (1-4), 103 patients (50.7%) had a poor outcome, and 14 patients (6.9%) died. The optimized in-hospital stroke emergency system was utilized in 58 cases (28.6%), and original emergency process in 145 cases (71.4%). The proportion of patients who received reperfusion therapy in optimized emergency process group was higher than that in original emergency process group (27.6% vs. 4.8%, P<0.001), especially receiving endovascular therapy (24.1% vs. 4.1%, P<0.001). Logistic regression analysis showed that older age (OR 1.036, 95%CI 1.014-1.059) and moderate-severe stroke (OR 10.951, 95%CI 5.338-22.467) were independent risk factors for poor outcome. Using the optimized in-hospital stroke emergency system can increase the proportion of patients with good function at discharge compared to the original emergency process, while the difference had no statistical significance.

Conclusions  This single-center study showed that in-hospital ischemic stroke was not uncommon, with higher percentage of moderate-severe stroke and poor prognosis. Optimizing in-hospital stroke emergency system can increase the proportion of patients receiving reperfusion therapy, and relatively improve the functional prognosis of patients at discharge.

Key words:  In-hospital stroke; Ischemic stroke; Stroke emergency system; Reperfusion therapy; Quality control

摘要：

目的     基于北京协和医院自2021年以来构建的院内卒中救治体系，回顾性分析院内卒中救治体系对院内卒中患者再灌注治疗及预后的影响。

方法     连续纳入2013年3月-2022年1月因非卒中病因在北京协和医院住院期间新发缺血性卒中患者并进行临床资料的回顾性分析。收集人口学资料、血管危险因素、新发卒中临床及影像资料、急性期再灌注治疗、未接受再灌注治疗的原因、出院时神经功能结局。采用NIHSS评估急性期神经功能障碍程度（NIHSS 0～5分为轻型卒中，NIHSS 6～42分为中重度卒中），采用mRS评估出院时功能结局。根据卒中发病时间和是否采用优化院内卒中救治体系将患者分为原流程组、新流程组（自2021年1月以来采用优化院内卒中救治体系：在全院开展卒中识别与预警培训，组建多学科卒中救治团队，定期开展医疗质量控制讨论会及流程演练等）。比较两组患者急性期再灌注治疗[静脉溶栓和（或）血管内治疗]、出院时功能结局良好（mRS 0～2分）比例的差异。采用二分类logistic回归分析院内新发缺血性卒中患者预后不良的独立危险因素。

结果     共纳入院内新发缺血性卒中患者203例，中位年龄为64（52～72）岁，其中男性126例（62.1%）。急性期NIHSS中位数为5（2～10）分，其中中重度卒中100例（49.3%）。接受急性期再灌注治疗者23例（11.3%），其中静脉溶栓2例（1.0%），血管内治疗20例（9.9%），静脉溶栓联合血管内治疗1例（0.5%）。未接受再灌注治疗的原因包括存在禁忌证104例（51.2%）、非时间窗内67例（33.0%）、其他原因（如患者或家属拒绝再灌注治疗等）9例（4.4%）。出院时mRS中位数为3（1～4）分，结局不良103例（50.7%），其中死亡14例（6.9%）。采用原流程、新流程的院内卒中患者分别为145例（71.4%）、58例（28.6%），新流程组接受急性期再灌注治疗的患者比例高于原流程（27.6% vs. 4.8%，P<0.001），尤其是血管内治疗（24.1% vs. 4.1%，P<0.001）。logistic回归分析显示，增龄（OR 1.036，95%CI 1.014～1.059）、中重度卒中（OR 10.951，95%CI 5.338～22.467）是院内缺血性卒中结局不良的独立危险因素；新流程组出院时功能良好患者比例有增加的趋势，但差异未达到统计学意义。

结论     院内新发缺血性卒中患者的中重度卒中和预后不良比例相对高。优化院内卒中救治体系包括卒中识别与预警培训、组建多学科卒中救治团队等举措，可显著提高接受急性期再灌注治疗患者比例，相对提高出院时功能结局良好患者比例。

关键词: 院内卒中; 缺血性卒中; 绿色通道; 再灌注治疗; 质量控制