Reduce the intravenous thrombolysis time of cerebral infarction, this combination is too powerful!

*For medical professionals to read and refer to the prospective, multi-center, controlled trial of the mobile stroke unit
.

 Within 4.
5 hours of the onset of acute ischemic stroke (also called "acute cerebral infarction"), intravenous alteplase (recombinant tissue-type plasminogen activator, rt-PA) thrombolytic therapy is an acute ischemic stroke One of the most effective treatments
.

In order to give patients with acute cerebral infarction the best chance of treatment, it is very important and necessary to give patients intravenous thrombolytic therapy as soon as possible
.

The treatment of acute ischemic stroke can be divided into three stages: pre-hospital, emergency, and hospitalization
.

In 2013, the American Heart Association (AHA)/American Stroke Association (American Stroke Association, ASA) issued guidelines for the early management of patients with acute ischemic stroke, which summarized the stroke first aid process as an 8D survival chain: detection, Dispatch (Dispatch), transfer (Delivery), arrival (Door), inspection data (Data), clinical decision (Decision), drug treatment (Drug), placement (Disposition)
.

Any delay in any link may cause the patient to miss the best treatment time
.

See Figure 1 for details
.

Figure 1: International Stroke Life Chain "8D" The current emergency medical service (EMS) process for patients with acute ischemic stroke is: emergency ambulances are delivered to the stroke treatment center, if CT shows no cerebral hemorrhage, alteplase ( rt-PA) treatment, and specific cerebral large vessel occlusion patients can receive thrombectomy (EVT) treatment.
The timeliness of thrombolysis or thrombectomy for stroke patients is significantly related to the prognosis of the patients (Figure 2)
.

Figure 2: General process of EMS So, is it possible to give data, emergency evaluation (data), clinical decision (decision), and give drug treatment (drug) before hospitalization, so as to shorten the time of rt-PA administration? Mobile Stroke Unit (MSU) is an ambulance equipped with CT, telemedicine unit and testing laboratory.
The personnel have received professional stroke diagnosis and treatment training, and can use rt-PA for treatment faster
.

In September 2021, the New England Journal published a related article comparing the effects of MSU and EMS on improving the prognosis of stroke patients
.

Figure 3: Screenshot of the title of the literature.
This study is an observational, prospective, multi-center, alternate weekly trial.
The researchers evaluated the impact of MSU or EMS management on the prognosis of patients with acute ischemic stroke within 4.
5 hours after the onset of symptoms
.

The main result of the study is the Rankin scale score (0-6, the higher the score, the worse the prognosis of the patient, and the score 0-1 indicates that the patient has a good prognosis).
For patients who meet the rt-PA treatment criteria, a modified Rankin scale score ( ≥0.
91 or <0.
91, representing the Rankin scale score ≤1 or >1)
.

1515 patients participated in the study, of which 1047 met the rt-PA treatment criteria, 617 received MSU, and 430 received EMS treatment
.

See Figure 3 for enrollment, screening, and follow-up
.

Figure 4: Enrollment, screening, randomization, and follow-up The median time from stroke onset to rt-PA treatment in the MSU group was 72 minutes, and that in the EMS group was 108 minutes
.

Among patients who met the rt-PA criteria, 97.
1% of the MSU group received rt-PA treatment, while 79.
5% of the EMS group received rt-PA treatment
.

For patients who meet the rt-PA standard, the average score of the 90-day modified Rankin scale is as follows: 0.
72 in the MSU group and 0.
66 in the EMS group (the odds ratio of the adjusted Rankin amount ≥ 0.
91 after adjustment is 2.
43, 95% CI 1.
75~3.
36, p< 0.
05)
.

Among patients meeting the rt-PA criteria, 55.
0% of patients in the MSU group and 44.
4% of patients in the EMS group had a Rankin scale score of 0 or 1 at 90 days, indicating a good prognosis
.

Among all patients, the average score of the modified Rankin scale at discharge was 0.
57 in the MSU group and 0.
51 in the EMS group (the odds ratio of the adjusted Rankin amount ≥ 0.
91 after adjustment was 1.
82, 95% CI 1.
39-2.
37, p<0.
05)
.

In terms of secondary results, the MSU group had an advantage.
The 90-day mortality rate was 8.
9% in the MSU group and 11.
9% in the EMS group
.

Figure 5: Modified Rankin score at 90 days▎ Conclusion: For patients with acute ischemic stroke who meet the criteria for tissue plasminogen thrombolysis, MSU treatment is better than EMS in terms of patient prognosis
.

Discussion: In acute ischemic stroke, about 1.
9 million neurons and 14 billion synapses die every minute before cerebral perfusion is restored
.

Therefore, the treatment of stroke must race against time.
Time is the brain.
The earlier intravenous thrombolysis, the more obvious the benefit (Figure 6).
If rt-PA is given for less than 90 minutes, one person will benefit from 3.
5 people, and rt-PA will be given for 3~4.
5 hours.
, 14 talents and one person benefited
.

Figure 6: The benefit of intravenous thrombolysis, the earlier the thrombolysis, the more obvious the benefit.
Previous trials have shown that the benefit of receiving rt-PA during the first "golden time" is greater than that of the subsequent time, but from 2009 to 2013 An analysis performed showed that only 1.
3% of patients in American stroke centers received rt-PA treatment within one hour after the onset of stroke
.

In this study, a total of 2.
6% of patients in the EMS group received this treatment, while in the MSU group, the proportion was 32.
9%.
MSU greatly shortened the time of intravenous thrombolysis, so that the benefit was more obvious after 90 days
.

We have reason to believe that with the continuous advancement of medical technology, CT devices can be equipped on the 120th, and patients with acute ischemic stroke can be given intravenous thrombolysis on the 120th, which can greatly shorten the time to receive rt-PA
.

References: [1] James C.
Grotta et al.
Prospective, Multicenter, Controlled Trial of Mobile Stroke Units.
N Engl J Med, September 9, 2021.