Den norske carotisstudien

Om studien

40 % av norske slagpasienter som skal gjennomgå risikoreduserende kirurgi får ikke behandling i tide. Et lite drypp kan være et forvarsel om et stort slag.

Hjerneslag rammer ca 15000 nordmenn hvert år. Hos en del av disse pasientene er årsaken blodpropp i hjernen som følge av en forsnevring i en av halspulsårene. Et lite «drypp» kan være et forvarsel om at et stort hjerneslag kan oppstå. Etter et slikt forvarsel kan rask kirurgisk behandling med fjerning av forsnevringen redusere risiko for slag. Det er i løpet av ett år samlet data fra over 99 % av alle som fikk gjennomført en slik operasjon. Nærmere 40 % av dem som ble operert fikk ikke sin behandling innen 2 uker, som er anbefalt tid. Dette medfører økt risiko for nye drypp eller slag, og i ventetiden fikk enkelte pasienter nye plager.

Studien så nærmere på tidsbruken fra pasienten først kjenner symptomer til behandlingen er utført. Hovedårsakene til forsinket behandling er at pasienten oppsøker lege for sent,og at sykehusene bruker for lang tid på å utrede og etterhvert organisere behandlingen. Det er både behov for økt kunnskap om sykdommen i befolkningen, og for bedre koordinering innad i helsevesenet for å minimere forlenget tidsbruk i pasientforløpet.

Kilde: http://www.ejves.com/article/S1078-5884(17)30449-5/fulltext

Artikkel

Artikkelen er åpent tilgjengelig på European Journal of Vascular and Endovascular surgery sine hjemmesider.

Abstrakt

Title:

THE NATIONAL NORWEGIAN CAROTID STUDY; TIME FROM SYMPTOM DEBUT TO SURGERY IS TOO LONG, GIVING ADDITIONAL NEUROLOGICAL EVENTSSHUNTING DURING CAROTID ENDARTERECTOMY: WHAT WE HAVE LEARNED FROM DIFFUSION-WEIGHTED MAGNETIC RESONANCE IMAGING.

Institution:

1. University Hospital of North Norway, Tromsø
2. Haugesund Hospital, Haugesund
3. Østfold Hospital, Fredrikstad 4. Vestfold Hospital, Tønsberg
5. Molde Hospital, Molde
6. Bodø Hospital, Bodø
7. Oslo University Hospital, Oslo
8. Haukeland University Hospital, Bergen
9. Hamar Hospital, Hamar
10. Drammen Hospital, Drammen
11. Akershus University Hospital, Lørenskog
12. Ålesund Hospital, Ålesund
13. Stavanger University Hospital, Stavanger
14. St. Olav’s University Hospital, Trondheim, Norway

Authors:

Knut Eivind Kjørstad, Svein T. Baksaas, Dorte Bundgaard, Erik Halbakken, Terje Hasselgård, Geir T. Jørgensen, Anne H. Krog, Kirsten Krohg-Sørensen, Elin Laxdal, Sven R. Mathisen, Gudmundur V. Oskarsson, Synnøve Seljeskog, Inge Settemsdal, Beate Viddal, Frode Aasgaard, Erney Mattsson

Introduction:

Recommendations for timing of surgical treatment of symptomatic carotid stenosis vary from within 48 hours (UK) to within 2 weeks (e.g.in Norway) from onset of symptoms. The aim of the study was to observe all patients in Norway operated upon for symptomatic carotid stenosis during one year with respect to; 1) the time from the index event to surgery and its neurological consequences, 2) the level in the health care system causing delay in surgical treatment, and 3) the possible relation between perioperative use of platelet inhibitors and recurrent neurological symptoms.

Methods:

All 15 hospitals in Norway performing carotid endarterectomy (CEA) contributed to this prospective national multicenter study. Patients were included when referred to surgery, and after written informed consent was obtained. We defined the index event as the neurological event promoting contact with the health care system.

Results:

371 patients were eligible for inclusion between April 1st 2014 and March 31st 2015, and 368 patients (99.2 %) were included. The index events were; minor stroke in 39.4 %, transitory ischemic attack in 36.7 %, amaurosis fugax in 17.4 %, and major stroke in 6.0 % of the patients. 54 % of the patients contacted their family doctor on the day of the index event. The primary health care referred 84.2 % of the patients to hospital on the same day as examined. In-hospital median time from arrival to referral for vascular surgery was three days, and after seven days 82.9 % of the patients had been referred. Median time between referral to the operative unit and actual CEA was five days, and 10 days after referral to vascular surgery 81.5 % had been operated. Overall, 61.7 % of the patients were operated within 2 weeks after the index event (see figure). There were no deaths between referral for surgery and time of CEA, but 25 patients (6.8 %) suffered a new neurological event while waiting for surgery. Less than half of the patients (44.0 %) who suffered a new neurological event were on a platelet inhibitor other than ASA. Among those that did not face a new neurological event the percentage was 74.6 (p = 0.01, Pearson’s Chi-Square test). There was no difference between the two groups with respect to use of ASA. Thirteen patients (3.5 %) suffered a perioperative stroke (6 major and 7 minor), and the 30-day mortality rate was 0.5 %. The combined 30-day mortality and stroke rate was 3.8 %. Nearly all patients were controlled one month or later after discharge (99.2%). Seven patients (1.9 %) had persistent signs of peripheral nerve injury at the control. No patients showed signs of new neurological events.

Conclusion:

This national study with almost complete inclusion and follow up shows a delay emerging at the level of the patient and in-hospital, including the departments of vascular surgery. The delay is connected with new neurological symptoms. Use of a second platelet inhibitor other than ASA is associated with reduced risk of having a new neurological event after symptom debut.

Studiegruppe

Studien var et samarbeidsprosjekt mellom samtlige norske sykehus som utfører slagrisikoreduserende kirurgi på halspulsårene.

Studien er gjennomført med støtte fra UNIKARD, Den norske legeforenings fond for kvalitet og pasientsikkerhet og Norsk Karkirurgisk Forening (NKKF). Studien var ledet av Knut E. Kjørstad ved Universitetssykehuset Nord-Norge (UNN) i samarbeid med NKKFs forskningsutvalg.

  • Studiekoordinator:  Knut E Kjørstad – knutek@unn.no
  • Daværende leder i NKKFs Forskningsutvalg: Erney Mattsson – erney.mattsson@ntnu.no

Lokale studieansvarlige:

  • S.T. Baksaas – Haugesund sjukehus
  • D. Bundgaard – Sykehuset i Østfold – Kalnes
  • E. Halbakken – Sykehuset i Vestfold – Tønsberg
  • T. Hasselgård – Molde sjukehus
  • T. Jonung – Haukeland universitetssykehus – Bergen
  • G.T. Jørgensen – Bodø sykehus
  • J.J. Jørgensen – Oslo universitetssykehus – Aker
  • A.H. Krog – Oslo universitetssykehus – Aker
  •  K. Krohg-Sørensen – Oslo universitetssykehus – Rikshospitalet
  • E. Laxdal – Haukeland universitetssykehus – Bergen
  • S.R. Mathisen – Sykehuset Innlandet – Hamar
  • G.V. Oskarsson – Drammen sykehus
  • S. Seljeskog -Akershus universitetssykehus – Lørenskog
  • I. Settemsdal – Ålesund sykehus
  • M. Vetrhus – Stavanger universitetssykehus
  • B.A. Viddal – Stavanger universitetssykehus
  • J. Wesche – Akershus universitetssykehus – Lørenskog
  • F. Aasgaard – St. Olavs universitetssykehus – Trondheim

Nyttige lenker

Europeiske retningslinjer:

European Journal of Vascular and Endovascular Surgery: Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)

Indikator på behandling innen 14 dager

Helsedirektoratet: Halspulsåren – tid fra symptomdebut til behandling av åreforkalkning i halspulsåren