Mechanische Thrombektomie beim akuten Schlaganfall

Zusammenfassung

Ziel der Akuttherapie des ischämischen Schlaganfalls ist die rasche Rekanalisation der verschlossenen Hirnarterie. Endovaskuläre Verfahren haben insbesondere bei Verschlüssen großer Hirnarterien höhere Rekanalisationsraten als die intravenöse Thrombolyse (IVT). Die mechanische Thrombektomie mit dem Merci-Retriever ist daher seit 2004 von der FDA in Ergänzung zur IVT oder bei Kontraindikationen einer IVT bis 8 h nach Infarktbeginn zugelassen. Mit diesem System konnte eine Rekanalisationsrate von 55 % erreicht werden, sodass weiteres Verbesserungspotenzial bestand. Seit 2008 darf auch das Penumbra-System angewendet werden. Der neueste endovaskuläre Behandlungsansatz mit wieder entfernbaren intrakraniellen Stents zeigt die bisher höchsten Rekanalisationsraten von über 90 % bei gleichzeitiger Reduktion der Behandlungsdauer ohne zunehmende Komplikationsrate. Die bisherigen ermutigenden Ergebnisse legen eine kombinierte Therapie nahe, bei der eine IVT auch in kleineren Häusern begonnen werden kann, um dann in einem spezialisierten neuroradiologischen Zentrum bei persistierendem Verschluss durch die endovaskuläre Rekanalisation ergänzt zu werden (sog. Bridging-Therapie). Patienten außerhalb des 4,5 h-Zeitfensters für die IVT können bis 8 h nach Infarktbeginn mittels mechanischer Thrombektomie therapiert werden.

Abstract

The therapy of acute ischemic stroke aims at fast recanalization of the occluded brain vessel. In contrast to intravenous thrombolysis (IVT), endovascular approaches yield higher recanalization rates especially in large vessel occlusions. Mechanical thrombectomy with the Merci Retriever received FDA approval in 2004 as an adjunct to IVT or in the case of failed recanalization after IVT. The time window for treatment is 8 h from stroke onset. However, the recanalization rate was 55 %, still leaving space for further improvement. In addition to the Merci Retriever, the Penumbra System received FDA approval in 2008. The newest endovascular approach comprising retrievable intracranial stents results in an increased recanalization rate exceeding 90 % and has markedly reduced the time to recanalization. On the other hand, the complication rate has not increased yet. These promising results suggest a combined therapy for acute ischemic stroke. In a first step IVT can be started independently of the size of the treating hospital and in a next step the patient is transferred to a neuroradiological center. If vessel occlusion persists, additional endovascular recanalization is performed (bridging concept). Patients who don‘t qualify for IVT are candidates for mechanical thrombectomy up to 8 h after stroke onset.

Key words

cerebral angiography - interventional procedures - ischemia/infarction

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