Lokale Therapie des ischämischen Insultes: mechanische Thrombektomie

Zusammenfassung

Die endovaskuläre Therapie, insbesondere die mechanische Thrombektomie des akuten Schlaganfalles erlangt zunehmend an Bedeutung. Innerhalb des 4,5 Stunden-Zeitfensters kann sie indiziert sein, wenn Kontraindikationen gegen eine i. v.-Lyse bestehen, diese keine klinische Besserung erzielt, ein langer Thrombus oder proximale Verschlüsse größerer hirnversorgender Arterien vorliegen. Außerhalb des Zeitfensters kann die i. a.-Therapie primär indiziert sein.

Neben der intraarteriellen Lysetherapie stehen verschiedene Methoden der mechanischen Thrombektomie zur Verfügung. Proximale Systeme sind Aspirationsthrombektomie-Systeme, die unmittelbar proximal des Verschluss platziert werden. Der Thrombus wird manuell oder maschinell unterstützt aspiriert, zumeist unter Zuhilfenahme einer zusätzlichen Fragmentierung des Thrombus.

Zu den distalen Systemen zählen Retriever, deren Form von bürsten-, über körbchen- bis korkenzieherartige Konfigurationen reicht.

In der jüngeren Vergangenheit kommen zunehmend Stent-Retriever zum Einsatz, die vielversprechende Reperfusionsergebnisse erzielen konnten. Randomisierte kontrollierte Studien sind vonnöten, um die klinische Effizienz der Stentretriever weiter zu beurteilen.

Abstract

Endovascular therapy plays a pivotal role in the management of acute ischemic stroke. Inside a 4.5 h time window, intra-arterial treatment should be considered if the patient is not eligible for i.v. lysis, if a long clot or occlusion of a large proximal vessel is present, and after failure of i.v. lysis. Outside the 4.5 h time window intra-arterial therapy is a primary option.

Different methods of mechanical thrombectomy in arteries of the intracranial circulation have become available. Proximal systems are aspiration thrombectomy devices, which are placed immediately proximal to the occlusion. The thrombus material is manually or mechanically aspirated through the guide catheter, sometimes assisted by fragmentation of the clot using a wire.

Distal systems include differently shaped clot retrievers, which range from brush- or basket- to corkscrew-like configurations.

In the recent past stentretrievers are being increasingly employed. The reported recanalization rates and clinical outcome are promising. Randomized controlled trials are needed to further evaluate the clinical efficiency of these devices.

Schlüsselwörter

Schlaganfall - mechanische Rekanalisierung - Neurointervention - digitale Subtraktionsangiografie

Keywords

stroke - mechanical recanalization - thrombectomy - embolectomy - reperfusion

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