Endovaskuläre Therapie des akut ischämischen Schlaganfalls unter Analgosedierung im Vergleich zur Intubationsnarkose – Durchführbarkeit, periprozedurale Sicherheit, klinisches und radiologisches Outcome

Zusammenfassung

Ziel: Ein entscheidender Faktor in der Therapie des akuten ischämischen Schlaganfalls ist die Rekanalisation des Gefäßverschlusses. Endovaskuläre Therapieverfahren spielen eine immer bedeutendere Rolle. Es besteht kein Konsens, ob hierfür eine Intubationsnarkose (ITN) notwendig ist oder die lokale Anästhesie (LA) im Zugangsbereich und bedarfsweise Analogosedierung ausreichend sind. Ziel der Studie war es, die Durchführbarkeit der lokalen Schlaganfalltherapie unter LA zu evaluieren.

Material und Methoden: Über 5 Jahren wurden retrospektiv 131 Patienten mit einem akut ischämischen Schlaganfall eingeschlossen, die endovaskulär behandelt wurden. Rekanalisationsrate, primäres anästhesiologisches Vorgehen, Konversion von LA zu ITN, Infarktvolumen sowie Komplikationen wurden systematisch analysiert.

Ergebnisse: Bei 7 Patienten kam es technisch bedingt zu einem Therapieabbruch, 65 (52 %) der verbliebenen 124 Patienten (mittleres Alter 68,8 ± 14,6) waren weiblich. Der Verschluss lag bei 94 (76 %) bzw. 30 Patienten (24 %) im vorderen bzw. im hinteren Stromgebiet. 105 Patienten (85 %) wurden in LA, 16 (13 %) primär in ITN behandelt. In 3 Fällen (2 %) erfolgte eine Konversion von LA in ITN. Eine primäre Thrombolyse bzw. mechanische Rekanalisation erfolge bei 60 (48 %) bzw. 27 (22 %) Patienten, in 37 Fällen (30 %) erfolgte eine Kombinationstherapie. Zwischen der LA- und ITN-Gruppe bestand weder hinsichtlich Rekanalisationsrate noch Komplikationen ein statistisch signifikanter Unterschied. Die Interventions- und Rekanalisationsdauer war in LA signifikant kürzer (p < 0,01).

Schlussfolgerung: Endovaskuläre rekanalisierende Verfahren in der Therapie des akuten ischämischen Schlaganfalls sind unter LA mit niedrigem Komplikationsrisiko möglich und gehen mit einer kürzeren Interventionsdauer einher.

Abstract

Purpose: Vessel recanalization is an important predictor of clinical outcome in the treatment of acute ischemic stroke. Endovascular therapies are used with increasing frequency. There is no general agreement on the policy of anesthesia during endovascular therapy, ranging from general anesthesia (GA) to local anesthesia at the puncture site with conscious sedation (CS) as needed. The aim of the study was to evaluate the safety and feasibility and radiological and clinical outcome of endovascular stroke therapy under CS. 

Materials and Methods: We retrospectively included all patients with acute ischemic stroke who were treated with endovascular therapy over a five-year period. Data was evaluated with respect to type of sedation, conversion from CS to GA, recanalization rate, infarct volume and peri- and post-procedural complications.

Results: There was a technical failure in 7 patients. Of the remaining 124 patients (mean age 68.8 ± 14.6 years), 65 were female (52 %). The site of occlusion was located in the anterior circulation in 94 patients (76 %) and in the posterior circulation in 30 cases (24 %). 105 patients (85 %) were treated under CS and 16 cases (13 %) primarily under GA. In 3 cases (2 %) peri-procedural conversion to GA was necessary. Primary intra-arterial thrombolysis, mechanical recanalization only, and combination therapy were performed in 60 (48 %), 27 (22 %) and 37 (30 %) patients, respectively. There were no significant differences for recanalization rate and complications between GA and CS. The mean procedure time was significantly shorter in patients treated under CS (p < 0.01).

Conclusion: Endovascular stroke therapy with CS is feasible, can be performed safely and is faster than with GA.

Key words

brain - thrombolysis - ischemia/infarction

• Literatur

• 1 Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 2007; 38: 967-973
• 2 Hacke W, Kaste M, Bluhmki E et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359: 1317-1329
• 3 Riedel CH, Zimmermann P, Jensen-Kondering U et al. The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke 2011; 42: 1775-1777
• 4 Bhatia R, Hill MD, Shobha N et al. Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke 2010; 41: 2254-2258
• 5 Brekenfeld C, Gralla J, Zubler C et al. Mechanische Thrombektomie beim akuten Schlaganfall. Fortschr Röntgenstr 2012; 184: 503-512
• 6 Furlan A, Higashida R, Wechsler L et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 1999; 282: 2003-2011
• 7 Penumbra Pivotal Stroke Trial Investigators. The penumbra pivotal stroke trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke 2009; 40: 2761-2768
• 8 Smith WS, Sung G, Saver J et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke 2008; 39: 1205-1212
• 9 Gizewski ER, Weber R, Forsting M. Diagnostik und endivaskuläre Therapie intrakranieller arterieller Stenosen. Fortschr Röntgenstr 2011; 183: 104-111
• 10 Jumaa MA, Zhang F, Ruiz-Ares G et al. Comparison of safety and clinical and radiographic outcomes in endovascular acute stroke therapy for proximal middle cerebral artery occlusion with intubation and general anesthesia versus the nonintubated state. Stroke 2010; 41: 1180-1184
• 11 McDonagh DL, Olson DM, Kalia JS et al. Anesthesia and Sedation Practices Among Neurointerventionalists during Acute Ischemic Stroke Endovascular Therapy. Front Neurol 2010; 1: 118
• 12 Sugg RM, Jackson AS, Holloway W et al. Is mechanical embolectomy performed in nonanesthetized patients effective?. Am J Neuroradiol 2010; 31: 1533-1535
• 13 Lee CZ, Litt L, Hashimoto T et al. Physiologic monitoring and anesthesia considerations in acute ischemic stroke. J Vasc Interv Radiol 2004; 15: S13-S19
• 14 Varma MK, Price K, Jayakrishnan V et al. Anaesthetic considerations for interventional neuroradiology. Br J Anaesth 2007; 99: 75-85
• 15 Hacke W, Kaste M, Fieschi C et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA 1995; 274: 1017-1025
• 16 Hacke W, Kaste M, Fieschi C et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet 1998; 352: 1245-1251
• 17 Higashida RT, Furlan AJ, Roberts H et al. Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke 2003; 34: e109-e137
• 18 Gasparotti R, Grassi M, Mardighian D et al. Perfusion CT in patients with acute ischemic stroke treated with intra-arterial thrombolysis: predictive value of infarct core size on clinical outcome. Am J Neuroradiol 2009; 30: 722-727
• 19 Lev MH, Segal AZ, Farkas J et al. Utility of perfusion-weighted CT imaging in acute middle cerebral artery stroke treated with intra-arterial thrombolysis: prediction of final infarct volume and clinical outcome. Stroke 2001; 32: 2021-2028
• 20 Parsons MW, Pepper EM, Chan V et al. Perfusion computed tomography: prediction of final infarct extent and stroke outcome. Ann Neurol 2005; 58: 672-679
• 21 Kamalian S, Konstas AA, Maas MB et al. CT Perfusion Mean Transit Time Maps Optimally Distinguish Benign Oligemia from True “At-Risk” Ischemic Penumbra, but Thresholds Vary by Postprocessing Technique. Am J Neuroradiol 2012; 33: 545-549
• 22 Bose A, Henkes H, Alfke K et al. The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism. Am J Neuroradiol 2008; 29: 1409-1413
• 23 The Interventional Management of Stroke (IMS) II Study. Stroke 2007; 38: 2127-2135
• 24 Davis MJ, Menon BK, Baghirzada LB et al. Anesthetic management and outcome in patients during endovascular therapy for acute stroke. Anesthesiology 2012; 116: 396-405
• 25 Abou-Chebl A, Lin R, Hussain MS et al. Conscious sedation versus general anesthesia during endovascular therapy for acute anterior circulation stroke: preliminary results from a retrospective, multicenter study. Stroke 2010; 41: 1175-1179
• 26 Nichols C, Carrozzella J, Yeatts S et al. Is periprocedural sedation during acute stroke therapy associated with poorer functional outcomes?. J Neurointerv Surg 2010; 2: 67-70
• 27 Hallevi H, Barreto AD, Liebeskind DS et al. Identifying patients at high risk for poor outcome after intra-arterial therapy for acute ischemic stroke. Stroke 2009; 40: 1780-1785
• 28 Molina CA, Selim MH. General or local anesthesia during endovascular procedures: sailing quiet in the darkness or fast under a daylight storm. Stroke 2010; 41: 2720-2721
• 29 Brekenfeld C, Mattle HP, Schroth G. General is better than local anesthesia during endovascular procedures. Stroke 2010; 41: 2716-2717
• 30 Henkes H, Reinartz J, Lowens S et al. A device for fast mechanical clot retrieval from intracranial arteries (Phenox clot retriever). Neurocrit Care 2006; 5: 134-140
• 31 Foerch C, Kessler KR, Steckel DA et al. Survival and quality of life outcome after mechanical ventilation in elderly stroke patients. J Neurol Neurosurg Psychiatry 2004; 75: 988-993
• 32 Mayer SA, Copeland D, Bernardini GL et al. Cost and outcome of mechanical ventilation for life-threatening stroke. Stroke 2000; 31: 2346-2353
• 33 Angermaier A, Langner S, Kirsch M et al. CT-angiographic collateralization predicts final infarct volume after intra-arterial thrombolysis for acute anterior circulation ischemic stroke. Cerebrovasc Dis 2011; 31: 177-184