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Rofo 2015; 187(07): 555-560
DOI: 10.1055/s-0034-1399222
Neuroradiology
© Georg Thieme Verlag KG Stuttgart · New York

Thrombectomy vs. Systemic Thrombolysis in Acute Embolic Stroke with High Clot Burden: A Retrospective Analysis

Thrombektomie vs. systemische Thrombolyse beim akuten embolischen Schlaganfall mit hoher Thrombuslast: Eine retrospektive Analyse
J. K. Meyne
1   Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
,
P. R. Zimmermann
1   Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
,
A. Rohr
2   Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Kiel, Germany
,
C. Riedel
2   Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Kiel, Germany
,
H. C. Hansen
3   Department of Neurology, FEK Neumünster, Germany
,
U. Pulkowski
4   Department of Neurology, Imland Klinik, Rendsburg, Germany
,
A. Thie
5   Department of Neurology, Klinikum Itzehoe, Germany
,
T. Holst
6   Department of Internal Medicine, Klinik Preetz, Germany
,
F. Papengut
1   Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
,
R. Stingele
7   Department of Neurology, DRK Kliniken Berlin, Berlin, Germany
,
K. Schepelmann
8   Department of Neurology, Helios Klinik, Schleswig, Germany
,
O. Jansen
2   Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Kiel, Germany
,
G. Deuschl
1   Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
,
A. Binder
1   Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
› Author Affiliations
Further Information

Publication History

23 December 2014

13 January 2015

Publication Date:
01 April 2015 (online)

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Abstract

Purpose: The efficacy of i. v. thrombolysis in acute stroke with high clot burden is limited. Successful recanalization is very unlikely if the thrombus length exceeds 7 mm. Thus this retrospective controlled study evaluated the efficacy and safety of neurothrombectomy in the treatment of acute embolic stroke in patients selected by a thrombus length of ≥ 8 mm using the stent retriever Trevo® device.

Materials and Methods: 40 patients with acute occlusion of the anterior intracranial arteries with a thrombus length of ≥ 8 mm were treated with neurothrombectomy. We compared the outcome with a historical cohort of 42 patients with a thrombus length of ≥ 8 mm that received i. v. thrombolysis only. Clinical outcome was assessed by modified Rankin scale in both groups at discharge and on day 90.

Results: Patients did not differ in age, mRS on admission, thrombus length or time from symptom onset to i. v. thrombolysis, but the thrombectomy group had higher NIHSS on admission. Successful recanalization was achieved in 33/40 patients (83 %) with neurothrombectomy. 15 patients received i. v. thrombolysis prior to neurothrombectomy. Median mRS at discharge was 3.5 (1.25 – 5) vs. 5 (4 – 6; p < 0.01) and on day 90 3 (1 – 4) vs. 5 (4 – 6; p < 0.01). Symptomatic hemorrhage occurred in 3 vs. 7 patients. 3 vs. 17 patients died within 90 days (thrombectomy vs. control each). There were only a few intervention-related complications.

Conclusion: Thrombectomy in acute stroke with high clot burden using the Trevo® device has a low risk and improved clinical outcome compared to i. v. thrombolysis alone. Treatment selection by a clot length of ≥ 8 mm might be a powerful approach to improve the outcome of mechanical thrombectomy.

Key Points:

• Clot length of ≥ 8 mm might be a valuable criterion for indicating neurothrombectomy.

• Thrombolysis only in high clot burden is associated with poor clinical outcome.

• Thrombectomy using the Trevo® stent retriever is safe and effective.

Citation Format:

• Meyne JK, Zimmermann PR, Rohr A. et al. Thrombectomy vs. Systemic Thrombolysis in Acute Embolic Stroke with High Clot Burden: A Retrospective Analysis. Fortschr Röntgenstr 2015; 187: 555 – 560

Zusammenfassung

Ziel: Der Nutzen einer i. v.-Thrombolyse bei akutem ischämischem Schlaganfall mit hoher Thrombuslast ist begrenzt. Eine erfolgreiche Rekanalisation durch die i. v.-Thrombolyse wird äußerst unwahrscheinlich, wenn die Thrombuslänge 7 mm übersteigt. Die vorliegende retrospektive Studie soll daher den Nutzen und die Sicherheit der Neurothrombektomie mittels des Trevo®-Stentretrievers in der Behandlung des akuten embolischen Schlaganfalles an Patienten mit einer Thrombuslänge von ≥ 8 mm prüfen.

Material und Methoden: 40 Patienten mit einem akuten Verschluss eines vorderen intrakraniellen Hirngefäßes und einer Thrombuslänge von ≥ 8 mm wurden mittels Neurothrombektomie behandelt. Es wurde das klinische Ergebnis mit einer historischen Kontrollgruppe aus 42 Patienten mit einer Thrombuslänge von ebenfalls ≥ 8 mm verglichen, welche nur mit einer i. v.-Thrombolyse behandelt wurden. In beiden Gruppen wurde das klinische Ergebnis anhand der modifizierten Rankin-Skala (mRS) bei Entlassung und nach 90 Tagen bestimmt.

Ergebnisse: Die Patienten unterschieden sich nicht bezüglich Alter, mRS bei Aufnahme, Thrombuslänge oder der Zeit vom Symptombeginn bis Beginn der i. v.-Thrombolyse, jedoch wies die Thrombektomie-Gruppe einen höheren NIHSS bei Aufnahme auf. Eine erfolgreiche Rekanalisation wurde in 33/40 Patienten (83 %) mit der Neurothrombektomie erreicht. 15 Patienten erhielten eine i. v.-Thrombolyse vor der Neurothrombektomie. Der mediane mRS bei Entlassung betrug 3,5 (1,25 – 5) vs. 5 (4 – 6; p < 0,01) und an Tag 90 3 (1 – 4) vs. 5 (4 – 6; p < 0,01). Symptomatische intrakranielle Blutungen traten in 3 vs. 7 Patienten auf, 3 vs. 17 Patienten starben innerhalb von 90 Tagen (je Thrombektomie vs. Kontrolle). Es ereigneten sich nur wenig Interventions-bezogene Komplikationen.

Schlussfolgerung: Eine Thrombektomie mit dem Trevo®-Device bei akutem Schlaganfall mit hoher Thrombuslast hat ein geringes Risiko und verbessert das klinische Ergebnis im Vergleich zur alleinigen Thrombolyse. Eine Indikationsstellung zur Thrombektomie anhand einer Thormbuslänge von ≥ 8 mm könnte das Behandlungsergebnis nach Thrombektomie verbessern.

Kernaussagen:

• Eine Thrombuslänge von ≥ 8 mm könnte ein nützliches Kriterium zur Indikationsstellung einer Neurothrombektomie darstellen.

• Eine alleinige Thrombolyse führt bei hoher Thrombuslast zu einem schlechten klinischen Ergebnis.

• Die Thrombektomie unter Verwendung des Trevo®-Stentretriever scheint sicher und effizient.

Key words

stroke - thrombectomy - thrombolysis - stent retriever
 

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