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Mechanische Thrombektomie beim ischämischen Schlaganfall

Studienlage und offene Fragen

Mechanical thrombectomy for acute ischemic stroke

Current evidence and open questions

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Zusammenfassung

Fragestellung

Bestimmung des Stellenwerts der mechanischen Thrombektomie (MT) beim ischämischen Schlaganfall.

Material und Methode

Analyse und Vergleich randomisierter kontrollierter Studien zur MT und i.v. Thrombolyse (IVT) unter Berücksichtigung pathophysiologischer und versorgungstechnischer Aspekte.

Ergebnisse

Die MT ist – auch bei alten Menschen (> 75–80 Jahre) – bei Karotis-T, M1- und Tandem-Läsionen (+ proximale A.-carotis-interna-Stenose bzw. Verschluss) wirksamer als die IVT. Für M2-Verschlüsse ist diese Frage aufgrund kleiner Fallzahlen nicht zu beantworten. Unklar ist, ob die MT bei niedrigem NIHSS unbedingt in Kombination mit IVT und nach welcher Bildgebung erfolgen soll. Etwa ein Drittel der behandelbaren Patienten wird zurzeit in Deutschland mechanisch thrombektomiert. Für die hintere Zirkulation fehlen randomisierte kontrollierte Studien mit Stent-Retrievern.

Schlussfolgerung

Nach der Etablierung als Therapie der Wahl bei Karotis-T, M1- und Tandem-Verschlüssen muss die Wirksamkeit der MT mit Stent-Retrievern bei Patienten mit distalen Verschlüssen, niedrigem NIHSS und sogar in der hinteren Zirkulation nachgewiesen werden.

Summary

Objective

To determine the importance of mechanical thrombectomy (MT) in the treatment of ischemic stroke.

Material and methods

Analysis and comparison of randomized controlled trials (RCT) of MT versus i.v. thrombolysis (IVT) considering pathophysiological and logistic aspects.

Results

The use of MT is more effective than IVT for internal carotid artery terminus (ICAT), M1 segment and tandem occlusions, i.e. proximal internal carotid artery (ICA) occlusion or stenosis, even in patients older than 75–80 years of age. Due to the small sample sizes this question cannot be answered for patients with M2 occlusions. It is still uncertain whether MT is needed in patients with a low National Institutes of Health stroke scale (NIHSS) score, whether IVT is needed before MT and what type of imaging should be performed. Approximately one third of eligible patients currently undergo MT in Germany. Results from RCTs with stent retrievers for patients with vertebrobasilar artery occlusions are lacking.

Conclusion

After becoming established as a first-line therapy for patients with ICAT, M1 segment and tandem occlusions, the effectiveness of MT with stent retrievers has to proven in patients with more distal occlusions, low NIHSS scores and even vertebrobasilar artery occlusions.

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Literatur

  1. Zeumer H, Hacke W, Kolmann HL, Poeck K (1982) Lokale Fibrinolysetherapie bei Basilaris-Thrombose. Local fibrinolysis in basilar artery thrombosis. Dtsch Med Wochenschr 107(19):728–731

    Article  CAS  PubMed  Google Scholar 

  2. Zoppo GJ del, Higashida RT, Furlan AJ et al (1998) PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. Stroke 29:4–11

    Article  PubMed  Google Scholar 

  3. Furlan A, Higashida R, Wechsler L et al (1999) Intra-arterial prourokinase for acute ischemic stroke – the PROACT II study: a randomized controlled trial. JAMA 282:2003–2011

    Article  CAS  PubMed  Google Scholar 

  4. Becker KJ, Brott T (2005) Approval of the MERCI clot retriever: a critical view. Stroke 35:400

    Article  Google Scholar 

  5. Broderick JP, Palesch YY, Demchuk AM et al (2013) Interventional Management of Stroke (IMS) III Investigators. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 368(10):893–903

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  6. Kidwell CS, Jahan R, Gornbein J et al (2013) A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 368(10):914–923

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  7. Ciccone A, Valvassori L, Nichelatti M et al (2013) Endovascular treatment for acute ischemic stroke. N Engl J Med 368(10):904–913

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  8. Perez MA, Miloslavski E, Fischer S et al (2012) Intracranial thrombectomy using the Solitaire stent: a historical vignette. J NeuroIntervent Surg 4:e32

    Article  Google Scholar 

  9. Saver JL, Jahan R, Levy EI et al (2012) Solitaire flow restoration device versus the merci retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 380:1241–1249

    Article  PubMed  Google Scholar 

  10. Nogueira RG, Lutsep HL, Gupta R et al (2012) Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 380:1231–40 (Erratum, Lancet 2012; 380:1230)

  11. Berkhemer OA, Fransen PS, Beumer D et al (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372(1):11–20

    Article  PubMed  Google Scholar 

  12. Goyal M, Demchuk AM, Menon BK et al (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372(11):1019–1030

    Article  CAS  PubMed  Google Scholar 

  13. Campbell BC, Mitchell PJ, Kleinig TJ et al (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372(11):1009–1111

    Article  CAS  PubMed  Google Scholar 

  14. Saver JL, Goyal M, Bonafe A et al (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med (Epub ahead of print)

  15. Jovin TG, Chamorro A, Cobo E et al (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med (Epub ahead of print)

  16. o A (1995) The National Institute of neurological disorders and stroke rt-PA stroke study group. Tissue plasminogen activator for acute ischemic stroke. N Eng J Med 333:1581–1587

    Article  Google Scholar 

  17. Hacke W, Kaste M, Fieschi C et al (1998) 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 352(9136):1245–1251

    Article  CAS  PubMed  Google Scholar 

  18. Clark WM, Wissman S, Albers GW et al (1999) Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. JAMA 282:2019–2026

    Article  CAS  PubMed  Google Scholar 

  19. Hacke W, Kaste M, Bluhmki E et al (2008) Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359:317

    Article  Google Scholar 

  20. Davis SM, Donnan GA, Parsons MW et al (2008) Effects of alteplase beyond 3 h after stroke in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET): a placebo-controlled randomised trial. Lancet Neurol 7:299–309

    Article  PubMed  Google Scholar 

  21. Lees KR, Bluhmki E, Kummer R von et al (2010) Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 375(9727):1695–1703

    Article  CAS  PubMed  Google Scholar 

  22. Ogawa A, Mori E, Minematsu K et al (2007) Randomized trial of intraarterial infusion of urokinase within 6 hours of middle cerebral artery stroke: the middle cerebral artery embolism local fibrinolytic intervention trial (MELT) Japan. Stroke 38:2633–2639

    Article  CAS  PubMed  Google Scholar 

  23. Demchuk AM, Goyal M, Yeatts SD et al (2014) Recanalization and clinical outcome of occlusion sites at baseline CT angiography in the interventional management of stroke III trial. Radiology 273(1):202–210

    Article  PubMed Central  PubMed  Google Scholar 

  24. Riedel CH, Zimmermann P, Jensen-Kondering U et al (2011) The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke 42:1775–1777

    Article  PubMed  Google Scholar 

  25. Kirchhof K, Welzel T, Mecke C et al (2003) Differentiation of white, mixed, and red thrombi: value of CT in estimation of the prognosis of thrombolysis phantom study. Radiology 228(1):126–130

    Article  PubMed  Google Scholar 

  26. Urbach H, Hartmann A, Pohl C et al (2002) Local intra-arterial thrombolysis in the carotid territory: does recanalization depend on the thromboembolus type? Neuroradiology 44(8):695–699

    Article  CAS  PubMed  Google Scholar 

  27. Fischer U, Arnold M, Nedeltchev K et al (2005) NIHSS score and arteriographic findings in acute ischemic stroke. Stroke 36(10):2121–2125

    Article  PubMed  Google Scholar 

  28. Daniere F, Lobotesis K, Machi P et al (2015) Patient selection for stroke endovascular therapy- DWI-ASPECTS thresholds should vary among age groups: insights from the RECOST study. AJNR Am J Neuroradiol 36(1):32–39

    Article  CAS  PubMed  Google Scholar 

  29. Singer O, Haring HP, Trenkler J et al (2013) Age dependency of successful recanalization in anterior circulation stroke: the ENDOSTROKE study. Cerebrovasc Dis 36:437–444

    Article  PubMed  Google Scholar 

  30. Flint AC, Cullen SP, Faigeles BS, Rao VA (2010) Predicting long-term outcome after endovascular stroke treatment: the totaled health risks in vascular events score. AJNR Am J Neuroradiol 31:1192–1196

    Article  PubMed  Google Scholar 

  31. Barber PA, Demchuk AM, Zhang J, Buchan AM (2000) Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS study group. Alberta stroke programme early CT score. Lancet 355:1670–1674

    Article  CAS  PubMed  Google Scholar 

  32. Gupta AC, Schaefer PW, Chaudhry ZA et al (2012) Interobserver reliability of baseline noncontrast CT alberta stroke program early CT score for intra-arterial stroke treatment selection. AJNR Am J Neuroradiol 33:1046–1049. doi:10.3174/ajnr.A2942

    Article  CAS  PubMed  Google Scholar 

  33. Bal S, Bhatia R, Menon BK et al (2015) Time dependence of reliability of noncontrast computed tomography in comparison to computed tomography angiography source image in acute ischemic stroke. Int J Stroke 10:55–60

    Article  PubMed  Google Scholar 

  34. Menon BK, d’Esterre CD, Qazi E et al (2015) Multi-phase CTA: a new tool for the imaging triage of patients with acute ischemic stroke. Radiology 275:510–520

    Article  PubMed  Google Scholar 

  35. Campbell BC, Yassi N, Ma H et al (2015) Imaging selection in ischemic stroke: feasibility of automated CT-perfusion analysis. Int J Stroke 10:51–54

    Article  PubMed  Google Scholar 

  36. Menon BK, Campbell BC, Levi C, Goyal M (2015) Role of imaging in current acute ischemic stroke workflow for endovascular therapy. Stroke 46(6):1453–1461. doi:10.1161/STROKEAHA.115.009160 (Epub 2015 May 5)

    Article  CAS  PubMed  Google Scholar 

  37. Grotta JC, Hacke W (2015) Stroke Neurologist’s perspective on the new endovascular trials. Stroke 46(6):1447–1452

    Article  PubMed  Google Scholar 

  38. Heuschmann PU et al (2010) Schlaganfallhäufigkeit und Versorgung von Schlaganfallpatienten in Deutschland. Akt Neurol 37:333–340

    Article  Google Scholar 

  39. Beumer DSG, Fonvile S, Van Oostenbrugge RJ et al (2013) Intra-arterial occlusion in acute ischemic stroke relative frequency in an unselected population. Cerebrovasc Dis 35(S33):66

    Google Scholar 

  40. Goyal M, Almekhlafi MA, Fan L et al (2014) Evaluation of interval times from onset to reperfusion in patients undergoing endovascular therapy in the IMS III trial. Circulation 130(3):265–272

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  41. Pfaff J, Herweh C, Pham M et al (2015) Mechanical thrombectomy using a combined CT/C-arm X-ray system. J Neurointerv Surg pii: neurintsurg-2015-011744. doi:10.1136/neurintsurg-2015-011744 (Epub ahead of print)

    Google Scholar 

  42. Brinjikji W, Murad MH, Rabinstein AA et al (2015) Conscious sedation versus general anesthesia during endovascular acute ischemic stroke treatment: a systematic review and meta-analysis. AJNR Am J Neuroradiol 36(3):525–529

    Article  CAS  PubMed  Google Scholar 

  43. Berg LA van den, Koelman DL, Berkhemer OA et al (2015) Type of anesthesia and differences in clinical outcome after intra-arterial treatment for ischemic stroke. Stroke 46:1257–1262

    Article  PubMed  Google Scholar 

  44. Schönenberger S, Möhlenbruch M, Pfaff J et al (2015) Sedation vs. Intubation for Endovascular Stroke TreAtment (SIESTA) – a randomized monocentric trial. Int J Stroke

  45. Schonewille WJ, Wijman CA, Michel P et al (2009) Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study. Lancet Neurol 8:724–730

    Article  PubMed  Google Scholar 

  46. Singer OC, Berkefeld J, Nolte CH et al (2015) Mechanical recanalization in basilar artery occlusion: the ENDOSTROKE study. Ann Neurol 77(3):415–424

    Article  PubMed  Google Scholar 

  47. Mocco J, Zaidat O, von Kummer R et al (2015) Results of the THERAPY trial: a prospective, randomized trial to define the role of mechanical thrombectomy as adjunctive treatment to IV rtPA in acute ischemic stroke. Presented at the European Stroke Organisation (ESO) conference 2015; April 17–19, 2015; Glasgow, United Kingdom

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Einhaltung ethischer Richtlinien

Interessenkonflikt. S. Meckel: Acandis GmbH & Co. KG, Germany: Reisekosten und Honorare als Mitglied des Scientific Advisory Board, Covidien/Medtronic: Reisekosten, Microvention: Reisekosten, Stryker: Reisekosten, Bracco S.p.A.: study grant (money paid to institution). C. Taschner: Board Membership: MircoVention, Acandis; Beratung: Stryker Neurovascular. S. EISheikh: Reisesponsoring zu verschiedenen Veranstaltungen im Jahr 2013 und 2014 durch die Firma Microvention. C.J. Maurer: Educational Grant und Travel Grant von Stryker 2014. H. Urbach gibt an, dass kein Interessenkonflikt besteht.

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  1. Klinik für Neuroradiologie, Uniklinik Freiburg, Breisacher Str. 64, 79106, Freiburg, Deutschland

    S. Meckel, C., Taschner, S. ElSheikh, C.J. Maurer & H. Urbach

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Meckel, S., Taschner, C., ElSheikh, S. et al. Mechanische Thrombektomie beim ischämischen Schlaganfall. Nervenarzt 86, 1226–1235 (2015). https://doi.org/10.1007/s00115-015-4270-4

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