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Periinterventionelles Management der akuten endovaskulären Schlaganfallbehandlung

Periinterventional management of acute endovascular stroke treatment

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Zusammenfassung

Die mechanische Thrombektomie (MT) ist beim akuten ischämischen Schlaganfall durch Verschluss eines großen Hirngefäßes der Standardbehandlung mit oder ohne systemische Lysetherapie mit rekombinantem Plasminogenaktivator (rtPA) allein überlegen. Damit besteht leitliniengerecht die Verpflichtung, Patienten mit großen relevanten Gefäßverschlüssen und kleinem Infarktkern in ein entsprechend ausgestattetes Zentrum zur MT zu verlegen. Neben der erfolgreichen Rekanalisation gehört zur MT gleichermaßen das Management des Patienten vor, während und nach der Behandlung. Eine der ungelösten Fragen ist z. B. die Wahl der Sedierung inklusive des Atemwegsmanagements und der Einfluss auf das funktionelle Ergebnis des Patienten. Nach aktueller Studienlage scheint die Behandlung in Intubationsnarkose („general anesthesia“, GA) für den Patienten – unter Beachtung vordefinierter Sicherheitskriterien – im Vergleich zur Leichtsedierung („conscious sedation“, CS) gleichwertig und nicht notwendigerweise nachteilig zu sein. Aber auch viele weitere Aspekte wie logistische Abläufe oder die optimale Blutdruckeinstellung sind bisher weitgehend offen. Dieser Übersichtsartikel stellt die aktuelle Datenlage zu den einzelnen Aspekten des periinterventionellen Managements während der MT dar und gibt pragmatische Vorschläge zum Management.

Abstract

Mechanical thrombectomy (MT) is more effective than standard medical treatment with or without intravenous thrombolysis alone for treating acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) in the anterior circulation. MT is therefore recommended in current international guidelines, and many acute-care hospitals and stroke centers will have to prepare for providing this treatment in an optimal way. Beside successful recanalization, management before, during, and after the intervention represents significant challenges. One unresolved matter is whether the choice of anesthetic strategy, including airway management, affects functional outcome. Based on current data, treatment under general anesthesia (GA)—respecting predefined safety criteria and contraindications—seem seems to be equivalent to treating the patient in conscious sedation (CS) and not necessarily disadvantageous. Aspects of periinterventional management of MT, including pragmatic recommendations concerning logistics, monitoring, postprocedural steps, and follow-up imaging, will be summarized in this overview.

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Authors and Affiliations

  1. Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland

    S. Schönenberger

  2. Neurologische Klinik, Klinikum Kassel, Kassel, Deutschland

    J. Bösel

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  1. S. Schönenberger
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Correspondence to S. Schönenberger.

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Interessenkonflikt

J. Bösel gibt an Honorare und Reisekostenunterstützung von Bard, Zoll, Boehringer Ingelheim, sowie einen Research Award SETOINT2 von PCORI erhalten zu haben. S. Schönenberger gibt an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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F. J. Erbguth, Nürnberg

M. Grond, Siegen

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Schönenberger, S., Bösel, J. Periinterventionelles Management der akuten endovaskulären Schlaganfallbehandlung. Med Klin Intensivmed Notfmed 114, 604–612 (2019). https://doi.org/10.1007/s00063-019-00612-y

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