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Die notfallmäßige Karotis-TEA bei neurologisch instabilen Patienten

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Zusammenfassung

Hintergrund

Die Karotis-TEA ist das Verfahren der Wahl für die Behandlung hochgradiger Karotisstenosen als Ursache transienter neurologischer Symptome in der jüngeren Anamnese. Bei Patienten mit akuten neurologischen Ausfällen, die einer vaskulären Insuffizienz der A. carotis zuzuordnen sind, ist die Indikation zur notfallmäßigen Operation dagegen weiterhin strittig.

Patienten und Methodik

Im Zeitraum vom 01.01.1995 bis 30.06.2003 wurden bei 621 Patienten 656 Karotisdesobliterationen bei 330 symptomatischen (50,3%) und 326 asymptomatischen (49,7%) Stenosen durchgeführt. Die Indikation zum Notfalleingriff wurde bei 30 Patienten (4,6%) mit Crescendo-TIA (n=11) oder inkonstantem neurologischen Defizit (n=19) innerhalb von 4–24 h nach Beginn der Symptome durchgeführt. Klinische Selektionskriterien für den Notfalleingriff waren ein akuter Beginn der neurologischen Symptomatik bei uneingeschränkter Bewusstseinslage, der Nachweis einer hochgradigen Karotisstenose, ein Blutungsausschluss im CT sowie kardiopulmonale Stabilität.

Ergebnisse

Die fachneurologische Untersuchung ergab als Frühergebnis eine komplette Remission der Symptome bei 12 und eine Verbesserung mit nicht behindernder Restsymptomatik bei 9 Patienten. Die neurologischen Defizite von 6 Patienten blieben postoperativ unverändert. 3 Patienten erlitten eine Verschlechterung (1 komplette, 2 inkomplette Hemiparese). 24/30 Patienten konnten innerhalb von 8 Tagen aus der stationären Behandlung entlassen werden. Innerhalb einer mittleren Nachbeobachtungszeit von 54 Monaten verstarben 9/30 Patienten. Bei 1 Patienten kam es zu einem erneuten zerebralen Ereignis, während es bei 7 Patienten zu einer weiteren Verbesserung der neurologischen Symptomatik kam.

Schlussfolgerung

Diese Analyse zeigt, dass sich mit der operativen Therapie der akuten Karotisinsuffizienz bei einem selektionierten Krankengut unter optimalen Bedingungen der Diagnostik, des intraoperativen Managements und der perioperativen Überwachung gute bis sehr gute Ergebnisse erzielen lassen.

Abstract

Background

Carotid endarterectomy (CEA) is well established as the elective treatment for moderate or severe carotid stenoses with a history of neurological symptoms. In contrast, the merits of carotid revascularization performed as an emergency procedure in patients with acute stroke or fluctuating neurological deficit remain controversial.

Patients and methods

A total of 656 CEAs were performed on 621 patients for 330 (50.3%) symptomatic and 326 (49.7%) asymptomatic carotid stenoses within an 8-year period between January 1995 and June 2003. Of the latter, emergency CEA was performed on 30 patients (4.6%). Eleven patients presented with a crescendo TIA, and 19 patients presented with progressive neurological deficits corresponding to contralateral carotid stenosis within 4–24 h after the onset of symptoms. Patients selected for urgent surgery fulfilled the following criteria: acute onset of fluctuating hemispheric neurological symptoms, significant carotid pathology, absence of cerebral hemorrhage, uncompromised vigilance, and stable cardiopulmonary conditions.

Results

Following CEA, the neurological deficits improved instantaneously to complete recovery in 12 patients. The symptoms of nine patients improved to non-disabling deficits, remained unchanged in one, and worsened in three patients (one complete and two incomplete hemipareses). Of 30 patients, 24 were discharged within 8 days after admission. The neurological status after discharge deteriorated in only one of the patients during follow-up of 54 months, but improved in 7 of the patients.

Conclusion

Our retrospective study suggests that rescue CEA may be beneficial for selected patients with stroke in evolution and fluctuating neurological deficits. Careful adherence to selection criteria, intraoperative shunting, and intensive care post surgery surveillance are recommended.

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Danksagung

Die Autoren möchten sich für die Mitarbeit bei der Datenerhebung und Einbestellung der Patienten bei der leitenden Ambulanzschwester Frau Theresa Hohenthanner ganz besonders bedanken.

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Authors and Affiliations

  1. Abteilung für Gefäßchirurgie, Klinikum rechts der Isar, Technische Universität München

    R. B. Brauer, M. D. O. Barone, P. Heider & O. Wolf

  2. Abteilung für Gefäßchirurgie, Städtisches Krankenhaus München-Schwabing

    R. Brandl

  3. Chirurgische Klinik, Klinikum rechts der Isar, Ismaningerstr. 22, 81675, München

    R. B. Brauer

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  1. R. B. Brauer
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  2. M. D. O. Barone
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  3. P. Heider
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  4. O. Wolf
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  5. R. Brandl
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Correspondence to R. B. Brauer.

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Brauer, R.B., Barone, M.D.O., Heider, P. et al. Die notfallmäßige Karotis-TEA bei neurologisch instabilen Patienten. Gefässchirurgie 8 (Suppl 1), S14–S21 (2003). https://doi.org/10.1007/s00772-003-0304-5

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