Endovaskulär interventionelles Notfallmanagement des akuten A. carotis-interna-Verschlusses

Endovaskulär interventionelles Notfallmanagement des akuten A. carotis-interna-Verschlusses

Eine retrospektive Analyse

Endovascular interventional management of acute internal carotid artery occlusion

A retrospective analysis

Philip Hoth

Doctoral thesis

Date of Examination: 2013-11-27

Date of issue: 2013-11-04

Advisor: Knauth, Michael Prof. Dr.

Referee: Mielke, Dorothee PD Dr.

Referee: Virsik-Köpp, Patricia Prof. Dr.

Persistent Address: http://hdl.handle.net/11858/00-1735-0000-0001-BC1E-A

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Abstract

English

Untreated acute occlusion of the internal carotid artery (ICA) comes along with high morbidity and mortality. The incidence rate is about 6 per 100000 persons a year. While for treatment of ICA stenosis interventional stent placement is an established method only few experience has been made with acute occlusion of the ICA. From january 2005 to march 2011 twentysix patients according to our criterions of inclusion were treated by emergency percutaneous transluminal angioplasty (PTA). The aim of this retrospective analysis was to evaluate the clinical benefit of PTA in acute ICA occlusion. Beside different kinds of occlusions and their origins periprocedural characteristics with influence on the methodical approach were particularly considered. After acquisition of epidemiological and clinical attributes from the health record the preinterventional imaging was evaluated. Depending on their availability CT- or MRT-maps were used to assess the degree of irreversible damaged infarct core and „tissue at risk“. Afterwards, the available images of the intervention itself with consideration of interventional protocol, interventional times, kind of occlusion and complications were analysed. To evaluate the result of reconstruction Qureshi- and Thrombolysis in Cerebral Infarction (TICI)-Scores were used. Both scores characterize patterns of cerebral perfusion. Finally the size of infarction was determined from postinterventional imaging. Reperfusion of the ICA was succesfull in 100% of the cases. Nineteen of twentysix acute occlusions of the ICA were caused by thrombemboly while seven were caused by dissection. The methodical approach was different in dissections, as beside confirming the correct lumen a more defensive procedure without ICA-dilatation was used. Thrombembolic material in the niveau of the artery wall should not be exprimated into the lumen. For both kinds of occlusions each used methodical approach was successfull. Due to high rates of intracranial tandem occlusions an intracranial reconstruction of vessels subsequent to the reperfusion of the ICA was needed in most cases. Close examination of the interventional times showed that later reconstruction of intracranial vessels took most of the overall time. In most cases this reconstruction was not completely successfull. Although all ICA-occlusions could be managed, in 40% of the patients the final size of infarction increased. Intracranial tandem occlusions, especially of the mid cerebral artery (MCA), had a bad prognosis. This corresponds to the experience of other authors (Jovin et al., 2005; Miyamoto et al., 2008). The most frequent complication was distal embolisation with seven cases (27%). Three of these were observed after probing the occlusion and four after placing the stent. Distal protection systems were used in three patients. The prevention of embolisation failed in one of these cases. The data on hand suggests that for acute occlusion of the ICA protection systems could play an important role. Especially proximal protection systems provide an interesting approach, as protection during probing of the occlusion is available.

Keywords: Stent; Internal carotid artery; occlusion