Entscheidungsfaktoren gegen die Durchführung einer Thrombektomie bei ischämischem Schlaganfall und großem Gefäßverschluss
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Abstract
A stroke is one of the leading causes of death in Germany and worldwide. It is also a major cause of morbidity and, if not treated promptly, can lead to a significant reduction in quality of life. There are various therapeutic options available in the acute phase for the treatment of ischemic stroke that can significantly improve prognosis. Among these, intravenous systemic thrombolysis plays a central role in this regard. However, in the case of a proximal vessel occlusion, systemic thrombolysis alone is often insufficient, as it typically involves a long thrombus. In such cases, mechanical recanalization (thrombectomy) combined with thrombolysis can significantly improve prognosis.
Thrombectomy is increasingly used in clinical practice nowadays. The indications for this procedure are often determined on an individual basis and are based on the sometimes very different inclusion and exclusion criteria of landmark studies on thrombectomy. This individualized approach can sometimes lead to decisions against this therapy. The aim of this retrospective study was to analyze the factors that played a role in deciding against thrombectomy. A total of 120 patients with a principal indication for thrombectomy were examined from a total stroke cohort of 1,069 patients who were presented at Siegen Hospital with ischemic stroke between January 1, 2019, and December 31, 2019.
The patients included in the study had proximal vessel occlusions at various locations (M1- or M2-segment of the middle cerebral artery, M1-segment of the middle cerebral artery as well as proximal internal carotid artery, distal internal carotid artery). Overall, the proportion of patients who did not undergo thrombectomy was small. 100 patients underwent thrombectomy, while 20 did not. The investigated decision-making parameters included the severity of the stroke, patient age, degree of new or pre-exisiting disability, use of antiplatelet or anticoagulant medications, temporal factors (e.g. time of presentation at the hospital), radiological findings (e.g. infarct demarcation), as well as vascular and cardiovascular risk factors.
The analysis identified that only age, initial stroke severity, and the extent of disability at presentation had a significant influence on the decision for thrombectomy. However, five key reasons were identified for why thrombectomy was not performed in some cases. These reasons were: a low stroke severity at presentation (NIHSS ≤ 4) without disabling symptoms (35%), advanced age combined with multimorbidity (30%), improving symptoms with a significant reduction in severity after intravenous thrombolysis or spontaneous improvement of symptoms (15%), patient refusal of the procedure (15%), and extensive infarct demarcation in CT or MRI (5%).
The results of this study, also taking into account current literature, suggest that patients with M1 occlusion and an extensive tissue at risk (penumbra) should be particularly considered for mechanical thrombectomy, even with a low NIHSS, and should not automatically be excluded from therapy. Furthermore, thrombectomy in older and multimorbid patients is not necessarily associated with poor outcomes. The benefit of the therapy is highly individual. Therefore, age should not be the sole exclusion criterion for a thrombectomy decision. The older and more multimorbid the patient is, the more individualized the decision for or against mechanical thrombectomy should be. Additionally, careful monitoring in the stroke unit of patients showing improving symptoms is of great importance to quickly diagnose any neurological deterioration and, if necessary, reassess the indication for thrombectomy. If the patient refuses thrombectomy, the issue of consent capacity should be evaluated. If the patient is capable of consent, a very individualized and detailed explanation of the benefits versus risks of therapy should be provided. If consent capacity is lacking, the decision must be made by the treating physician in an emergency setting. Since this is a potentially life-threatening condition, the treatment is covered under the physician’s duty of care. Furthermore, for patients with large infarct volumes, a trial of endovascular thrombectomy as a last resort should be considered, taking potential complications into account. This is particularly relevant for younger patients at higher risk of malignant middle cerebral artery infarction.
In conclusion, I find that in patients with acute ischemic stroke and proximal vessel occlusion, thrombectomy should be pursued in cases of doubt, as the spontaneous prognosis is generally poor, whereas the complication rate of thrombectomy is low.
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Issued: 2026-01-13
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FB20:Medizin
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de
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DoctoralThesis
Keywords
ThrombektomieSchlaganfallLVOGroßer GefäßverschlussNIHSSNiedriger NIHSSHirninschämieASPECTThrombolyseInfarktdemarkationZeitfenster
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Alatawi, Abdelkareem: Entscheidungsfaktoren gegen die Durchführung einer Thrombektomie bei ischämischem Schlaganfall und großem Gefäßverschluss. : 2026-01-13.
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