Schlaganfall als periprozedurale Komplikation kardialer Interventionen

ZUSAMMENFASSUNG

Der periprozedurale Schlaganfall gehört zu den relevantesten Komplikationen kardialer Interventionen und beeinflusst die Prognose der Betroffenen. Interventions-spezifische Faktoren, Patienten-spezifische Faktoren als auch die Erfahrung des Interventionalisten bzw. des intervenierenden Zentrums bestimmen das periprozedurale Schlaganfallrisiko. Anhand einer intensiven Auseinandersetzung mit möglichen Risikofaktoren für einen Schlaganfall, dem verstärkten Einsatz bildgebender Verfahren und technischer Weiterentwicklungen konnte in den letzten Jahren eine Senkung des periprozeduralen Schlaganfallrisikos erreicht werden, das nach kardialer Operation etwa 1 %, nach katheterbasiertem Verfahren zwischen 0,1–3 % und nach Kardioversion etwa 0,1 % beträgt.

Relevant für die Therapie des periprozeduralen Schlaganfalls erscheint neben einer diesbezüglichen interdisziplinären Awareness die Vorhaltung von Standard Operating Procedures (SOPs), die neben präventiven Maßnahmen, das Blutdruckmanagement, die post-interventionelle Gerinnungshemmung als auch deren Antagonisierung im Falle einer (intrakraniellen) Blutung adressieren. Nach akuter zerebraler Ischämie mit behinderndem neurologischem Defizit kann im interdisziplinären Dialog auf der Basis einer Einzelfallentscheidung nach bestimmten kardialen Prozeduren eine systemische Thrombolyse und/oder eine mechanische Rekanalisation erwogen werden, auch wenn keine spezifischen Studien zur Effizienz und Sicherheit dieser Therapieverfahren für prozedurassoziierte Schlaganfälle vorliegen.

ABSTRACT

Procedure-related stroke is one of the most relevant complications of cardiac interventions and impacts on the prognosis of affected patients. The peri-procedural stroke risk is related to intervention-specific factors, patient-related factors and to the experience of the interventionist and the intervening center, respectively. Due to an intensive analysis of potential stroke risk factors, the increased use of imaging techniques and technical developments, there is a reduction of peri-procedural stroke rate in recent years. In general, peri-procedural stroke risk after cardiac surgery is about 1 %, 0.1–3 % after catheter-based interventions, and about 0.1 % after cardioversion of atrial fibrillation. In addition to interdisciplinary awareness regarding peri-procedural stroke, standard operating procedures (SOPs) addressing preventive measures, blood pressure management, post-interventional coagulation management as well as immediate antagonization of anticoagulation in case of (intracranial) bleeding appear to be relevant. In case of acute ischemic stroke with clinically-relevant neurological deficit, intravenous thrombolysis and/or endovascular treatment can be considered case-by-case after specific cardiac interventions, despite of the fact that there are no studies demonstrating efficacy and safety after procedure-related stroke.

Schlüsselwörter

Ischämischer Schlaganfall - MRT - Katheterintervention - kardiale Operation - Antikoagulation - Prävention

Key words

Stroke - MRI - catheter based intervention - cardiac surgery - anticoagulation - prevention

Publication History

Article published online:
14 December 2020

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