Therapieentscheidung zur Thrombektomie: Rolle der zerebralen Bildgebung

Zusammenfassung

Der ischämische Schlaganfall ist eine potenziell reversible Erkrankung und bedarf einer schnellen Diagnostik und Therapie. Unbehandelt kann er innerhalb kürzester Zeit persistierende Behinderung oder Tod zur Folge haben. In dieser Übersichtsarbeit werden Techniken der nicht invasiven zerebralen Bildgebung erläutert und speziell ihre Rolle für die Therapieentscheidung zur Thrombektomie dargelegt.

Abstract

Six recent randomized controlled trials showed a significant benefit of endovascular therapy on patient outcome in acute ischemic stroke due to anterior cerebral artery occlusion. The positive results of these trials need to be implemented in clinical routine. Suitable patients should be evaluated for thrombectomy reliably and fast. All trials confirmed the role of pretherapeutic neuroimaging as crucial in selecting patients who can benefit from endovascular therapy. However, different approaches have been used, including imaging of the target vascular occlusion, infarct core, arterial collateral supply or the penumbra. In this review we discuss, in the context of the recent trials, the different methods of non-invasive neuroimaging and their role in decision-making for thrombectomy in acute ischemic stroke.

Kernaussagen

• Acht aktuelle randomisierte kontrollierte Studien haben einen signifikanten Behandlungseffekt der Thrombektomie auf den klinischen Verlauf bei Patienten mit akutem Schlaganfall aufgrund eines proximalen Gefäßverschlusses im vorderen Stromgebiet gezeigt.

• Alle Studien bestätigten die entscheidende Rolle einer prätherapeutischen Bildgebung in der Auswahl der Patienten, die von einer endovaskulären Therapie profitieren können. Dabei wurden jedoch unterschiedliche bildgebungsbasierte Ansätze mit Darstellung des behandelbaren Gefäßverschlusses, des Infarktkerns, der arteriellen Kollateralversorgung oder der Penumbra gewählt.

• Die native CT ist aufgrund ihrer weiten Verbreitung und der schnellen Durchführbarkeit oft die bildgebende Methode der ersten Wahl bei Schlaganfallpatienten. Der ASPECTS wird dabei verwendet, um das Ausmaß früher ischämischer Veränderungen des Mediastromgebiets systematisch zu erfassen. Das hyperdense Gefäßzeichen ist hochspezifisch, jedoch wenig sensitiv für einen Gefäßverschluss der A. cerebri media.

• Die CTA mit kontrastmittelverstärkter Darstellung der zerebralen Blutgefäße hat eine hohe Sensitivität und Spezifität für den Nachweis eines intrakraniellen Verschlusses. Mit ihr ist eine Lokalisation des Gefäßverschlusses möglich und sie liefert wichtige Informationen zur Interventionsplanung, zum Parenchymstatus und zur Kollateralversorgung.

• Die CTP mit Darstellung des Infarktkerns und der Penumbra hat eine zentrale Rolle in der Evalution von Schlaganfallpatienten für die Thrombektomie im erweiterten Zeitfenster.

• Die MRT ermöglicht einen hochspezifischen und -sensitiven Nachweis ischämischer Veränderungen, ist aber u. a. aufgrund ihrer Kontraindikationen für verschiedene Implantate und wegen ihrer hohen Artefaktanfälligkeit nur eingeschränkt bei Schlaganfallpatienten einsetzbar.

Schlüsselwörter

Schlaganfall - zerebrale Bildgebung - Thrombektomie

Keywords

stroke - neuroimaging - endovascular thrombectomy

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