Aktuelle Neurologie 2011; 38(08): 428-435
DOI: 10.1055/s-0031-1297240
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

Schlaganfallprävention: intrakranielle arterielle Stenosen

Stroke Prevention: Intracranial Arterial Stenoses
E. R. Gizewski
1   Neuroradiologie, Universitätsklinikum Gießen und Marburg, Justus-Liebig Universität Gießen
,
A. E. Grams
1   Neuroradiologie, Universitätsklinikum Gießen und Marburg, Justus-Liebig Universität Gießen
,
M. Kaps
2   Neurologische Klinik, Universitätsklinikum Gießen und Marburg, Justus-Liebig Universität Gießen
› Author Affiliations
Further Information

Publication History

Publication Date:
14 December 2011 (online)

Zusammenfassung

Intrakranielle arterielle Stenosen (IAS) sind für etwa 6,5–8% aller ischämischen Schlaganfälle verantwortlich. Für Patienten mit einer symptomatischen IAS wurde bislang trotz medikamentöser Sekundärprophylaxe innerhalb eines Jahres ein hohes Reinsultrisiko bis zu 12% in dem zugehörigen Gefäßterritorium beschrieben. Dabei haben IAS mit einem Stenosegrad ≥ 70% das höchste Reinsultrisiko (18%). Die Warfarin vs. Aspirin for Symptomatic Intracranial Stenosis Studie (WASID) führte zu der Empfehlung, dass bei symptomatischen IAS zunächst eine medikamentöse Sekundärprophylaxe mit Azetylsalizylsäure erfolgen sollte. Bei einem unter Thrombozytenfunktionshemmern auftretenden erneuten ischämischen Schlaganfall/TIA im Gefäßterritorium der symptomatischen IAS kann insbesondere bei Stenosen ≥ 70% eine interventionelle (stentgestützte) Angioplastie in einem spezialisierten Zentrum empfohlen werden. Zahlreiche aktuelle Veröffentlichungen legten nahe, dass durch die zunehmende Erfahrung der interventionell tätigen Neuroradiologen die periprozedurale Komplikationsrate zwischen 6 und 7% liegt, das Reinfraktrisiko bei bis zu 7,8% bei IAS > 70% liegen. Allerdings zeigte eine neue randomisierte Studie (SAMMPRIS), die bei symptomatischen IAS eine aggressive medikamentöse Sekundärprophylaxe mit der interven­tionellen Therapie vergliechen hat, dass in dieser Kohorte die Letalität im interventionellen Arm bei 14% lag, im medikamentösen Arm nur bei 5,8%. Eine abschließende Bewertung dieser noch sehr neuen Daten kann aktuell noch nicht erfolgen; ein Zwischenfazit könnte sein, dass eine endovaskuläre Therapie an speziellen Zentren in Betracht gezogen werden sollte wenn Patienten unter doppelter Thrombozytenfunktionshemmung weiterhin symptomatisch sind. Die Leitlinien werden sicher eine Weiterentwicklung und erneute Diskussion erfahren.

Abstract

Intracranial arterial stenosis (IAS) are responsible to 5–8% of all ischaemic strokes in Caucasian patients. For patients with symptomatic IAS even under optimal medical prevention, a high annual risk for recurrent ischaemic stroke of about 12% has been reported. High-grade IAS of ≥ 70% is associated with the highest recurrent stroke risk of 18%. The Warfarin vs. Aspirin for Symptomatic Intracranial Stenosis trial (WASID) led to the advice that IAS patients should be treated with aspirin. Patients who suffer a recurrent ischaemic stroke or a transient ischaemic attack under aspirin and stenosis ≥ 70% can be treated with endovascular stenting or angioplasty in specialised centres. The periprocedural complication rate of these endovascular techniques is about 6–7% in experienced neuro-interventional centres, the risk of recurrent stroke amounts to 7.8% in IAS > 70%. However, one recent randomised study (SAMMPRIS) comparing aggressive medical secondary prevention and endovascular therapy has shown a high complication rate for endovascular treatment with a mortality rate of 14% compared to 5.8% under aggressive medicamentous treatment. There is no final interpretation of the data yet. However, endovascular therapy might be considered in specialised centres if patients are still symptomatic under aggressive medical treatment. The guidelines have to be adopted and will certainly be subject of further discussion in the future.

 
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