Akutdiagnostik und Akuttherapie des ischämischen Insultes

Zusammenfassung

In Deutschland treten pro Jahr etwa 200 000 erstmalige Schlaganfälle, zumeist ischämische Insulte auf. Durch große randomisierte Studien ist der therapeutische Nutzen der Behandlung auf einer Schlaganfall-Spezialstation (Stroke Unit) und die Rekanalisationstherapie durch systemische Thrombolyse belegt. Die Diagnostik umfasst neben der Erhebung des neurologischen Befundes eine zerebrale Bildgebung mittels CT oder MRT mit CT-/MR-Angiographie, Ultraschall der hirnversorgenden Arterien, EKG und Langzeit-EKG und – wenn indiziert – transösophageale Echokardiographie. Die frühe Sekundärprävention besteht zumeist aus Acetylsalicylsäure, im weiteren Verlauf orientiert sich die Sekundärprophylaxe an der Pathophysiologie. Bei hämodynamisch oder arterio-arteriell bedingten zerebralen Infarkten durch hochgradige Stenosen der A. carotis interna erfolgt eine Carotisendarterektomie oder Stent-gestützte Angioplastie. Bei kardialer Embolie aufgrund von Vorhofflimmern wird nach der Akutphase eine orale Antikoagulation mit Vitamin K-Antagonisten oder neuen oralen Antikoagulantien eingeleitet. Bei den übrigen Patienten sowie in der Akutphase erfolgt die Sekundärprävention durch Thrombozytenfunktionshemmer.

Abstract

The incidence of first stroke in Germany is about 200.000, most of which are ischemic. The benefit of stroke unit treatment and systemic thrombolysis has been shown in large randomized trials. Diagnostic work-up besides neurologic examination includes cerebral imaging by CT or MR imaging including angiography, ultrasound of brain supplying arteries, ECG and Holter ECG and – if indicated – transesophageal echocardiography. Aspirin is the cornerstone of early secondary prevention in the acute phase, thereafter secondary prevention is determined by stroke etiology. Carotid endarterectomy or stent-assisted angioplasty are indicated in patients with hemodynamic or arterio-arterial stroke etiologies due to high-grade carotid stenosis. For cardioembolism due to atrial fibrillation, oral anticoagulation with vitamin K-antagonists or new oral anticoagulants should be started after the acute phase. In patients with non-cardioembolic stroke etiologies, platelet inhibitors are used for secondary prevention.

Schlüsselwörter

Schlaganfall - Hirninfarkt - zerebrale Ischämie - Bildgebung - Sekundärprophylaxe - Antikoagulation - Thrombozytenfunktionshemmer

Keywords

Stroke - ischemic stroke - cerebral ischemia - imaging - secondary stroke prevention - anticoagulation - platelet inhibitors

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