Neues beim Schlaganfall

Trotz weiterentwickelter Therapieverfahren erleiden heute weltweit nach wie vor mehr als 10 Millionen Menschen pro Jahr einen Schlaganfall. Diese Übersichtsarbeit fasst neue Erkenntnisse zur Epidemiologie, Diagnostik, Akuttherapie sowie Primär- und Sekundärprävention des Schlaganfalls aus den Jahren 2015 und 2016 zusammen.

Abstract

This review summarizes new findings on epidemiology, diagnosis, acute therapy, primary and secondary prevention of stroke published in 2015 and 2016. Recent epidemiological studies show that treatable risk factors such as hypertension, diabetes mellitus, smoking, physical inactivity, nutrition and stress can explain 90 % of stroke risk. In patients with asymptomatic high degree carotid stenosis, stenting has a similar complication rate as endarterectomy. New randomised studies and results from large-scale registries indicate that systemic thrombolysis of acute ischemic stroke can be safely performed in more patients than originally labelled for. This applies to patients > 80 years, with severe strokes or with systolic blood pressure values > 160 mmHg. Patients with dissection of brain supplying arteries also benefit from thrombolysis. In patients treated with non-vitamin-K dependent oral anticoagulants (NOAC) for stroke prevention in atrial fibrillation (AF), thrombolysis can be performed if the last intake was ago long enough that coagulation parameters are normal. The most effective treatment of acute occlusions of the distal internal carotid artery and the proximal middle cerebral artery is systemic thrombolysis with rt-PA followed by mechanical thrombectomy with a stent-retriever (number needed to treat = 2.6 for good functional outcome). In patients with mild to moderate ischemic stroke or high-risk TIA, ticagrelor was not superior to aspirin in the prevention of recurrent stroke, MI or vascular death. However, ticagrelor was superior to aspirin in preventing recurrent ischemic stroke. In patients with acute cerebral haemorrhage and high blood pressure, lowering of blood pressure has only minor efficacy. In patients with vitamin-K antagonist related intracerebral haemorrhage, Prothrombin complex concentrate (PPSB) is more effective than fresh frozen plasma (FFP). Occlusion of patent foramen ovale in patients with cryptogenic stroke should be restricted to selected cases.

Kernaussagen

• Große epidemiologische Studien zeigen, dass behandelbare Risikofaktoren wie die arterielle Hypertonie, Diabetes mellitus, Rauchen, Bewegungsmangel und Ernährung bis zu 90 % des Schlaganfallrisikos erklären.

• Bei asymptomatischen Karotisstenosen haben die Operation und das Stenting vergleichbare Komplikationsraten.

• In randomisierten Studien und großen Registern hat sich gezeigt, dass sehr viel mehr Patienten als früher für eine systemische Thrombolyse mit rt-PA zugänglich sind. Dies betrifft Patienten über 80 Jahre, Patienten mit schweren Schlaganfällen und Patienten mit einem systolischen Blutdruck über 160 mmHg. Auch Patienten mit Dissektionen der hirnversorgenden Arterien profitieren von einer Lyse. Die Lyse kann auch bei Einnahme von NOAK durchgeführt werden, wenn die letzte Einnahme so lange zurückliegt, dass die Gerinnungswerte normal sind. Die wirksamste Therapie distaler Karotisverschlüsse und von Verschlüssen der proximalen A. cerebri media ist die Lyse, gefolgt von der mechanischen Thrombektomie mit einer NNT von 2,6 für ein gutes Outcome.

• Der Thrombozytenfunktionshemmer Ticagrelor war in der frühen Prävention des ischämischen Schlaganfalls oder nach transitorisch-ischämischer Hochrisikoattacke nicht wirksamer als Azetylsalizylsäure für den kombinierten vaskulären Endpunkt aus Schlaganfall, Myokardinfarkt und vaskulärem Tod. Diese Substanz verhinderte allerdings signifikant ischämische Insulte.

• Bei der Therapie zerebraler Blutungen ist bei hohen Blutdruckwerten die Blutdrucksenkung nur marginal wirksam.

• In der Therapie von durch Vitamin-K-Antagonisten induzierten zerebralen Blutungen ist PPSB besser wirksam als FFP.

• Der Verschluss eines PFO bei Patienten mit kryptogenem Schlaganfall ist bei < 60-jährigen Patienten gerechtfertigt.

Schlüsselwörter

Schlaganfall - Prävention - Akuttherapie - zerebrale Blutung - offenes Foramen ovale

Keywords

stroke - prevention - acute therapy - cerebral haemorrhage - patent foramen ovale

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