Aktuelles zur Diagnostik und Therapie der asymptomatischen Karotisstenose

Zusammenfassung

Obwohl in den letzten Jahren wesentliche Fortschritte in der Akutbehandlung des Schlaganfalls zu verzeichnen sind (Thrombolyse, Behandlung auf der Stroke-Unit, optimierte Frührehabilitation) stellt der Schlaganfall nach wie vor die häufigste zu dauerhafter Behinderung führende Erkrankung dar. Von daher kommt einer gezielten Primärprävention eine wesentliche Bedeutung zu.

10 - 20 % aller zerebralen Ischämien werden durch Stenosen oder Verschlüsse der extrakraniellen Arteria carotis verursacht. In dieser Übersichtsarbeit werden Indikation, Diagnostik und aktuelle Datenlage zur konservativen, endovaskulären und operativen Therapie einer asymptomatischen Karotisstenose dargestellt.

Summary

Stroke is the leading cause of long-term major disability in developed countries, although several improvements could be achieved in acute stroke therapy (e. g. thrombolysis, stroke-unit treatment, optimized early rehabilitation strategies). Therefore, primary prevention is essential to reduce the burden of stroke.

10 -20 % of all cerebral ischemias are caused due to stenosis or occlusion of the extracranial carotid arteries. This review summarizes the indications, diagnostics as well as the actual data for a medical, endovascular or operative treatment of asymptomatic carotid stenosis.

Schlüsselwörter

Schlaganfall - Prävention - asymptomatische Karotisstenose - Therapie - Diagnostik

Key words

stroke - prevention - asymptomatic carotid stenosis - therapy - diagnostics

Literatur

• 1 Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST).  Lancet. 1998;  351 1379-1387
• 2 Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial.  Lancet. 2001;  357 1729-1737
• 3 x x. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial.  Lancet. 2002;  360 7-22
• 4 Alberts M J. Results of a multicenter prospective randomized trial of carotid artery stenting vs. carotid endarterectomy.  Stroke. 2001;  32 325d (Abstract)
• 5 Amarenco P, Bogousslavsky J, Callahan 3rd A. et al . High-dose atorvastatin after stroke or transient ischemic attack.  N Engl J Med. 2006;  355 549-559
• 6 Amarenco P, Labreuche J, Lavallee P, Touboul P J. Statins in stroke prevention and carotid atherosclerosis: systematic review and up-to-date meta-analysis.  Stroke. 2004;  35 2902-2909
• 7 Back M R, Rogers G A, Wilson J S. et al . Magnetic resonance angiography minimizes need for arteriography after inadequate carotid duplex ultrasound scanning.  J Vasc Surg. 2003;  38 422-430
• 8 Baker W H, Howard V J, Howard G, Toole J F. Effect of contralateral occlusion on long-term efficacy of endarterectomy in the asymptomatic carotid atherosclerosis study (ACAS). ACAS Investigators.  Stroke. 2000;  31 2330-2334
• 9 Bates E R, Babb J D, Casey Jr D E. et al . ACCF/SCAI/SVMB/SIR/ASITN 2007 clinical expert consensus document on carotid stenting: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (ACCF/SCAI/SVMB/SIR/ASITN Clinical Expert Consensus Document Committee on Carotid Stenting).  J Am Coll Cardiol. 2007;  49 126-170
• 10 Bond R, Rerkasem K, Shearman C P, Rothwell P M. Time trends in the published risks of stroke and death due to endarterectomy for symptomatic carotid stenosis.  Cerebrovasc Dis. 2004;  18 37-46
• 11 Brooks W H, McClure R R, Jones M R, Coleman T L, Breathitt L. Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomized trial in a community hospital.  Neurosurgery. 2004;  54 318-324
• 12 Chaturvedi S, Bruno A, Feasby T. et al . Carotid endarterectomy-an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.  Neurology. 2005;  65 794-801
• 13 Colhoun H M, Betteridge D J, Durrington P N. et al . Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial.  Lancet. 2004;  364 685-696
• 14 Collaborators. NASCET. . Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.  N Engl J Med. 1991;  325 445-453
• 15 Collins R, Peto R, MacMahon S. et al . Blood pressure, stroke, and coronary heart disease. Part 2, Short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context.  Lancet. 1990;  335 827-838
• 16 Dodick D W, Meissner I, Meyer F B, Cloft H J. Evaluation and management of asymptomatic carotid artery stenosis.  Mayo Clin Proc. 2004;  79 937-944
• 17 Dupuis F, Atkinson J, Liminana P, Chillon J M. Comparative effects of the angiotensin II receptor blocker, telmisartan, and the angiotensin-converting enzyme inhibitor, ramipril, on cerebrovascular structure in spontaneously hypertensive rats.  J Hypertens. 2005;  23 1061-1066
• 18 Eckstein H H, Heider P, Wolf O. Chirurgische Therapie extracranieller Carotisstenosen: Schlaganfallprophylaxe auf höchstem Evidenzniveau.  Deutsches Ärzteblatt. 2004;  101 2753-2763
• 19 Fayad P. Endarterectomy and stenting for asymptomatic carotid stenosis: a race at breakneck speed.  Stroke. 2007;  38 707-714
• 20 Gaede P, Vedel P, Larsen N. et al . Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes.  N Engl J Med. 2003;  348 383-393
• 21 Goldstein L B, Adams R, Alberts M J. et al . Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: the American Academy of Neurology affirms the value of this guideline.  Stroke. 2006;  37 1583-1633
• 22 Grau A J, Weimar C, Buggle F. et al . Risk factors, outcome, and treatment in subtypes of ischemic stroke: the German stroke data bank.  Stroke. 2001;  32 2559-2566
• 23 Halliday A, Mansfield A, Marro J. et al . Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial.  Lancet. 2004;  363 1491-1502
• 24 Hennerici M, Hulsbomer H B, Hefter H, Lammerts D, Rautenberg W. Natural history of asymptomatic extracranial arterial disease. Results of a long-term prospective study.  Brain. 1987;  110 777-791
• 25 Lawes C M, Bennett D A, Feigin V L, Rodgers A. Blood pressure and stroke: an overview of published reviews.  Stroke. 2004;  35 1024
• 26 Mas J L, Chatellier G, Beyssen B. et al . Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis.  N Engl J Med. 2006;  355 1660-1671
• 27 Mathiesen E B, Bonaa K H, Joakimsen O. Echolucent plaques are associated with high risk of ischemic cerebrovascular events in carotid stenosis: the tromso study.  Circulation. 2001;  103 2171-2175
• 28 Moore W S, Vescera C L, Robertson J T. et al . Selection process for surgeons in the Asymptomatic Carotid Atherosclerosis Study.  Stroke. 1991;  22 1353-1357
• 29 Naylor A R, Bolia A, Abbott R J. et al . Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial.  J Vasc Surg. 1998;  28 326-334
• 30 Nighoghossian N, Derex L, Douek P. The vulnerable carotid artery plaque: current imaging methods and new perspectives.  Stroke. 2005;  36 2764-2772
• 31 Rijbroek A, Wisselink W, Vriens E M. et al . Asymptomatic carotid artery stenosis: past, present and future. How to improve patient selection?.  European Neurology. 2006;  56 139-154
• 32 Ringleb P A, Allenberg J, Bruckmann H. et al . 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial.  Lancet. 2006;  368 1239-1247
• 33 Rothwell P M. ACST: which subgroups will benefit most from carotid endarterectomy?.  Lancet. 2004;  364 1122-1123
• 34 Spence J D, Tamayo A, Lownie S P, Ng W P, Ferguson G G. Absence of microemboli on transcranial Doppler identifies low-risk patients with asymptomatic carotid stenosis.  Stroke. 2005;  36 2373-2378
• 35 Staessen J A, Wang J G, Thijs L. Cardiovascular protection and blood pressure reduction: a meta-analysis.  Lancet. 2001;  358 1305-1315
• 36 Study ECftACA. Endarterectomy for asymptomatic carotid artery stenosis.  JAMA. 1995;  273 1421-1428
• 37 Takaya N, Yuan C, Chu B. et al . Association between carotid plaque characteristics and subsequent ischemic cerebrovascular events: a prospective assessment with MRI - initial results.  Stroke. 2006;  37 818-823
• 38 Wardlaw J M, Chappell F M, Best J J, Wartolowska K, Berry E. Non-invasive imaging compared with intra-arterial angiography in the diagnosis of symptomatic carotid stenosis: a meta-analysis.  Lancet. 2006;  367 1503-1512
• 39 Wasserman B A, Wityk R J, Trout 3rd  H H, Virmani R. Low-grade carotid stenosis: looking beyond the lumen with MRI.  Stroke. 2005;  36 2504-2513
• 40 Weimar C, Diener H C. Diagnose und Therapie der Schlaganfallbehandlung in Deutschland.  Dtsch Ärztebl. 2003;  100 A2576-A2582
• 41 Wilcox R, Bousser M G, Betteridge D J. et al . Effects of pioglitazone in patients with type 2 diabetes with or without previous stroke: results from PROactive (PROspective pioglitAzone Clinical Trial In macroVascular Events 04).  Stroke. 2007;  38 865-873
• 42 Williams B, Lacy P S, Thom S M. et al . Differential impact of blood pressure-lowering drugs on central aortic pressure and clinical outcomes: principal results of the Conduit Artery Function Evaluation (CAFE) study.  Circulation. 2006;  113 1213-1225
• 43 Yadav J S, Wholey M H, Kuntz R E. et al . Protected carotid-artery stenting versus endarterectomy in high-risk patients.  N Engl J Med. 2004;  351 1493-1501