Was gibt es Neues beim Schlaganfall?

Zusammenfassung

Diese Übersichtsarbeit informiert über Studienergebnisse des vergangenen Jahres zum Thema ischämischer und hämorrhagischer Schlaganfall und stellt Konferenzbeiträge der Internationalen und Europäischen Schlaganfallkonferenz 2010 vor, die noch nicht publiziert worden sind. Hervorzuheben sind die Ergebnisse der inzwischen veröffentlichten ICSS- und CREST-Studien, die randomisiert die Karotis-Thrombendarteriektomie und das Karotisstenting verglichen. In der ICSS-Studie war die Karotis-Thrombendarteriektomie dem Karotisstenting bei symptomatischen Karotisstenosen in dem bisher analysierten 120-Tages-Zeitraum hinsichtlich Schlaganfall, Tod und periprozeduralem Herzinfarkt überlegen. In CREST wurden sowohl Pat. mit asymptomatischen und symptomatischen ≥ 70 %igen Karotisstenosen eingeschlossen. Hier zeigte sich kein signifikanter Behandlungsunterschied hinsichtlich des primären kombinierten Endpunktes (periprozeduraler Schlaganfall, Myokardinfarkt oder Tod und ipsilateraler Schlaganfall innerhalb von 4 Jahren nach dem Eingriff). Bei Patienten unter 70 Jahren war die periprozedurale Komplikationsrate signifikant niedriger beim Stenting und bei Patienten über 70 Jahren signifikant niedriger bei der Operation. Weiterhin gibt es kein Neuroprotektivum beim ischämischen Schlaganfall, auch Erythropoietin war nicht wirksam gewesen. Mit dem direkten Thrombininhibitor Dabigatran steht möglicherweise bald eine Alternative zu Vitamin-K-Antagonisten für die Schlaganfallprophylaxe bei Vorhofflimmern zur Verfügung. In der RE-LY-Studie war die niedrige Dosis von Dabigatran genauso wirksam wie Warfarin, die höhere Dosis signifikant wirksamer. Die Rate schwerwiegender Blutungskomplikationen war zwischen Warfarin und der höheren Dosis von Dabigatran vergleichbar und bei der niedrigeren Dosis signifikant geringer. Wie die früheren Studien konnte auch die große industrieunabhängige VITATOPS-Studie keine Wirksamkeit von B-Vitaminen in der Schlaganfallsekundärprophylaxe zeigen.

Abstract

The results of recently published trials dealing with ischaemic and haemorrhagic stroke and conference proceedings from the International and the European Stroke conference 2010 are presented. Carotid endarterectomy was compared with carotid stenting in two trials, the International Carotid Stenting Study (ICSS) and the North American Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST). The incidence of stroke, death, or procedural myocardial infarction during the first 120 days was significantly lower in the endarterectomy group in ICSS. CREST randomly assigned patients with symptomatic or asymptomatic carotid stenosis ≥ 70 % and did not show a significant difference in the estimated 4-year rates of the combined end point stroke, myocardial infarction, or death from any cause during the periprocedural period or any ipsilateral stroke within 4 years. However, periprocedural complication rates were significantly lower in patients aged < 70 years treated with stenting and in patients > 70 years treated with endarterectomy. There is still no neuroprotective agent available in ischaemic stroke. Erythropoietin also failed to be efficacious. The direct thrombin inhibitor dabigatran might soon be used as an alternative to vitamin K-antagonists in patients with atrial fibrillation. In the randomised RE-LY trial, dabigatran given at a lower dose was associated with rates of stroke and systemic embolism that were similar to those associated with warfarin, as well as lower rates of major haemorrhage. Dabigatran administered at a higher dose was associated with lower rates of stroke and systemic embolism but similar rates of major haemorrhage. Similar to previous randomised trials, the investigator-initiated Vitamins to Prevent Stroke (VITATOPS) trial found no significant benefit for secondary stroke prevention to supplementation with B vitamins.

Schlüsselwörter

Schlaganfall - Akuttherapie - Prävention - Karotisstenose - intrakranielle Blutung

Keywords

stroke - acute therapy - stroke prevention - carotid stenosis - intracranial haemorrhage

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