Karotisstenose – Diagnostik und Therapie

Abstract

Carotid artery stenosis is one of the prominent prerequisites of ischemic stroke. It is mandatory to differentiate symptomatic from asymptomatic carotid artery stenosis because it significantly impacts further treatment. Antiplatelet therapy and aggressive treatment of vascular risk factors are the mainstays of treatment. Since randomized trials comparing carotid endarterectomy with former „best medical treatment” have been published, surgery emerged as gold standard in symptomatic and asymptomatic patients.

Nevertheless, CAS represents an alternative treatment option, not only in symptomatic but also in asymptomatic patients with carotid artery stenosis. Large registries and randomized trials have shown comparable results regarding periprocedural stroke, myocardial infarction, or death.

Kernaussagen

• Die extrakranielle Karotisstenose ist in 10 – 36 % Ursache aller ischämischen Schlaganfälle.

• Die klinische Symptomatik und der Stenosegrad sind die wesentlichen Prognosefaktoren der Karotisstenose. Nach den NASCET-Kriterien werden 3 Stenosegrade unterschieden: leichtgradig (< 50 %), mittelgradig (50 – 69 %) und hochgradig (≥ 70 %). Als klassische Symptome einer relevanten Karotisstenose gelten die ipsilaterale Amaurosis fugax, die kontralaterale Hemiparese oder Hemihypästhesie, die Dysarthrie oder Aphasie.

• Diagnostisch kommen die Doppler-/Duplexsonografie und ggf. die CT/MRT zum Einsatz.

• Patienten, deren Karotisstenose symptomatisch und hochgradig ist, profitieren von einer frühen Revaskularisation. Bei mittelgradigen symptomatischen Stenosen ist der therapeutische Nutzen ebenfalls noch vorhanden. Die Revaskularisation sollte innerhalb von 2 Wochen nach dem Indexereignis stattfinden. Bei asymptomatischer Karotisstenose ist ein chirurgisches oder interventionelles Vorgehen sinnvoll, falls der Stenosegrad > 70 % beträgt und die periinterventionelle 30-Tage-Komplikationsrate < 3 % beträgt.

• Für Patienten mit kardiovaskulärem Risikoprofil oder bereits vorhandener Karotisstenose ist die Risikofaktorenintervention und medikamentöse Therapie Grundstein der Therapie.

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