Intravenöse Thrombolyse bleibt zentrales Behandlungselement

Zusammenfassung

Die Thrombolysetherapie (Lysetherapie) stellt das entscheidende und evidenzbasierte Instrument zur Behandlung des akuten ischämischen Hirninsultes dar. Mittlerweile stehen neben der intravenösen Lysetherapie intraarterielle und neue alternative Rekanalisationsverfahren (z. B. Sonothrombolyse) zur Verfügung. Im Folgenden sollen die entscheidenden Argumente für die i.v.-Lysetherapie als das weiterhin bedeutsamste Instrument zur Rekanalisationstherapie geliefert werden. Für die Priorisierung der i.v.-Lysetherapie im Vergleich zu intraarteriellen Verfahren sprechen: das höhere wissenschaftliche Evidenzniveau, die einzig vorliegende Zulassung, der reichhaltigere klinische Erfahrungsschatz, die Datenlage für betagte Patienten, die überlegene Verfügbarkeit, die raschere Applikationsmöglichkeit, auch bei unauffälliger Gefäßdarstellung, der bislang nicht belegte Vorteil intraarterieller Verfahren, das unbefriedigende Outcome trotz erfolgreicher endovaskulärer Intervention und die Eskalationsmöglichkeit mit sekundär-endovaskulären Verfahren. Insgesamt sind die verschiedenen Rekanalisationsverfahren nicht kompetitiv, sondern additiv-supplementär anzusehen. Bis auf Weiteres wird die i.v.-Lysetherapie das zentrale Element bleiben.

Summary

Thrombolytic therapy has been the key instrument for acute stroke treatment. Besides intravenous thrombolysis, currently intraarterial thrombolysis as well as new, alternative modalities (e. g. sonothrombolysis) are under discussion. In this article, the most relevant arguments are given, favouring IV-thrombolysis to remain the most important therapeutic modality: higher scientific evidence, official drug approval for this application mode, more profound clinical experience, significant safety data also for very old stroke victims, much higher availability, faster applicability, applicability also without vessel occlusion, lacking evidence of superiority of endovascular modalities, the “mismatch”-phenomenon of unfavourable clinical outcome despite successful endovascular procedure, and the remaining option of secondary endovascular treatment in case of unsuccessful IV-thrombolysis. In summary, the various recanalization modalities should considered to be additive rather than competitive. Specific algorithms need to be established to improve individual patient stratification for the optimum recanalization modality. Meanwhile, IV-thrombolysis will remain the key element for this purpose.

Schlüsselwörter

Schlaganfall - Hirninfarkt - Thrombolyse

Keywords

Stroke - cerebral infarction - thrombolysis

• Literatur

• 1 Ahmed N. et al. Implementation and outcome of thrombolysis with alteplase 3–4.5 h after an acute stroke: an updated analysis from SITS-ISTR. Lancet Neurol 2010; 9: 866-74.
• 2 Arnold M. et al. Intra-arterial thrombolysis in 100 patients with acute stroke due to middle cerebral artery occlusion. Stroke 2002; 33: 1828-33.
• 3 Berrouschot J. et al. Outcome and severe hemorrhagic complications of intravenous thrombolysis with tissue plasminogen activator in very old (> or = 80 years) stroke patients. Stroke 2005; 36: 2421-5.
• 4 Castaño C. et al. Mechanical thrombectomy with the Solitaire AB device in large artery occlusions of the anterior circulation: a pilot study. Stroke 2010; 41: 1836-40.
• 5 del Zoppo GJ. et al. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann Neurol 1992; 32: 78-86.
• 6 Demchuk AM. et al. Thrombolysis in brain ischemia (TIBI) transcranial doppler flow grades predict clinical severity, early recovery, and mortality in patients treated with intravenous tissue plasminogen activator. Stroke 2001; 32: 89-93.
• 7 Ford GA. et al. Intravenous alteplase for stroke in those older than 80 years old. Stroke 2010; 41: 2568-74.
• 8 Furlan A. et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 1999; 282: 2003-11.
• 9 Hacke W. et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359: 1317-29.
• 10 Heuschmann PU. et al. Schlaganfallhäufigkeit und Versorgung von Schlaganfallpatienten in Deutsch-land. Akt Neurol 2010; 37: 333-40.
• 11 IMS Study Investigators.. Combined intravenous and intra-arterial recanalization for acute ischemic stroke: the Interventional Management of Stroke Study. Stroke 2004; 35: 904-11.
• 12 Leitlinie der Deutschen Gesellschaft für Neurologie: www.dgn.org/inhalte-a-z/535-leitlinien-derdgn-akuttherapie-des-ischaemischen-schlaganfalls.html
• 13 Leitlinie der European Stroke Organisation: www.eso-stroke.org/pdf/ESO%20Guidelines_update_Jan_2009.pdf
• 14 Mikulik R. et al. Outcome of patients with negative CT angiography results for arterial occlusion treated with intravenous thrombolysis. Stroke 2009; 40: 868-72.
• 15 Nagel S. et al. Therapy of acute basilar artery occlusion: intraarterial thrombolysis alone vs. bridging therapy. Stroke 2009; 40: 140-6.
• 16 Neumann-Haefelin T. et al. Effect of incomplete (spontaneous and postthrombolytic) recanalization after middle cerebral artery occlusion: a magnetic resonance imaging study. Stroke 2004; 35: 109-14.
• 17 Pervez MA. et al. Remote supervision of IV-tPA for acute ischemic stroke by telemedicine or telephone before transfer to a regional stroke center is feasible and safe. Stroke 2010; 41: e18-24.
• 18 Riedel CH. et al. The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke 2011; 42: 1775-7.
• 19 Ritter MA. et al. CT angiography in acute stroke: does it provide additional information on occur-rence of infarction and functional outcome after 3 months?. Cerebrovasc Dis 2006; 22: 362-7.
• 20 Schonewille WJ. et al. Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study. Lancet Neurol 2009; 8: 724-30.
• 21 Stolz E, Hamann GF, Kaps M, Misselwitz B. Regionale Unterschiede in den Zuweisungs- und Thrombolyseraten bei akutem Hirninfarkt in Hessen. Dtsch Arztebl Int 2011; 108: 607-11.
• 22 Tanne D. et al. Intravenous tissue plasminogen activator for acute ischemic stroke in patients aged 80 years and older: the tPA stroke survey experience. Stroke 2000; 31: 370-5.
• 23 The National Institute of Neurological Disorders and Stroke rtPA Stroke Study Group.. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333: 1581-7.
• 24 Wahlgren N. et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet 2007; 369: 275-82.
• 25 Wardlaw JM. et al. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev 2003: CD000213.