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DOI: 10.1055/s-0028-1090146
© Georg Thieme Verlag KG Stuttgart · New York
Diagnostik, Prognose und Therapie von symptomatischen intrakraniellen Stenosen
Diagnosis, Prognosis and Therapy of Symptomatic Intracranial StenosisPublication History
Publication Date:
03 February 2009 (online)
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Zusammenfassung
Intrakranielle arterielle Stenosen (IAS) finden sich bei Kaukasiern bei etwa 6,5–8 % aller ischämischen Schlaganfälle. Patienten mit einer symptomatischen IAS haben trotz medikamentöser Sekundärprophylaxe innerhalb eines Jahres ein hohes Reinsultrisiko von bis zu 12 % in dem zugehörigen Gefäßterritorium. Dabei haben IAS mit einem Stenosegrad ≥ 70 % das höchste Reinsultrisiko / Jahr (19 %), während das Risiko bei Stenosen < 70 % jährlich bei ca. 6 % liegt. Weitere nachgewiesene Prädiktoren für einen erneuten Schlaganfall sind weibliches Geschlecht, systolischer Blutdruck ≥ 140 mm Hg sowie ein Gesamtcholesterinwert ≥ 200 mg / dl. Die digitale Subtraktionsangiografie stellt weiterhin den Goldstandard in der Diagnose und Stenosegraduierung einer IAS dar, eignet sich aber aufgrund ihrer Invasivität nicht als Screeninguntersuchung. Als nicht invasive Untersuchungsmethode ist die CT-Angiografie der MR-Angiografie aufgrund einer höheren Sensitivität und Spezifität vorzuziehen. Daneben eignet sich die transkranielle Doppler- / Duplexsonografie als Bedside-Verfahren sowohl in der Akutdiagnostik insbesondere zum Ausschluss einer IAS, als auch für Verlaufsuntersuchungen. Nach den Ergebnissen der Warfarin versus Aspirin for Symptomatic Intracranial Stenosis (WASID)-Studie sollte bei symptomatischen IAS zunächst eine medikamentöse Sekundärprophylaxe mit Azetylsalizylsäure erfolgen. Eine orale Antikoagulation kann aufgrund einer signifikant erhöhten Blutungsrate und Mortalität nicht empfohlen werden. Bei einem unter Thrombozytenfunktionshemmern auftretenden erneuten ischämischen Schlaganfall / TIA im Gefäßterritorium der symptomatischen IAS kann insbesondere bei Stenosen ≥ 70 % eine interventionelle (stentgestützte) Angioplastie in einem spezialisierten Zentrum erfolgen. Durch die zunehmende Erfahrung der interventionell tätigen Neuroradiologen liegt die periprozedurale Komplikationsrate in aktuellen Studien zwischen 6 und 7 %. Eine randomisierte Studie, die bei symptomatischen IAS die medikamentöse Sekundärprophylaxe mit der interventionellen Therapie vergleicht, ist bisher nicht durchgeführt worden.
Abstract
In Caucasians, approximately 6.5 to 8 % of ischaemic strokes are caused by intracranial arterial stenosis (IAS). In spite of medical prevention, patients with symptomatic IAS have a high annual risk for recurrent ischaemic stroke of about 12 %. High-grade IAS (≥ 70 %) is associated with the highest recurrent stroke risk (19 %), compared to 6 % in patients with a stenosis < 70 %. Other independent predictors for recurrent stroke include female sex, systolic blood pressure > 140 mm Hg and total cholesterol > 200 mg / dl. Digital subtraction angiography remains the gold standard for diagnosis and grading of IAS but is not appropriate as a screening tool. Non-invasive imaging techniques include computed tomography (CT), magnetic resonance (MR) angiography, or transcranial Doppler and duplex ultrasound examinations. CT angiography is preferred over MR angiography due to its higher sensitivity and specifity. Bedside transcranial Doppler and Duplex ultrasound can reliably exclude IAS in patients with acute cerebral ischaemia and is a non-invasive method for follow-up examinations. The Warfarin versus Aspirin for Symptomatic Intracranial Stenosis trial (WASID) showed that aspirin was as effective as warfarin in the prevention of recurrent stroke or vascular death, but had a significantly lower rate of major haemorrhage and mortality. IAS patients who suffer a recurrent ischaemic stroke or transient ischaemic attack under aspirin can be treated with endovascular stenting or angioplasty in specialised centres. The periprocedural complication rate of these endovascular techniques is about 6–7 % in experienced neuro-interventional centres. To date, no randomised study comparing medical secondary prevention and endovascular therapy has been completed.
Schlüsselwörter
intrakranielle Stenose - ischämischer Schlaganfall - endovaskuläre Therapie
Key words
intracranial stenosis - ischemic stroke - endovascular therapy
Literatur
- 1 Feldmann E, Daneault N, Kwan E. et al . Chinese-white differences in the distribution of occlusive cerebrovascular disease. Neurology. 1990; 40 1541-1545
- 2 Sacco R L, Kargman D E, Gu Q. et al . Race-ethnicity and determinants of intracranial atherosclerotic cerebral infarction. The Northern Manhattan Stroke Study. Stroke. 1995; 26 14-20
- 3 Shin D H, Lee P H, Bang O Y. Mechanisms of recurrence in subtypes of ischemic stroke: a hospital-based follow-up study. Arch Neurol. 2005; 62 1232-1237
- 4 Weimar C, Goertler M, Harms L. et al . Distribution and outcome of symptomatic stenoses and occlusions in patients with acute cerebral ischemia. Arch Neurol. 2006; 63 1287-1291
- 5 Wityk R J, Lehman D, Klag M. et al . Race and sex differences in the distribution of cerebral atherosclerosis. Stroke. 1996; 27 1974-1980
- 6 Caplan L R, Hennerici M. Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol. 1998; 55 1475-1482
- 7 Lee D K, Kim J S, Kwon S U. et al . Lesion patterns and stroke mechanism in atherosclerotic middle cerebral artery disease: early diffusion-weighted imaging study. Stroke. 2005; 36 2583-2588
- 8 Chimowitz M I, Lynn M J, Howlett-Smith H. et al . Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med. 2005; 352 1305-1316
- 9 Williams J E, Chimowitz M I, Cotsonis G A. et al . Gender differences in outcomes among patients with symptomatic intracranial arterial stenosis. Stroke. 2007; 38 2055-2062
- 10 Chaturvedi S, Turan T N, Lynn M J. et al . Risk factor status and vascular events in patients with symptomatic intracranial stenosis. Neurology. 2007; 69 2063-2068
- 11 Kasner S E, Chimowitz M I, Lynn M J. et al . Predictors of ischemic stroke in the territory of a symptomatic intracranial arterial stenosis. Circulation. 2006; 113 555-563
- 12 Chimowitz M I, Kokkinos J, Strong J. et al . The Warfarin-Aspirin Symptomatic Intracranial Disease Study. Neurology. 1995; 45 1488-1493
- 13 Qureshi A I, Ziai W C, Yahia A M. et al . Stroke-free survival and its determinants in patients with symptomatic vertebrobasilar stenosis: a multicenter study. Neurosurgery. 2003; 52 1033-1039; discussion 1039–1040
- 14 Mazighi M, Tanasescu R, Ducrocq X. et al . Prospective study of symptomatic atherothrombotic intracranial stenoses: the GESICA study. Neurology. 2006; 66 1187-1191
- 15 Wong K S, Li H. Long-term mortality and recurrent stroke risk among Chinese stroke patients with predominant intracranial atherosclerosis. Stroke. 2003; 34 2361-2366
- 16 Wong K S, Ng P W, Tang A. et al . Prevalence of asymptomatic intracranial atherosclerosis in high-risk patients. Neurology. 2007; 68 2035-2038
- 17 Kaufmann T J, Huston J, Mandrekar 3rd J N. et al . Complications of diagnostic cerebral angiography: evaluation of 19,826 consecutive patients. Radiology. 2007; 243 812-819
- 18 Droste D W, Junker K, Hansberg T. et al . Circulating microemboli in 33 patients with intracranial arterial stenosis. Cerebrovasc Dis. 2002; 13 26-30
- 19 Allendoerfer J, Goertler M, Reutern G M von. Prognostic relevance of ultra-early doppler sonography in acute ischaemic stroke: a prospective multicentre study. Lancet Neurol. 2006; 5 835-840
- 20 Stolz E, Cioli F, Allendoerfer J. et al . Can early neurosonology predict outcome in acute stroke?: a metaanalysis of prognostic clinical effect sizes related to the vascular status. Stroke. 2008; 39 3255-3261
- 21 Feldmann E, Wilterdink J L, Kosinski A. et al . The Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis (SONIA) trial. Neurology. 2007; 68 2099-2106
- 22 Alexandrov A V, Demchuk A M, Wein T H. et al . Yield of transcranial Doppler in acute cerebral ischemia. Stroke. 1999; 30 1604-1609
- 23 Baumgartner R W, Mattle H P, Schroth G. Assessment of ≥ 50 % and < 50 % intracranial stenoses by transcranial color-coded duplex sonography. Stroke. 1999; 30 87-92
- 24 Postert T, Federlein J, Przuntek H. et al . Insufficient and absent acoustic temporal bone window: potential and limitations of transcranial contrast-enhanced color-coded sonography and contrast-enhanced power-based sonography. Ultrasound Med Biol. 1997; 23 857-862
- 25 Droste D W, Jurgens R, Weber S. et al . Benefit of echocontrast-enhanced transcranial color-coded duplex ultrasound in the assessment of intracranial collateral pathways. Stroke. 2000; 31 920-923
- 26 Choi C G, Lee D H, Lee J H. et al . Detection of intracranial atherosclerotic steno-occlusive disease with 3D time-of-flight magnetic resonance angiography with sensitivity encoding at 3T. AJNR Am J Neuroradiol. 2007; 28 439-446
- 27 Gizewski E R, Ladd M E, Paul A. et al . Water excitation: a possible pitfall in cerebral time-of-flight angiography. AJNR Am J Neuroradiol. 2005; 26 152-155
- 28 Anzalone N. Contrast-enhanced MRA of intracranial vessels. Eur Radiol. 2005; 15 (Suppl. 5) E3-10
- 29 Nael K, Ruehm S G, Michaely H J. et al . High spatial-resolution CE-MRA of the carotid circulation with parallel imaging: comparison of image quality between 2 different acceleration factors at 3.0 Tesla. Invest Radiol. 2006; 41 391-399
- 30 Nguyen-Huynh M N, Wintermark M, English J. et al . How accurate is CT angiography in evaluating intracranial atherosclerotic disease?. Stroke. 2008; 39 1184-1188
- 31 Bash S, Villablanca J P, Jahan R. et al . Intracranial vascular stenosis and occlusive disease: evaluation with CT angiography, MR angiography, and digital subtraction angiography. AJNR Am J Neuroradiol. 2005; 26 1012-1021
- 32 Sadikin C, Teng M M, Chen T Y. et al . The current role of 1.5T non-contrast 3D time-of-flight magnetic resonance angiography to detect intracranial steno-occlusive disease. J Formos Med Assoc. 2007; 106 691-699
- 33 Benesch C G, Chimowitz M I. Best treatment for intracranial arterial stenosis? 50 years of uncertainty. The WASID Investigators. Neurology. 2000; 55 465-466
- 34 Mohr J P, Thompson J L, Lazar R M. et al . A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med. 2001; 345 1444-1451
- 35 Kasner S E, Lynn M J, Chimowitz M I. et al . Warfarin vs aspirin for symptomatic intracranial stenosis: subgroup analyses from WASID. Neurology. 2006; 67 1275-1278
- 36 Weigele J B, Taylor R A, Kasner S E. Current management of symptomatic intracranial stenosis: medical versus endovascular therapy. Curr Atheroscler Rep. 2007; 9 296-304
-
37 Diener H C, Aichner F, Bode C. et al .
Primär- und Sekundärprophylaxe der zerebralen Ischämie. In: Diener HC, Puzki N, Hrsg Leitlinien für Diagnostik und Therapie in der Neurologie. Stuttgart, New York; Thieme 2008: 261-287 - 38 Kharbanda R K, Walton B, Allen M. et al . Prevention of inflammation-induced endothelial dysfunction: a novel vasculo-protective action of aspirin. Circulation. 2002; 105 2600-2604
- 39 Ridker P M, Cushman M, Stampfer M J. et al . Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men. N Engl J Med. 1997; 336 973-979
- 40 Campbell C L, Smyth S, Montalescot G. et al . Aspirin dose for the prevention of cardiovascular disease: a systematic review. JAMA. 2007; 297 2018-2024
- 41 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
- 42 Kwon S U, Cho Y J, Koo J S. et al . Cilostazol prevents the progression of the symptomatic intracranial arterial stenosis: the multicenter double-blind placebo-controlled trial of cilostazol in symptomatic intracranial arterial stenosis. Stroke. 2005; 36 782-786
- 43 The EC / IC Bypass Study Group . Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N Engl J Med. 1985; 313 1191-1200
- 44 Amin-Hanjani S, Butler W E, Ogilvy C S. et al . Extracranial-intracranial bypass in the treatment of occlusive cerebrovascular disease and intracranial aneurysms in the United States between 1992 and 2001: a population-based study. J Neurosurg. 2005; 103 794-804
- 45 Sundt T M, Smith Jr H C, Campbell J K. et al . Transluminal angioplasty for basilar artery stenosis. Mayo Clin Proc. 1980; 55 673-680
- 46 Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results. Stroke. 2004; 35 1388-1392
- 47 Bose A, Hartmann M, Henkes H. et al . A novel, self-expanding, nitinol stent in medically refractory intracranial atherosclerotic stenoses: the Wingspan study. Stroke. 2007; 38 1531-1537
- 48 Cruz-Flores S, Diamond A L. Angioplasty for intracranial artery stenosis. The Cochrane Library 2006. Oxford; Update Software © Cochrane Library, John Wiley & Sons Ltd 2006 3
- 49 Zaidat O O, Klucznik R, Alexander M J. et al . The NIH registry on use of the Wingspan stent for symptomatic 70–99 % intracranial arterial stenosis. Neurology. 2008; 70 1518-1524
- 50 Derdeyn C P, Chimowitz M I. Angioplasty and stenting for atherosclerotic intracranial stenosis: rationale for a randomized clinical trial. Neuroimaging Clin N Am. 2007; 17 355-363
- 51 Siddiq F, Vazquez G, Memon M Z. et al . Comparison of primary angioplasty with stent placement for treating symptomatic intracranial atherosclerotic diseases: a multicenter study. Stroke. 2008; 39 2505-2510
Dr. med. Ralph Weber
Universitätsklinik für Neurologie, Universitätsklinikum Essen
Hufelandstr. 55
45122 Essen
Email: weberralph@yahoo.com