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.

Schlaganfall - Akuttherapie - Prävention - Karotisstenose - intrakranielle Blutung

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

Literatur

• 1 Strazzullo P, D’Elia L, Kandala N B. et al . Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies.  BMJ. 2009;  339 b4567
• 2 De Berardis G, Sacco M, Strippoli G F. et al . Aspirin for primary prevention of cardiovascular events in people with diabetes: meta-analysis of randomised controlled trials.  BMJ. 2009;  339 b4531
• 3 Reiff T, Stingele R, Eckstein H H. et al . Stent-protected angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy: SPACE2 – a three-arm randomised-controlled clinical trial.  Int J Stroke. 2009;  4 294-299
• 4 Markus H S, King A, Shipley M. et al . Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study.  Lancet Neurol. 2010;  9 663-671
• 5 Marquardt L, Geraghty O C, Mehta Z. et al . l. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study.  Stroke. 2010;  41 e11-e17
• 6 Brott T G, Hobson 2nd  R W, Howard G. et al . Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis.  N Engl J Med. 2010;  363 11-23
• 7 Skyler J S, Bergenstal R, Bonow R O. et al . Intensive glycemic control and the prevention of cardiovascular events: implications of the ACCORD, ADVANCE, and VA diabetes trials: a position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart Association.  Circulation. 2009;  119 351-357
• 8 Cushman W C, Evans G W, Byington R P. et al . Effects of intensive blood-pressure control in type 2 diabetes mellitus.  N Engl J Med. 2010;  362 1575-1585
• 9 Ginsberg H N, Elam M B, Lovato L C. et al . Effects of combination lipid therapy in type 2 diabetes mellitus.  N Engl J Med. 2010;  362 1563-1574
• 10 Bluhmki E, Chamorro A, Davalos A. et al . Stroke treatment with alteplase given 3.0–4.5 h after onset of acute ischaemic stroke (ECASS III): additional outcomes and subgroup analysis of a randomised controlled trial.  Lancet Neurol. 2009;  8 1095-1102
• 11 Lees K R, Bluhmki E, von Kummer R. et al . Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials.  Lancet. 2010;  375 1695-1703
• 12 Diedler J, Ahmed N, Sykora M. et al . Safety of intravenous thrombolysis for acute ischemic stroke in patients receiving antiplatelet therapy at stroke onset.  Stroke. 2010;  41 288-294
• 13 Levy E I, Siddiqui A H, Crumlish A. et al . First Food and Drug Administration-approved prospective trial of primary intracranial stenting for acute stroke: SARIS (stent-assisted recanalization in acute ischemic stroke).  Stroke. 2009;  40 3552-3556
• 14 Ehrenreich H, Hasselblatt M, Dembowski C. et al . Erythropoietin therapy for acute stroke is both safe and beneficial.  Mol Med. 2002;  8 495-505
• 15 Ehrenreich H, Weissenborn K, Prange H. et al . Recombinant human erythropoietin in the treatment of acute ischemic stroke.  Stroke. 2009;  40 e647-e656
• 16 Dengler R, Diener H C, Grond M. et al . Early treatment with aspirin and extended-release dipyridamole versus low dose aspirin alone for TIA / ischaemic stroke within 24 hour of symptom-onset (EARLY-trial): a randomised, open-label, blinded-endpoint trial.  Europ J Neurol. 2009;  16 (Suppl. 3) 656
• 17 Dengler R, Diener H C, Schwartz A. et al . Early treatment with aspirin plus extended-release dipyridamole for transient ischaemic attack or ischaemic stroke within 24 h of symptom onset (EARLY trial): a randomised, open-label, blinded-endpoint trial.  Lancet Neurol. 2010;  9 159-166
• 18 Diener H, Bogousslavsky J, Brass L. et al . Acetylsalicylic acid on a background of clopidogrel in high-risk patients randomised after recent ischaemic stroke or transient ischaemic attack: The MATCH trial results.  Lancet. 2004;  364 331-334
• 19 Kennedy J, Hill M D, Ryckborst K J. et al . Fast assessment of stroke and transient ischaemic attack to prevent early recurrence (FASTER): a randomised controlled pilot trial.  Lancet Neurol. 2007;  6 961-969
• 20 Wong K S, Chen C, Fu J. et al . Clopidogrel plus aspirin versus aspirin alone for reducing embolisation in patients with acute symptomatic cerebral or carotid artery stenosis (CLAIR study): a randomised, open-label, blinded-endpoint trial.  Lancet Neurol. 2010;  9 489-497
• 21 O’Donoghue M L, Braunwald E, Antman E M. et al . Pharmacodynamic effect and clinical efficacy of clopidogrel and prasugrel with or without a proton-pump inhibitor: an analysis of two randomised trials.  Lancet. 2009;  374 989-997
• 22 Connolly S J, Ezekowitz M D, Yusuf S. et al . Dabigatran versus warfarin in patients with atrial fibrillation.  N Engl J Med. 2009;  361 1139-1151
• 23 Hohnloser S H, Crijns H J, van Eickels M. et al . Effect of dronedarone on cardiovascular events in atrial fibrillation.  N Engl J Med. 2009;  360 668-678
• 24 Connolly S J, Crijns H J, Torp-Pedersen C. et al . Analysis of stroke in ATHENA: a placebo-controlled, double-blind, parallel-arm trial to assess the efficacy of dronedarone 400 mg BID for the prevention of cardiovascular hospitalization or death from any cause in patients with atrial fibrillation / atrial flutter.  Circulation. 2009;  120 1174-1180
• 25 Rothwell P, Eliasziw M, Gutnikov S. et al, Carotid Endarterectomy Trialists Collaboration . Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery.  Lancet. 2004;  363 915-924
• 26 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
• 27 Eckstein H H, Ringleb P, Allenberg J R. et al . Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial.  Lancet Neurol. 2008;  7 893-902
• 28 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
• 29 Mas J L, Trinquart L, Leys D. et al . Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial.  Lancet Neurol. 2008;  7 885-892
• 30 Ederle J, Dobson J, Featherstone R L. et al . Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial.  Lancet. 2010;  375 985-997
• 31 Qureshi A I, Palesch Y Y, Martin R. et al . Effect of systolic blood pressure reduction on hematoma expansion, perihematomal edema, and 3-month outcome among patients with intracerebral hemorrhage: results from the antihypertensive treatment of acute cerebral hemorrhage study.  Arch Neurol. 2010;  67 570-576
• 32 Wong G K, Poon W S, Chan M T. et al . Intravenous magnesium sulphate for aneurysmal subarachnoid hemorrhage (IMASH): a randomized, double-blinded, placebo-controlled, multicenter phase III trial.  Stroke. 2010;  41 921-926
• 33 Connolly S, Pogue J, Hart R. ACTIVE Writing Group on behalf of the ACTIVE Investigators . Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial.  Lancet. 2006;  367 1903-1912
• 34 Akins P T, Feldman H A, Zoble R G. et al . Secondary stroke prevention with ximelagatran versus warfarin in patients with atrial fibrillation: pooled analysis of SPORTIF III and V clinical trials.  Stroke. 2007;  38 874-880
• 35 Rothwell P M, Giles M F, Chandratheva A. et al . Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison.  Lancet. 2007;  370 1432-1442