Was gibt es Neues beim Schlaganfall?

Zusammenfassung

Anhand von selektierten Publikationen aus den vergangenen 12 Monaten werden aktuelle Entwicklungen und Neuheiten in der Prävention und Behandlung des Schlaganfalls dargestellt. Der orale direkte Thrombininhibitor Dabigatran zeigt weniger intrakranielle Blutungskomplikationen bei überlegener Wirksamkeit gegenüber Warfarin und ist seit August 2011 für die Behandlung von Patienten mit Vorhofflimmern zugelassen. Andere Antikoagulantien der neuen Generation wie Rivaroxaban und Apixaban sind gegenüber Warfarin ebenfalls überlegen, jedoch in Europa bislang noch nicht zur Behandlung von Patienten mit Vorhofflimmern zugelassen. Bei Patienten mit Vorhofflimmern wird das Risiko kardio- oder zerebrovaskulärer Ereignisse durch Angiotensin-Rezeptorblocker nicht reduziert. Eine aggressive Therapie des Diabetes mellitus senkt das Risiko für mikrovaskuläre, nicht jedoch für zerebro- und kardiovaskuläre Ereignisse oder die Sterblichkeit. Das Absetzen von Thrombozytenfunktionshemmern erhöht das Schlaganfall-Rezidivrisiko um 40%. Die Ausweitung des Zeitfensters für eine systemische Thrombolyse von 3 auf 4,5 Stunden hat weder die Blutungsrate oder Mortalität noch die mediane Latenzzeit von Aufnahme bis Lysebeginn erhöht. Ein Alter über 80 Jahre allein sollte kein Grund sein Patienten von der Lysetherapie auszuschließen. Angiotensin-Rezeptorblocker führen weder zur Verbesserung des Behandlungsergebnisses noch zur Reduktion kognitiver Störungen nach Schlaganfall. Zur Behandlung symptomatischer Carotisstenosen ist die Thrombendarteriektomie dem Stenting vorzuziehen. Das Stenting intrakranieller Stenosen und asymptomatischer extrakranieller Stenosen wird eher nicht empfohlen. Die zeitnahe Gabe von niedermolekularen Heparinen zur Thromboseprophylaxe und die Wiederaufnahme der oralen Antikoagulation 10–30 Wochen nach intrazerebraler Blutung sind wahrscheinlich sicher. Durch moderne CT-Diagnostik können Subarachnoidalblutungen und intrakranielle Aneurysmen ausreichend zuverlässig diagnostiziert werden. Endothelin-Rezeptor-Antagonisten sind zur Behandlung von Vasospasmen nach Subarachnoidalblutung unwirksam.

Abstract

Based on selected publications from the past 12 months, current developments and innovations in the prevention and treatment of stroke are presented. The direct thrombin inhibitor dabigatran is superior to warfarin with a lower risk of intracranial bleeding complications and has been approved in patients with atrial fibrillation since August 2011. Other new generation oral anticoagulants like rivaroxaban and apixaban also are superior to warfarin but have not yet been approved in Europe in patients with atrial fibrillation. Aggressive antidiabetic treatment is associated with fewer microvascular complications but does not reduce the risk of stroke, cardiovascular events or mortality. The risk of recurrent stroke increases by 40% after stopping antiplatelet therapy. Extension of the time-window for systemic thrombolysis from 3 to 4.5 h did not result in higher rates of bleeding complications or mortality, and admission-to-treatment time did not increase. Age >80 years alone should not be a barrier to treatment with thrombolysis. Angiotensin receptor blockers do not improve functional outcome and neither reduce cognitive impairment after stroke nor the risk of cardio- or cerebrovascular events in patients with atrial fibrillation. Surgical treatment is preferable to stenting for treatment of symptomatic high-grade carotid stenosis. Stenting of intracranial stenoses or asymptomatic extracranial stenoses is rather not recommended. Early administration of low molecular weight heparins for prophylaxis of thromboembolism and resumption of oral anticoagulation 10–30 weeks after intracerebral haemorrhage are probably safe. Advanced CT imaging is sufficiently reliable in detecting subarachnoid haemorhage and intracranial aneurysms. Endothelin receptor antagonists are not effective for the treatment of vasospasm.

Schlüsselwörter

Schlaganfall - Epidemiologie - Prävention - Rehabilitation

Keywords

stroke - epidemiology - prevention - rehabilitation

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