Schlaganfallprävention: intrakranielle arterielle Stenosen

Zusammenfassung

Intrakranielle arterielle Stenosen (IAS) sind für etwa 6,5–8% aller ischämischen Schlaganfälle verantwortlich. Für Patienten mit einer symptomatischen IAS wurde bislang trotz medikamentöser Sekundärprophylaxe innerhalb eines Jahres ein hohes Reinsultrisiko bis zu 12% in dem zugehörigen Gefäßterritorium beschrieben. Dabei haben IAS mit einem Stenosegrad ≥ 70% das höchste Reinsultrisiko (18%). Die Warfarin vs. Aspirin for Symptomatic Intracranial Stenosis Studie (WASID) führte zu der Empfehlung, dass bei symptomatischen IAS zunächst eine medikamentöse Sekundärprophylaxe mit Azetylsalizylsäure erfolgen sollte. 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 empfohlen werden. Zahlreiche aktuelle Veröffentlichungen legten nahe, dass durch die zunehmende Erfahrung der interventionell tätigen Neuroradiologen die periprozedurale Komplikationsrate zwischen 6 und 7% liegt, das Reinfraktrisiko bei bis zu 7,8% bei IAS > 70% liegen. Allerdings zeigte eine neue randomisierte Studie (SAMMPRIS), die bei symptomatischen IAS eine aggressive medikamentöse Sekundärprophylaxe mit der interven­tionellen Therapie vergliechen hat, dass in dieser Kohorte die Letalität im interventionellen Arm bei 14% lag, im medikamentösen Arm nur bei 5,8%. Eine abschließende Bewertung dieser noch sehr neuen Daten kann aktuell noch nicht erfolgen; ein Zwischenfazit könnte sein, dass eine endovaskuläre Therapie an speziellen Zentren in Betracht gezogen werden sollte wenn Patienten unter doppelter Thrombozytenfunktionshemmung weiterhin symptomatisch sind. Die Leitlinien werden sicher eine Weiterentwicklung und erneute Diskussion erfahren.

Abstract

Intracranial arterial stenosis (IAS) are responsible to 5–8% of all ischaemic strokes in Caucasian patients. For patients with symptomatic IAS even under optimal medical prevention, a high annual risk for recurrent ischaemic stroke of about 12% has been reported. High-grade IAS of ≥ 70% is associated with the highest recurrent stroke risk of 18%. The Warfarin vs. Aspirin for Symptomatic Intracranial Stenosis trial (WASID) led to the advice that IAS patients should be treated with aspirin. Patients who suffer a recurrent ischaemic stroke or a transient ischaemic attack under aspirin and stenosis ≥ 70% 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, the risk of recurrent stroke amounts to 7.8% in IAS > 70%. However, one recent randomised study (SAMMPRIS) comparing aggressive medical secondary prevention and endovascular therapy has shown a high complication rate for endovascular treatment with a mortality rate of 14% compared to 5.8% under aggressive medicamentous treatment. There is no final interpretation of the data yet. However, endovascular therapy might be considered in specialised centres if patients are still symptomatic under aggressive medical treatment. The guidelines have to be adopted and will certainly be subject of further discussion in the future.

Schlüsselwörter

Angioplastie - intrakranielle Stenose - Prävention Schlaganfall

Keywords

angioplasty - intracranial stenosis - prevention of ischaemic stroke

• Literatur

• 1 Wong KS, Ng PW, Tang A et al. Prevalence of asymptomatic intracranial atherosclerosis in high-risk patients. Neurology 2007; 68: 2035-2038
• 2 Su LL, Huang HW, Tan SQ et al. Prevalence of asymptomatic intracranial artery stenosis in middle-aged and elderly population in the community of Foshan city, Guangdong province: a cross-sectional study. Zhonghua Liu Xing Bing Xue Za Zhi 32: 469-472
• 3 Kremer C, Schaettin T, Georgiadis D et al. Prognosis of asymptomatic stenosis of the middle cerebral artery. J Neurol Neurosurg Psychiatry 2004; 75: 1300-1303
• 4 Gorelick PB, Wong KS, Bae HJ et al. Large artery intracranial occlusive disease: a large worldwide burden but a relatively neglected frontier. Stroke 2008; 39: 2396-2399
• 5 McTaggart RA, Jayaraman MV, Haas RA et al. Intracranial athero­sclerotic disease: epidemiology, imaging and treatment. Med Health R I 2009; 92: 412-414
• 6 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
• 7 Yue X, Xi G, Lu T et al. Influence of residual stenosis on clinical outcome and restenosis after middle cerebral artery stenting. Cardiovasc Intervent Radiol 34: 744-750
• 8 Homburg PJ, Plas GJ, Rozie S et al. Prevalence and calcification of in­tracranial arterial stenotic lesions as assessed with multidetector computed tomography angiography. Stroke 42: 1244-1250
• 9 Chimowitz MI, Lynn MJ, Derdeyn CP et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med 365: 993-1003
• 10 Caplan LR, Hennerici M. Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol 1998; 55: 1475-1482
• 11 Chimowitz MI, Lynn MJ, Howlett-Smith H et al. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med 2005; 352: 1305-1316
• 12 Mazighi M, Tanasescu R, Ducrocq X et al. Prospective study of symptomatic atherothrombotic intracranial stenoses: the GESICA study. Neurology 2006; 66: 1187-1191
• 13 Chaturvedi S, Turan TN, Lynn MJ et al. Risk factor status and vascular events in patients with symptomatic intracranial stenosis. Neurology 2007; 69: 2063-2068
• 14 Kasner SE, Chimowitz MI, Lynn MJ et al. Predictors of ischemic stroke in the territory of a symptomatic intracranial arterial stenosis. Circulation 2006; 113: 555-563
• 15 Weber R, Kraywinkel K, Diener HC et al. Symptomatic intracranial atherosclerotic stenoses: prevalence and prognosis in patients with acute cerebral ischemia. Cerebrovasc Dis 30: 188-193
• 16 Campbell CL, Smyth S, Montalescot G et al. Aspirin dose for the prevention of cardiovascular disease: a systematic review. Jama 2007; 297: 2018-2024
• 17 Diener HC, Aichner F, Bode C. Primär- und Sekundärprophylaxe der zerebralen Ischämie. In Diener HC, Puzki N. eds Leitlinien für Diagnostik und Therapie in der Neurologie. Stuttgart, New York: Thieme; 2008: 261-287
• 18 Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or In­tracranial Arteries (SSYLVIA): study results. Stroke 2004; 35: 1388-1392
• 19 Kwon SU, Cho YJ, Koo JS 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
• 20 Mazighi M, Yadav JS, Abou-Chebl A. Durability of endovascular therapy for symptomatic intracranial atherosclerosis. Stroke 2008; 39: 1766-1769
• 21 Wittkugel O, Rosenkranz M, Burckhardt D et al. Long-term outcome after endovascular treatment of high-risk patients with recurrently symptomatic intracranial stenoses of the posterior circulation. Rofo 2009; 181: 782-791
• 22 Nguyen TN, Zaidat OO, Gupta R et al. Balloon angioplasty for intracranial atherosclerotic disease: periprocedural risks and short-term outcomes in a multicenter study. Stroke 42: 107-111
• 23 Marks MP, Wojak JC, Al-Ali F et al. Angioplasty for symptomatic intracranial stenosis: clinical outcome. Stroke 2006; 37: 1016-1020
• 24 Wojak JC, Dunlap DC, Hargrave KR et al. Intracranial angioplasty and stenting: long-term results from a single center. AJNR Am J Neuroradiol 2006; 27: 1882-1892
• 25 Lylyk P, Vila JF, Miranda C et al. Endovascular reconstruction by means of stent placement in symptomatic intracranial atherosclerotic stenosis. Neurol Res 2005; 27 (Suppl. 01) S84-S88
• 26 Cruz-Flores S, Diamond AL. Angioplasty With or Without Stenting for Intracranial Artery Stenosis. Stroke 2006;
• 27 Groschel K, Schnaudigel S, Pilgram SM et al. A systematic review on outcome after stenting for intracranial atherosclerosis. Stroke 2009; 40: e340-e347
• 28 Fiorella D, Chow MM, Anderson M et al. A 7-year experience with balloon-mounted coronary stents for the treatment of symptomatic vertebrobasilar intracranial atheromatous disease. Neurosurgery 2007; 61: 236-242 discussion 233–242
• 29 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
• 30 Turk AS, Niemann DB, Ahmed A et al. Use of self-expanding stents in distal small cerebral vessels. AJNR Am J Neuroradiol 2007; 28: 533-536
• 31 Gizewski ER, Weber R, Forsting M. Actual review of diagnostics and endovascular therapy of intracranial arterial stenoses. Rofo 183: 104-111
• 32 Rezende MT, Spelle L, Mounayer C et al. Hyperperfusion syndrome after stenting for intracranial vertebral stenosis. Stroke 2006; 37: e12-e14
• 33 Choo KS, Lee TH, Choi CH et al. Assessment of the Intracranial Stents Patency and Re-Stenosis by 16-Slice CT Angiography with Optimized Sharp Kernel: Preliminary Study. J Korean Neurosurg Soc 2009; 45: 284-288
• 34 Zaidat OO, Klucznik R, Alexander MJ et al. The NIH registry on use of the Wingspan stent for symptomatic 70–99% intracranial arterial stenosis. Neurology 2008; 70: 1518-1524
• 35 Turk AS, Levy EI, Albuquerque FC et al. Influence of patient age and stenosis location on wingspan in-stent restenosis. AJNR Am J Neuroradiol 2008; 29: 23-27
• 36 Derdeyn CP, Chimowitz MI. Angioplasty and stenting for athero­sclerotic intracranial stenosis: rationale for a randomized clinical trial. Neuroimaging Clin N Am 2007; 17: 355-363 viii–ix
• 37 Kurre W, Berkefeld J, Brassel F et al. In-Hospital Complication Rates After Stent Treatment of 388 Symptomatic Intracranial Stenoses. Results From the INTRASTENT Multicentric Registry. Stroke
• 38 Siddiq F, Vazquez G, Memon MZ et al. Comparison of primary angioplasty with stent placement for treating symptomatic intracranial atherosclerotic diseases: a multicenter study. Stroke 2008; 39: 2505-2510
• 39 Henkes H, Miloslavski E, Lowens S et al. Treatment of intracranial atherosclerotic stenoses with balloon dilatation and self-expanding stent deployment (WingSpan). Neuroradiology 2005; 47: 222-228
• 40 Costalat V, Maldonado IL, Zerlauth JB et al. Endovascular treatment of symptomatic intracranial arterial stenosis: six-year experience in a single-center series of 42 consecutive patients with acute and mid-term results. Neurosurgery 67: 1505-1513 discussion 1504–1513
• 41 Vajda Z, Schmid E, Guthe T et al. The modified Bose-method for the endovascular treatment of intracranial atherosclerotic arterial stenoses using the Enterprise stent. Neurosurgery
• 42 Fields JD, Liu KC, Barnwell SL et al. Indications and applications of arterial stents for stroke prevention in atherosclerotic intracranial stenosis. Curr Cardiol Rep 12: 20-28
• 43 Sundt Jr TM, Smith HC, Campbell JK et al. Transluminal angioplasty for basilar artery stenosis. Mayo Clin Proc 1980; 55: 673-680
• 44 Qureshi AI, Feldmann E, Gomez CR et al. Consensus conference on intracranial atherosclerotic disease: rationale, methodology, and results. J Neuroimaging 2009; 19 (Suppl. 01) 1S-10S
• 45 Wong KS, 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 9: 489-497
• 46 Mandell DM, Han JS, Poublanc J et al. Quantitative measurement of cerebrovascular reactivity by blood oxygen level-dependent MR imaging in patients with intracranial stenosis: preoperative cerebrovascular reactivity predicts the effect of extracranial-intracranial bypass surgery. AJNR Am J Neuroradiol 32: 721-727
• 47 Blaser T, Hofmann K, Buerger T et al. Risk of stroke, transient ischemic attack, and vessel occlusion before endarterectomy in patients with symptomatic severe carotid stenosis. Stroke 2002; 33: 1057-1062
• 48 Kozak O, Tariq N, Suri MF et al. High Risk of Recurrent Ischemic Events among Patients with Deferred Intracranial Angioplasty and Stent Placement for Symptomatic Intracranial Atherosclerosis. Neurosurgery