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Aktuelle Neurologie 2014; 41(01): 35-39
DOI: 10.1055/s-0033-1360054
Aktuelles Thema
© Georg Thieme Verlag KG Stuttgart · New York

Kryptogener ischämischer Schlaganfall: Zeit für einen Paradigmenwechsel in Diagnose und Therapie?

Cryptogenic Ischemic Stroke: Time for a Paradigm Shift in Diagnosis and Therapy?
H. C. Diener
1   Universitätsklinik für Neurologie und Schlaganfallzentrum der Universität Duisburg-Essen
,
C. Weimar
1   Universitätsklinik für Neurologie und Schlaganfallzentrum der Universität Duisburg-Essen
,
B. Frank
1   Universitätsklinik für Neurologie und Schlaganfallzentrum der Universität Duisburg-Essen
,
K. Hajjar
1   Universitätsklinik für Neurologie und Schlaganfallzentrum der Universität Duisburg-Essen
,
M. Grond
2   Klinik für Neurologie, Kreiskrankenhaus Siegen, Siegen
› Author Affiliations
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Publication History

Publication Date:
16 January 2014 (online)

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Zusammenfassung

Ein kryptogener ischämischer Schlaganfall wird nach den TOAST-Kriterien angenommen wenn andere Ursachen wie eine kardiale Emboliequelle, eine Makroangiopathie, ein lakunärer Infarkt oder eine andere Schlaganfallätiologie nicht nachgewiesen werden konnten. Während für die meisten definierten Schlaganfallätiologien mittlerweile gezielt Sekundärpräventionsstudien durchgeführt wurden, bestand bisher bei Patienten mit kryptogenem Schlaganfall das Problem, dass diese Ätiologie bisher nicht ausreichend operational definiert ist. Das neue Konzept des „Embolic Stroke of Undetermined Source“ (ESUS) umfasst eine operationale Definition anhand der bildgebenden Diagnostik mit Ausschluss von lakunären Infarkten. Außerdem müssen durch Ultraschall, CTA oder MRA hämodynamisch relevante Stenosen der hirnversorgenden Gefäße im Gefäßgebiet des aktuellen Infarkts ausgeschlossen werden. Die minimale kardiale Diagnostik zum Ausschluss von Vorhofflimmern ist ein 24-Stunden-Holter-Monitoring. Da die meisten Schlaganfälle, welche die ESUS-Kriterien erfüllen, wahrscheinlich embolischer Natur sind, ist eine randomisierte Sekundärpräventionsstudie mit neuen oralen Antikoagulanzien versus Thrombozytenfunktionshemmern gerechtfertigt.

Abstract

According to the TOAST criteria, an ischemic stroke is defined as cryptogenic when common causes like cardioembolism, large artery atherosclerosis, small vessel disease or other defined etiologies can be excluded. While several stroke prevention trials have investigated well-defined stroke etiologies, cryptogenic stroke so far was insufficiently defined. The new definition of “Embolic Stroke of Undetermined Source (ESUS)” is based on the exclusion of lacunar infarction by brain imaging and of relevant stenosis of vessels supplying the affected brain territory by ultrasound, CT- or MR-angiography. Cardiac workup must include ECG Holter monitoring for 24 hours to rule out atrial fibrillation. Because the majority of strokes meeting the ESUS criteria are of (cardio-)embolic origin, a randomized secondary prevention trial investigating new oral anticoagulants versus antiplatelet therapy is warranted.

Schlüsselwörter

ischämischer Schlaganfall - TOAST-Kriterien - Makroangiopathie - lakunärer Infarkt - kardiogene Embolie

Keywords

ischemic stroke - TOAST criteria - large artery atherosclerosis - lacunar infarction - cardioembolism
 

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