Neues beim akuten Schlaganfall

Zusammenfassung

Die Therapie des akuten Schlaganfalls bleibt zu Recht ein sehr innovatives und forschungsaktives Gebiet. Die systemische Thrombolyse ist und bleibt die einzig zugelassene und hocheffektive Therapie der Wahl, was sich durch kürzlich publizierte Analysen aus großen Registern in Europa und den USA nochmals bestätigte. Obwohl es hieraus Hinweise gibt, dass eine Lysetherapie auch in einem Zeitfenster von bis zu 6 Stunden sinnvoll sein kann, bestätigen alle Daten dennoch deutlich, dass ein möglichst früher Therapiebeginn entscheidend für einen Erfolg ist.

Drei große Studien zur mechanischen Throm­bektomie (MR-Rescue/IMS-3/Synthesis) haben Anfang des Jahres viel Aufsehen erregt. Keine dieser Studien konnte einen zusätzlichen Nutzen der interventionellen Behandlung nachweisen, boten aber wegen mehr oder weniger offensichtlicher methodologischer Schwächen viel Anlass zur Diskussion. Da sich trotz guter Rekanalisierungsraten keine Verbesserung des Outcomes ergeben hat, lohnt es vielleicht, einen näheren Blick auf das periprozedurale Management entsprechender Patienten zu werfen.

In der Intensivtherapie des akuten Schlaganfalls haben wir nun durch die positive DESTINY-II-Studie eine gute Entscheidungshilfe bzgl. einer Hemikraniektomie bei älteren Patienten zur Verfügung. Es zeigte sich kein signifikanter Nutzen eines chirurgischen Vorgehens bei lobären Blutungen (STICH II) oder einer aggressiven Blutdrucksenkung bei akuter intrazerebraler Blutung (INTERACT II).

Mit Präsentation der endgültigen Daten der negativen AXIS-2-, und der MACSI- und ALIAS-Studien fehlt weiterhin der Nachweis einer effektiven Neuroprotektion beim Schlaganfall und stellt einmal mehr die Übertragbarkeit von Tiermodellen auf die Klinik in Frage.

Bezüglich innovativer Therapieansätze haben in den letzten Monaten nun große Studien zur Sonothrombolyse, und zur Hypothermie und zum Wake-up Schlaganfall begonnen.

Abstract

Therapy of acute stroke remains a very active and innovative area of research. Systemic thrombolysis was and still is the only approved and highly effective treatment of choice. This has recently been confirmed by published analyses of large stroke registries in Europe and the USA. Although these suggest thrombolysis might be beneficial in a time window of up to 6 h, all data clearly show that early treatment is decisive for maximum ­efficacy.

Three large studies on mechanical thrombectomy (MR-rescue/IMS-3/Synthesis) caused some excitement at the beginning of the year. None of these studies could demonstrate an additional benefit associated with an interventional approach. However, they gave rise to lively discussions due to more or less apparent methodological limitations. In spite of good recanalization rates, there was no outcome benefit for affected patients; this suggests that it might be useful to focus more on peri-procedural management in the future.

The positive DESTINY II study provides help in decision making with regard to hemicraniectomy in older patients in intensive care of acute stroke patients. In contrast, there was no significant benefit in a surgical approach for lobar bleeds (STICH II) or in aggressive blood pressure lowering in acute intracerebral hemorrhage (INTERACT II).

With the presentation of the final data of the negative AXIS-2, MACSI and ALIAS studies, data on effective neuroprotection in acute stroke are still lacking. This strengthens concern that translating animal models to clinical situations might be problematic. Large studies on sonothrombolysis, hypothermia and wake-up stroke have been initiated in the last few months in search of innovative therapy approaches.

Schlüsselwörter

Schlaganfall - Thrombolyse - mechanische ­Thrombek­tomie - intrakranielle Blutung - klinische Studie

Keywords

stroke - thrombolysis - mechanical thrombectomy - intracranial hemorrhage - clinical trials

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