Antikoagulation beim Schlaganfall

Zusammenfassung

Der Einsatz von Heparin, Heparinoiden und Vitamin-K-Antagonisten zur Akutbehandlung bzw. Prävention von Schlaganfällen wird heutzutage kontrovers diskutiert. Bei Vorhofflimmern und -flattern wird eine orale Antikoagulation insbesondere bei Hochrisikopatienten befürwortet. Als weitere Indikationen werden Erkrankungen mit hohem kardialen Embolierisiko (z. B. mechanische Herzklappen und intrakardiale Thromben), symptomatische Dissektionen hirnversorgender Arterien, Basilaris- und Sinusvenen-Thrombose sowie Erkrankungen mit vorwiegend genetisch bedingter Thrombophilie angesehen. Da für viele Befundkonstellationen das Verhältnis von Nutzen und Risiko einer Antikoagulation bislang nicht durch aussagekräftige Studien geklärt ist, sollten therapeutische Entscheidungen unter Berücksichtigung des individuellen Risikoprofils und der spezifischen Pathophysiologie der abgelaufenen zerebralen Ischämie getroffen werden.

Summary

Therapeutic benefit of heparin, heparinoids and Vitamin-K-antagonists in acute stroke as well as in stroke prevention is still a controversial issue. In patients with atrial fibrillation and flutter, oral anticoagulation is recommended when further high risk factors are present. Most experts agree that anticoagulation therapy is useful in disorders with increased cardiogenic embolisation risk (e. g. mechanical valves and intracardiac thrombus), symptomatic dissection of brain-supplying arteries, thrombosis of the basilar artery, sinus venous thrombosis, and in thrombophilia. Since for many clinical constellations controlled randomized studies differentially assessing the benefits and the risks of anticoagulation are lacking, therapeutic decisions have to be based on the patients individual risk profile and pathophysiology of cerebral ischemia.

Literatur

• 1 Adams H P, Bendixen B H, Leira E. et al . Antithrombotic treatment of ischemic stroke among patients with occlusion or severe stenosis of the internal carotid artery: A report of the Trial of Org 10 172 in Acute Stroke Treatment (TOAST).  Neurology. 1999;  53 122-125
• 2 Atrial Fibrillation Investigators . Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation.  Arch Intern Med. 1994;  154 1449-1457
• 3 Baker W F, Bick R L. Treatment of hereditary and acquired thrombophilic disorders.  Semin Thromb Hemost. 1999;  25 387-406
• 4 Bath P M, Iddenden R, Bath F J. Low-molecular-weight heparins and heparinoids in acute ischemic stroke: a meta-analysis of randomized controlled trials.  Stroke. 2000;  31 1770-1778
• 5 Bath P M, Lindenstrom E, Boysen G. et al . Tinzaparin in acute ischaemic stroke (TAIST): a randomised aspirin-controlled trial.  Lancet. 2001;  358 702-710
• 6 Baumgartner R W, Studer A, Arnold M, Georgiadis D. Recanalisation of cerebral venous thrombosis.   J Neurol Neurosurg Psychiatry . 2003;  74 459-461
• 7 Berge E, Abdelnoor M, Nakstad P H, Sandset P M. HAEST Study Group . Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study.  Lancet. 2000;  355 1205-1210
• 8 Bertram M, Bonsanto M, Hacke W, Schwab S. Managing the therapeutic dilemma: patients with spontaneous intracerebral hemorrhage and urgent need for anticoagulation.  J Neurol. 2000;  247 209-214
• 9 Bogousslavsky J, Kaste M, Skyhoj-Olsen T, Hacke W, Orgogozo J M. Risk factors and stroke prevention.  Cerebrovasc Dis. 2000;  10 (Suppl 3) 12-21
• 10 Bonow R O, Carabello B, de Leon A C. et al . Guidelines for the management of patients with valvular heart disease: executive summary.  Circulation. 1998;  98 1949-1984
• 11 Brandt T, Caplan L. Spontaneous Arterial Dissection.  Curr Treat Options Neurol. 2001;  3 463-469
• 12 Cairns J A, Theroux P, Lewis H D, Ezekowitz M, Meade T W. Antithrombotic agents in coronary artery disease.  Chest. 2001;  119 (Suppl 1) 228S-252S
• 13 Camerlingo M, Casto L, Censori B. et al . Immediate anticoagulation with heparin for first-ever ischemic stroke in the carotid artery territories observed within 5 hours of onset.  Arch Neurol. 1994;  51 462-467
• 14 CAPRIE Steering Committee . A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE).  Lancet. 1996;  348 1329-1339
• 15 Cerebral Embolism Study Group . Immediate anticoagulation of embolic stroke: a randomized trial.  Stroke. 1983;  14 668-676
• 16 Chamorro A, Vila N, Saiz A, Alday M, Tolosa E. Early anticoagulation after large cerebral embolic infarction: a safety study.  Neurology. 1995;  45 861-865
• 17 Darius H. Neue Aspekte zur Antikoagulationsbehandlung bei Vorhofflimmern.  Hämostaseologie. 2002;  22 30-35
• 18 Diener H C, Cunha L, Forbes C, Sivenius J, Smets P, Lowenthal A. European Stroke Prevention Study 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke.  J Neurol Sci. 1996;  143 1-13
• 19 Diener H C, Ringelstein E B, von Kummer R. et al . Treatment of acute ischemic stroke with the low-molecular-weight heparin certoparin: results of the TOPAS trial.  Stroke. 2001;  32 22-29
• 20 Dressler F A, Craig W R, Castello R, Labovitz A J. Mobile aortic atheroma and systemic emboli: efficacy of anticoagulation and influence of plaque morphology on recurrent stroke.  J Am Coll Cardiol. 1998;  31 134-138
• 21 Droste D W, Freund F, Wichter T. et al . Paradoxe Hirnembolien als Ursache des Schlaganfalls.  Dtsch Ärztebl. 2002;  99 A281-291
• 22 Duke R J, Bloch R F, Turpie A G, Trebilcock R, Bayer N. Intravenous heparin for the prevention of stroke progression in acute partial stable stroke.  Ann Intern Med. 1986;  105 825-828
• 23 Engelter S T, Lyrer P A, Kirsch E C, Steck A J. Long-term follow-up after extracranial internal carotid artery dissection.  Eur Neurol. 2000;  44 199-204
• 24 European stroke prevention study 2 investigators . European Stroke Prevention Study 2. Efficacy and safety data.  J Neurol Sci. 1997;  151 (Suppl) S1-77
• 25 Fuster V, Rydén L E, Asinger R W. et al . ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary.  Circulation. 2001;  104 2118-2150
• 26 Hacke W, Kaste M, Skyhoj-Olsen T, Bogousslavsky J, Orgogozo J M. Acute treatment of ischemic stroke.  Cerebrovasc Dis. 2000;  10 (Suppl 3) 22-33
• 27 Hart R G, Halperin J L. Atrial fibrillation and thromboembolism: a decade of progress in stroke prevention.  Ann Intern Med. 1999;  131 688-695
• 28 Hart R G, Halperin J L. Atrial fibrillation and stroke: concepts and controversies.  Stroke. 2001;  32 803-808
• 29 Hart R G, Palacio S, Pearce L A. Atrial fibrillation, stroke, and acute antithrombotic therapy: analysis of randomized clinical trials.  Stroke. 2002;  33 2722-2727
• 30 Hetzel A. Stellenwert der Vollheparinisierung bei V.a. akuten thrombembolischen Insult.  Dtsch Med Wochenschr. 2003;  128 569-570
• 31 International Stroke Trial Collaborative Group . The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19.435 patients with acute ischaemic stroke.  Lancet. 1997;  349 1564-1565
• 32 Klein E A. Assessment of cardioversion using transesophageal echocardiography (TEE) multicenter study (ACUTE I): Clinical outcomes at eight weeks.  J Am Coll Cardiol. 2000;  36 324
• 33 Mas J L, Arquizan C, Lamy C. et al. Patent Foramen Ovale and Atrial Septal Aneurysm Study Group . Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both.  N Engl J Med. 2001;  345 1740-1746
• 34 Mattioli A V, Bonetti L, Aquilina M. et al . Association between Atrial Septal Aneurysm and Patent Foramen ovale in Young Patients with Recent Stroke and Normal Carotid Arteries.  Cerebrovasc Dis. 2003;  15 4-10
• 35 Meyer-Lindenberg A, Mewes J, Biniek R. Megadolichobasilaris als Indikator intensivmedizinisch relevanter vertebrobasilärer Ischämien.  Nervenarzt. 1997;  68 674-677
• 36 Mohr J P, Thompson J L, Lazar R M. et al . A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke.  N Engl J Med. 2001;  345 1444-1451
• 37 Morocutti C, Amabile G, Fattapposta F. et al . Indobufen versus warfarin in the secondary prevention of major vascular events in nonrheumatic atrial fibrillation.  Stroke. 1997;  28 1015-1021
• 38 Overell J R, Bone I, Lees K R. Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies.  Neurology. 2000;  55 1172-1179
• 39 Pessin M S, Estol C J, Lafranchise F, Caplan L R. Safety of anticoagulation after hemorrhagic infarction.  Neurology. 1993;  43 1298-1303
• 40 Rance A, Emmerich J, Fiessinger J N. Anticardiolipin antibodies and recurrent thromboembolism.  Thromb Haemost. 1997;  77 221-222
• 41 Rothwell P M, Eliasziw M, Gutnikov S A. et al . Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis.  Lancet. 2003;  361 107-116
• 42 Sacco R L. Risk factors, outcomes, and stroke subtypes for ischemic stroke.  Neurology. 1997;  49 (Suppl 4) S39-44
• 43 Schuchlenz H W, Weihs W, Horner S, Quehenberger F. The association between the diameter of a patent foramen ovale and the risk of embolic cerebrovascular events.  Am J Med. 2000;  109 456-462
• 44 Stokman P J, Nandra C S, Asinger R W. Left Ventricular Thrombus.  Curr Treat Options Cardiovasc Med. 2001;  3 515-521
• 45 Tatlisumak T, Fisher M. Hematologic disorders associated with ischemic stroke.  J Neurol Sci. 1996;  140 1-11
• 46 The Stroke Prevention in Reversible Ischemia Trial (SPIRIT) Study Group . A randomized trial of anticoagulants versus aspirin after cerebral ischemia of presumed arterial origin.  Ann Neurol. 1997;  42 857-865
• 47 Villringer A, Einhäupl K M. Dural sinus and cerebral venous thrombosis.  New Horiz. 1997;  5 332-341
• 48 Weih M, Junge-Hülsing J, Mehraein S, Ziemer S, Einhäupl K M. Hereditäre Thrombophilien bei ischämischem Schlaganfall und Sinusvenenthrombosen.  Nervenarzt. 2000;  71 936-945
• 49 Weitz J I. Low-molecular-weight heparins.  N Engl J Med. 1997;  337 688-698
• 50 Wolf P A, Abbott R D, Kannel W B. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study.  Stroke. 1991;  22 983-988