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Akuttherapie des Schlaganfalls

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Acute stroke therapy

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Zusammenfassung

Dieser Artikel befasst sich mit drei Schwerpunkten der akuten Schlaganfalltherapie: der Verlängerung des Zeitfensters bei Thrombolyse mit Desmoteplase, der Effektivität der dekompressiven Trepanation beim malignen Mediainfarkt und dem Stellenwert der hämostatischen Therapie mit rekombinantem Faktor VIIa bei spontanen intrazerebralen Blutungen.

Die bisher einzige zugelassene Akuttherapie des akuten Hirninfarktes ist die Thrombolyse mit rt-PA im 3-Stunden-Zeitfenster. Die Erweiterung dieses Zeitfensters durch eine optimierte auf neuroradiologischen Informationen basierende Patientenselektion war Gegenstand langjähriger Forschung. Nach den vorteilhaften Resultaten zweier Phase-II-Studien zur Anwendung des Thrombolytikums Desmoteplase in einem erweiterten Zeitfenster nach akutem Hirninfarkt wurde von 2005–2006 die DIAS-2-Studie als Phase-III-Studie durchgeführt. Die ersten Ergebnisse der insgesamt 186 Patienten werden berichtet. Überraschenderweise hatten die mit Desmoteplase behandelten Patienten kein besseres Outcome als die Plazebo-Patienten und in der Hochdosisgruppe war die Mortalität erhöht.

Der raumfordernde maligne Mediainfarkt gehört zu den Schlaganfällen mit der schlechtesten Prognose. Auch unter maximaler intensivmedizinischer Therapie versterben die meisten der Patienten innerhalb weniger Tage an dem sich entwickelnden massiven Hirnödem. Eine effektive Methode zur Behandlung der lokalen Hirnschwellung stellt die dekompressive Hemikraniektomie dar. Bislang war diese Therapie allerdings sehr umstritten. Wir stellen hier die Ergebnisse der in diesem Jahr veröffentlichten randomisierten Studien zu diesem Thema vor und diskutieren ihren Stellenwert in der Akuttherapie.

Bei einem Drittel aller Patienten mit einer intrazerebralen Blutung (ICB) nimmt das Volumen der Blutung innerhalb der ersten 4 h zu. Prospektive, multizentrische, plazebokontrollierte Studien zeigten, dass die intravenöse Gabe von rFVIIa die Zunahme der Blutung reduziert. Wir stellen Teilergebnisse der FAST („recombinant factor VIIa in acute hemorrhagic stroke“) -Studie vor, die sich mit der Frage befasste, ob der biologische Effekt Auswirkungen auf das klinisch funktionelle Ergebnis hat.

Summary

This article covers three major topics of acute stroke therapy: extension of the time window for thrombolysis with desmoteplase, decompressive surgery after malignant middle cerebral artery infarction, and the effect of hemostatic therapy with recombinant activated factor VII (rFVIIa) in patients with spontaneous primary intracerebral hemorrhage. Thrombolytic therapy with recombinant tissue or tissue-type plasminogen activator is still the only approved acute stroke therapy within a 3-h time window. Imaging-based patient selection seems to help extending this time window. After promising results of two phase II trials with the thrombolytic agent desmoteplase in an extended time window after acute ischemic stroke, the DIAS-II study was reconducted in Europe, North America, and Australia as a phase III trial. First results of the included 186 patients are shown. Surprisingly, patients treated with desmoteplase had no better outcome than placebo-treated patients, and there was increased mortality in the high-dose group. Among all stroke subtypes, space-occupying malignant middle cerebral artery is one with the poorest prognosis. Most patients die within a few days due to the development of massive brain edema, despite maximum intensive care. Decompressive hemicraniectomy represents a much more effective therapy for the treatment of local brain swelling. However, until recently this method was highly controversial. Here we present the results of the randomized trials published in 2007 and discuss their relevance for acute therapy. Hematoma growth occurs within 4 h in one third of patients who suffer from intracerebral hemorrhage. Prospective, placebo-controlled, multicenter trials have shown that intravenous application of rFVIIa reduces volume increase. We present preliminary results of the latest phase III trial (FAST: recombinant factor VIIa in acute hemorrhagic stroke), which tried to find whether the hemostatic effect will translate into clinical effect.

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Authors and Affiliations

  1. Neurologische Klinik, Universitätsklinikum, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland

    T. Steiner, E. Jüttler & P. Ringleb

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  1. T. Steiner
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  2. E. Jüttler
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  3. P. Ringleb
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Correspondence to T. Steiner.

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Steiner, T., Jüttler, E. & Ringleb, P. Akuttherapie des Schlaganfalls. Nervenarzt 78, 1147–1154 (2007). https://doi.org/10.1007/s00115-007-2352-7

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  • DOI: https://doi.org/10.1007/s00115-007-2352-7

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