Der Nervenarzt

, Volume 77, Issue 12, pp 1444–1455

Endovaskuläre Behandlung intrakranieller Stenosen

Eine gemeinsame Stellungnahme von Neurologen und Neuroradiologen
  • J. Berkefeld
  • G. F. Hamann
  • R. du Mesnil
  • W. Kurre
  • H. Steinmetz
  • F. E. Zanella
  • M. Sitzer
Übersicht

Zusammenfassung

Intrakranielle Stenosen verursachen 5–10% der Schlaganfälle und werden mit zunehmender Häufigkeit mittels moderner bildgebender Verfahren detektiert. Das Schlaganfallrisko symptomatischer Stenosen im Spontanverlauf unter konservativer Behandlung liegt mit Werten um 10% pro Jahr relativ hoch. Die Behandlung mit Marcumar führt zu erhöhten Blutungsrisiken, so dass in der Nutzen-Risiko-Abwägung Thrombozytenaggregationshemmer bevorzugt werden sollten. Eine kleinere Gruppe von Patienten mit unter medikamentöser antithrombotischer Therapie rezidivierend symptomatischen oder einmalig symptomatischen hämodynamisch relevanten Stenosen ohne adäquate Kollateralversorgung hat möglicherweise ein noch höheres Schlaganfallrisiko im Spontanverlauf, so dass für diese Patienten eine endovaskuläre Behandlung eine Therapieoption darstellt, die aber mit einem bis zu 10%igen prozeduralen Risiko verbunden ist. Ein Problem der nur mit kleinen Fallzahlen angewandten neuartigen Methode sind die für einen prophylaktischen Eingriff relativ hohen Komplikationsraten. Infarkte durch Verschlüsse der aus dem stenosierten Segment abgehenden perforierenden Äste und Blutungskomplikationen stehen dabei im Vordergrund. Nach erfolgreich durchgeführter Intervention sind die Schlaganfallraten im Verlauf nach den bisherigen Daten niedrig. Die Rate an hochgradigen und eventuell erneut interventionsbedürftigen Restenosen beträgt etwa 10%. Verbesserungen der Methode zielen auf die Verringerung des Gefäßwandtraumas bei der Ballonangioplastie durch bewusste Unterdilatation oder die Verwendung von selbstexpandierenden Stents. Solange die Komplikationsraten nicht zuverlässig in einen Bereich von 5–6% gesenkt werden können, kommt die interventionelle Behandlung nur mit strenger Indikationsstellung bei Patienten ohne therapeutische Alternative in Betracht. Angesichts der bisherigen spärlichen Daten mit großer Streubreite zwischen den einzelnen Studien wird ein multizentrisches prospektives Register zur weiteren Evaluation und Entwicklung der Methode angeregt.

Schlüsselwörter

Intrakranielle Stenose Intrakranielle Atherosklerose Schlaganfall Stent Angioplastie 

Endovascular treatment for intracranial stenoses

Acommon statement by neurologists and neuroradiologists

Summary

Intracranial stenoses cause 5–10% of all strokes and are increasingly detected by means of modern imaging methods. The stroke danger of high-grade symptomatic stenoses is relatively high, with an annual risk of approximately 10% under medical treatment. Coumadin increases the risk of hemorrhage, and after risk/benefit considerations, antiplatelets should be preferred for antithrombotic therapy. Despite optimized medical treatment, a small group of patients with recurrent symptoms or symptomatic stenoses without adequate collateral supply probably carry higher spontaneous stroke risk and may be considered for intracranial stenting, which itself is associated with procedural risks of up to 10%. Currently published case series show relatively high complication rates as a major drawback of endovascular treatment, mainly strokes after occlusion of perforating branches extending from the stenotic vessel segment or hemorrhagic complications. According to data from smaller feasibility studies, stroke rates in follow-up after successful stenting seem to be low. The average rate of high-grade restenosis with possible indication for reintervention is 10%. Improvements in endovascular treatment aim at reducing vessel wall trauma during balloon angioplasty by underdilatation or the use of self-expanding stents. Until complication rates are dependably reduced to values of 5–6%, indication for endovascular treatment should be restricted to patients without therapeutic alternatives. According to limited data with large variation between different studies, a prospective multicentric registry is proposed for systematic evaluation and further development of the method.

Keywords

Intracranial stenosis Intracranial atherosclerosis Stroke Stent Angioplasty 

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Copyright information

© Springer Medizin Verlag 2006

Authors and Affiliations

  • J. Berkefeld
    • 3
  • G. F. Hamann
    • 1
  • R. du Mesnil
    • 3
  • W. Kurre
    • 3
  • H. Steinmetz
    • 2
  • F. E. Zanella
    • 3
  • M. Sitzer
    • 2
  1. 1.Klinik für NeurologieDr.-Horst-Schmidt-Kliniken WiesbadenWiesbadenDeutschland
  2. 2.Klinik für NeurologieJohann-Wolfgang-Goethe-UniversitätFrankfurt am MainDeutschland
  3. 3.Institut für NeuroradiologieKlinikum der Johann-Wolfgang-Goethe-UniversitätFrankfurt am MainDeutschland

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