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Thrombolytische Therapie des akuten Schlaganfalls

Thrombolytic treatment of acute stroke

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Zusammenfassung

Der ischämische Schlaganfall ist ein medizinischer Notfall, der gemäß dem „Time-is-brain“-Konzept schnellstmöglich behandelt werden muss. Die derzeit einzig nachgewiesen wirksame Akutbehandlung stellt die i.v.-Gabe von „recombinant tissue plasminogen activator“ (rt-PA) dar, die innerhalb eines 4,5-h-Fensters wirksam und sicher, allerdings bislang nur innerhalb der ersten 3 h nach Symptombeginn zugelassen ist (0,9 mg/kgKG, Maximum von 90 mg, 10% der Gesamtdosis als Bolus, die restlichen 90% im Anschluss als Infusion über 60 min). Den therapeutischen Effekt Magnetresonanztomographie(MRT)-basierter thrombolytischer Therapien jenseits des 4,5-h-Fensters gilt es noch zu untersuchen. Bei proximalen Verschlüssen der A. cerebri media führt die katheterbasierte intraarterielle Behandlung mit einem Plasminogenaktivator innerhalb eines 6-h-Zeitfensters zu einer signifikanten Verbesserung des Outcomes und kann als individueller Heilversuch angesehen werden. Akute Basilarisverschlüsse sollten in spezialisierten Zentren mit intraarterieller Applikation von Urokinase, rt-PA oder mechanischer Rekanalisation behandelt werden; hierbei ist die i.v.-Thrombolyse auch jenseits des 3-h-Zeitfensters eine akzeptable Alternative.

Abstract

Ischemic stroke is a medical emergency and must be treated as quickly as possible according to the “time-is-brain” concept. At present, intravenous administration of recombinant tissue plasminogen activator (rt-PA) within the first 4.5 h from stroke onset is the only effective treatment but is currently still only approved within the first 3 h from onset of symptoms (0.9 mg/kg body weight, maximum dose 90 mg, 10% of the cumulative dose as bolus, remaining 90% subsequently infused within 60 min). The therapeutic effect of magnetic resonance imaging (MRI) based thrombolytic therapy beyond the 4.5 h time window remains to be proven. Proximal occlusions of the middle cerebral artery can be treated successfully within the first 6 h from stroke onset by catheter-based intra-arterial administration of plasminogen activator leading to a significant improvement of outcome. Acute basilar artery occlusion should be treated in specialized centres using intra-arterial application of urokinase, rt-PA or mechanical recanalization but intravenous thrombolysis beyond the 3 h window is an acceptable alternative.

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehungen hin: W. Hacke war Vorsitzender der Steering Committees von ECASS 1–3 sowie DIAS und DIAS 2 und hat Zahlungen von Boehringer Ingelheim (BI) bzw. Paion für studienbezogene Tätigkeiten erhalten. Er hat Vorträge in von BI gesponserten Veranstaltungen gehalten, solche organisiert und hat dafür finanziellen Ausgleich bekommen. Er ist „co-chair“ des Steering Committee für RIVER 3 und wird für seine Tätigkeiten in dieser Studie von Codman a Johnson & Johnson honoriert werden. Bei H. Amiri und J. Bösel besteht kein Interessenkonflikt.

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Authors and Affiliations

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

    H. Amiri, W. Hacke & J. Bösel

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  1. H. Amiri
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  2. W. Hacke
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  3. J. Bösel
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Correspondence to H. Amiri.

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Amiri, H., Hacke, W. & Bösel, J. Thrombolytische Therapie des akuten Schlaganfalls. Internist 52, 1310–1316 (2011). https://doi.org/10.1007/s00108-011-2837-0

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