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Patientenauswahl zur Thrombolyse mittels Perfusions- und Diffusions-MRT

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Patient selection for thrombolysis using perfusion and diffusion MRI

An overview

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Zusammenfassung

Die multiparametrische MRT mit Diffusions- und Perfusionsbildgebung gibt in einem Untersuchungsgang Informationen über das Ausmaß des bereits ischämisch geschädigten Gewebes, die Größe des kritisch minderperfundierten Areals und den Gefäßstatus. Über das Perfusions-Diffusions-Mismatch lässt sich vom Untergang bedrohtes Gewebe identifizieren, das auch noch nach 3 h nach Symptombeginn durch eine erfolgreiche Reperfusionstherapie gerettet werden kann. Neuere Studien zum Mismatch-Konzept haben gezeigt, dass Reperfusion eine entscheidende Bedingung für ein gutes Ergebnis nach einer Thrombolyse darstellt. Große Fallserien und nichtrandomisierte Kohortenstudien ergaben, dass bei mittels Perfusions-Diffusions-Mismatch ausgewählten Patienten eine intravenöse Thrombolyse jenseits des 3-Stunden-Zeitfensters sicher und effektiv durchgeführt werden kann; randomisierte kontrollierte Studien zur Effektivität der Mismatch-basierten Thrombolyse jenseits des 3-Stunden-Zeitfensters existieren allerdings bisher nicht. Bis eine solche Studie durchgeführt wird, kann in erfahrenen Zentren auch nach 3 h nach Symptombeginn eine Thrombolyse nach individueller Risikoabwägung anhand moderner Bildgebungsbefunde durchgeführt werden.

Summary

Multiparametric MRI including diffusion and perfusion imaging provides information on the extent of irreversibly damaged ischemic and/or critically hypoperfused tissue. Magnetic resonance angiography provides additional information on vessel status. The concept of perfusion-diffusion mismatch allows the estimation of tissue at risk of infarction which might be salvaged by timely reperfusion. In large case series and nonrandomized cohort studies, perfusion-diffusion mismatch-based thrombolysis was performed not less than 3 h after symptom onset with excellent safety and signs of good efficacy. However no randomised controlled trial has confirmed this to date. Recent studies improved the understanding of the mismatch concept and identified reperfusion unequivocally as an important predictor of the clinical response to thrombolysis. At the moment MRI-based thrombolysis can be performed after 3 h based on individual benefit:risk assessment in experienced stroke centers.

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Interessenskonflikt

Der korrespondierende Autor weist auf folgende Beziehungen hin: Götz Thomalla erhielt Reisekostenerstattungen durch die Firma Boehringer Ingelheim, dem Hersteller von Alteplase. Martin Köhrmann erhielt Reisekostenerstattungen durch die Firma Boehringer Ingelheim. Peter D. Schellinger erhielt Reisekostenerstattungen, Vortragshonorare sowie Beraterhonorare durch die Firma Boehringer Ingelheim. P. Ringleb erhielt Vortragshonorare von Boehringer Ingelheim und Paion sowie Aufwandsentschädigungen im Rahmen klinischer Studien von Paion.

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Authors and Affiliations

  1. Klinik und Poliklinik für Neurologie, Neuro-Zentrum, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland

    G. Thomalla

  2. Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland

    P. Ringleb

  3. Neurologische Klinik, Universitätsklinikum Erlangen, Erlangen, Deutschland

    M. Köhrmann & P.D. Schellinger

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  1. G. Thomalla
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  2. P. Ringleb
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  3. M. Köhrmann
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  4. P.D. Schellinger
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Thomalla, G., Ringleb, P., Köhrmann, M. et al. Patientenauswahl zur Thrombolyse mittels Perfusions- und Diffusions-MRT. Nervenarzt 80, 119–129 (2009). https://doi.org/10.1007/s00115-008-2592-1

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  • DOI: https://doi.org/10.1007/s00115-008-2592-1

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