Zusammenfassung
Beim akuten ischämischen Schlaganfall ist die akute Wiederherstellung der Gehirnperfusion Ziel der Behandlung. Therapie der Wahl ist die systemische intravenöse Thrombolyse mit rt-PA, die entsprechend klinischer Studien und anhand der Auswertung des SITS-MOST-Registers eine gesicherte und effektive Therapie darstellt (Evidenzlevel A). In der Notfallversorgung der Patienten ist – durch Leitlinien gestützt – das diagnostische Prozedere und die Indikationsstellung strukturiert und in vielen Zentren durch Einrichtungen von Stroke Units etabliert. Mit den Parametern Zeitfenster, klinisch-neurologischer Status, zerebrale Bildgebung und Gerinnungsanalyse ist die Indikation in der Regel sicher zu stellen. Das enge Behandlungszeitfenster von wenigen Stunden bedingt die Notfallversorgung und verlegt den „point of care“ meist in die Bildgebung. In der Praxis werden weniger als 4% der Patienten behandelt, was aufgrund der Datenlage nicht mehr zu rechtfertigen ist. Durch spezielle Bildgebungsverfahren (Mismatch-Darstellungen), intraarterielle Lysen und Angioplastieverfahren, mechanische Thrombusentfernung und die Sonothrombolyse können die Behandlungsoptionen möglicherweise erweitert werden, dies bleibt aber heute nur wenigen hochspezialisierten Zentren vorbehalten.
Abstract
The main therapeutic target in treatment of acute ischemic stroke is the acute restoration of the cerebral perfusion. Therapy of choice is the systemic intravenous thrombolysis with rt-PA. This therapy is based and proven in large clinical trials recently given by the results of the SITS-MOST register. The diagnostic procedure and the indication for thrombolysis is well documented in national guidelines and established in many centers providing stroke units. The parameters time window (time since symptom onset), clinical-neurological deficits, cerebral imaging and laboratory data are sufficient to put the indication and to start the treatment. The narrow time window of a few hours determines the emergency character of acute stroke. Thus, the “point of care” is often located in the imaging room, the bottle neck in the diagnostic chain. In the daily practice, only 4% of the stroke patients are treated, which is not justified regarding the clinical data. Special cerebral imaging methods (MRI with PWI/DWI mismatch calculation) to extend the time-window, intra-arterial thrombolysis, angioplasty, mechanical clot extraction as well as the sonothrombolysis are only provided in highly specialized centers and have to be further evaluated.
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Siebler, M., Schellinger, P., Sykora, J. et al. Update Thrombolyse des akuten ischämischen Schlaganfalls. Notfall Rettungsmed 11, 178–182 (2008). https://doi.org/10.1007/s10049-008-1043-7
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DOI: https://doi.org/10.1007/s10049-008-1043-7