Rofo 2019; 191(07): 643-652
DOI: 10.1055/a-0855-4298
Neuroradiology
© Georg Thieme Verlag KG Stuttgart · New York

Endovaskuläre Behandlung intrakranieller arteriosklerotischer Stenosen

Article in several languages: English | deutsch
Hannes Nordmeyer
1   Department of Interventional Radiology and Neuroradiology, Neurocenter Solingen, radprax St. Lukas Hospital, Solingen, Germany
2   School of Medicine, Department of Health, Witten/Herdecke University, Witten, Germany
,
René Chapot
3   Diagnostic and Interventional Radiology and Neuroradiology, Alfried-Krupp-Hospital, Essen, Germany
,
Patrick Haage
4   Department of diagnostic and interventional Radiology, Helios Universitiy Hospital, Wuppertal, Germany
› Author Affiliations
Further Information

Publication History

11 September 2018

25 January 2019

Publication Date:
04 April 2019 (online)

Zusammenfassung

Hintergrund Intrakranielle arteriosklerotische Stenosen (ICAS) sind in der europäischen Bevölkerung ursächlich für 5 – 10 % der zerebralen Ischämien. Die Indikationsstellung zur endovaskulären Therapie stellt eine besondere Herausforderung dar und die Wahl des Materials sowie die Interventionstechnik unterscheiden sich wesentlich von der Behandlung extrakranieller Stenosen. Die Behandlungsindikation ist durch die aktuelle Studienlage evidenzbasiert geworden, sollte jedoch nicht zu einer Abkehr von der Methode führen. Neue technische Konzepte können zur Vermeidung technischer Komplikationen beitragen.

Methode Die Arbeit widmet sich unter Würdigung der aktuellen Literatur der konservativen und interventionellen Therapie intrakranieller Stenosen. Die technischen Ansätze der endovaskulären Behandlung werden detailliert beschrieben und es werden insbesondere Strategien zur Vermeidung typischer Komplikationen herausgearbeitet. Anhand der Indikationsstellung werden die Standpunkte der öffentlichen Instanzen und der Fachgesellschaften erörtert.

Ergebnisse und Schlussfolgerung Für die endovaskuläre Behandlung steht als einzig zugelassenes Produkt ein selbstexpandierender Stent zur Verfügung. Off-Label kommen Ballon-expandierbare und verschiedene selbstexpandierende Stents zur Verfügung, deren Wahl von den anatomischen Gegebenheiten und den Charakteristika der Stenose abhängt. Blutungen durch distale Drahtperforationen sind technische Komplikationen, die vor allem bei der Durchführung von Wechselmanövern auftreten. Komplikationen wie Perforator-Infarkte sind demgegenüber kaum vermeidbar und stehen vor allem bei Stenosen der hinteren Zirkulation sowie des M1-Segments der A. cerebri im Zusammenhang mit der Erkrankung. Das Morbiditäts- und Mortalitätsrisiko ist in der hinteren Zirkulation höher. Die Ergebnisse der großen randomisierten prospektiven Studien haben die Rolle der konservativen Therapie intrakranieller Stenosen gestärkt. Patienten mit hämodynamisch wirksamen, unter Blutdruckschwankungen symptomatischen Stenosen oder rezidivierenden Ischämien unter optimierter medikamentöser Therapie und solchen mit akuten Verschlüssen sollte die Stent-PTA aber nicht vorenthalten werden.

Kernaussagen:

  • Intrakranielle Stenosen werden primär medikamentös und durch Risikofaktorreduktion behandelt.

  • Indikation sind rezidivierende Ischämien unter optimierter konservativer Therapie (sog. best medical treatment) und akute Verschlüsse aufgrund einer intrakraniellen Stenose.

  • Akute Verschlüsse aufgrund einer intrakraniellen Stenose werden häufig nach erfolgter Thrombektomie mit Stent-PTA versorgt.

  • Wechselmanöver können durch distale Drahtperforation zu intrakraniellen Blutungen führen.

  • Stammganglien- und Hirnstammischämien stellen ein hohes Behandlungsrisiko in Gefäßabschnitten mit vielen perforierenden Ästen dar.

Zitierweise

  • Nordmeyer H, Chapot R, Haage P. Endovascular Treatment of Intracranial Atherosclerotic Stenosis. Fortschr Röntgenstr 2019; 191: 643 – 652

 
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