Was ist gesichert in der Diagnostik, Therapie und Prophylaxe zerebraler Ischämien?

Zusammenfassung

Zerebrale Ischämien stellen die Hauptursache des Schlaganfalls dar. Eine optimale Diagnostik ist notwendig, um die Fortschritte in der Therapie zerebraler Ischämien anwenden zu können. Arteriosklerose der großen und kleinen hirnversorgenden Arterien ist für die Mehrheit der ischämischen Infarkte verantwortlich. Etwa ein Viertel der Infarkte ist durch kardiale Embolien bedingt. Darüber hinaus treten insbesondere bei jüngeren Patienten andere Makroangiopathien, Gerinnungsstörungen oder immunologische Erkrankungen auf, die als Ursache des Schlaganfalls anzusehen sind. Die Differentialdiagnose zerebraler Ischämien umfaßt daher ein breites Spektrum von Grunderkrankungen und verlangt die enge interdisziplinäre Zusammenarbeit zwischen Neurologie, Neuroradiologie und innerer Medizin. Die Akutbehandlung hat primär das Ziel einer Rekanalisation der meist embolisch bedingten intrakraniellen Gefäßverschlüsse. Hierfür steht die thrombolytische Therapie mit rekombinantem Gewebsplasminogen-Aktivator (rt-PA) unter strengen Auswahlkriterien zur i.v. Applikation zur Verfügung. Insbesondere für die Basilaris-Thrombose ist eine i.a. Lysetherapie angezeigt. Neben diesem Therapieprinzip werden der Einsatz von Antikoagulanzien, Thrombozytenfunktionshemmern und die basale medikamentöse Behandlung auf einer Schlaganfallstation (stroke unit) dargestellt. In einem letzten Abschnitt wird in Abhängigkeit von der Differentialdiagnose der zerebralen Ischämien die Bedeutung der operativen und medikamentösen Primär- und Sekundärprophylaxe betont.

Summary

Cerebral ischemia is the leading cause of stroke. Optimal diagnostics are needed to benefit from the advances in ischemic stroke therapy. Atherosclerosis of the arteries, large and small, that supply the brain is the most common cause of ischemic stroke. About a quarter of the infarctions are due to cardiogenic embolization. Non-atherosclerotic macroangiopathies, coagulation disturbances or immunological diseases which are considered as cause of the stroke may also occur, especially in younger patients. The differential diagnosis of cerebral ischemia includes a wide spectrum of underlying diseases requiring close interdisciplinary cooperation between neurology, neuroradiology and internal medicine. Acute treatment is aimed primarily at recanalization of the predominantly embolic occlusion of intracranial arteries. For this, thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) is available under strict selection criteria for IV application. Intraarterial thrombolytic therapy is indicated especially for basilary thrombosis. The use of anticoagulants, antiplatelet agents and the current basic drug therapy in the stroke unit are presented. Finally, the importance of primary and secondary operative and drug prophylaxis in dependence on the differential diagnosis of the cerebral ischemia is discussed.

Schlüsselwörter

Schlaganfall - Differentialdiagnose zerebraler Ischämien

Keywords

Stroke - differential diagnosis of cerebral ischemia - acute therapy - prophylaxis

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