Effektive Schlaganfalltherapie jenseits der Zulassungsbeschränkungen: intravenöse Thrombolyse im erweiterten Zeitfenster (> 3 h) und bei alten Patienten (≥ 80 J.)

Zusammenfassung

Die intravenöse Thrombolyse mit tPA ist die einzige zugelassene und effektive spezifische Therapie des akuten ischämischen Schlaganfalls. Die Beschränkung der Zulassung auf die ersten 3 Stunden sowie die Empfehlung, Patienten über 80 Jahren nicht zu behandeln, sind wesentliche Gründe dafür, dass nicht mehr Patienten mit dieser effektiven Therapie behandelt werden. Dabei gibt es zunehmend Hinweise, dass Patienten auch jenseits dieser Beschränkungen sicher und effektiv mittels Thrombolyse behandelt werden können. In einer Übersicht wird die Datenlage zur systemischen Thrombolyse jenseits des 3 Stunden Zeitfensters und bei sehr alten Patienten dargestellt und bewertet. Aufgrund dieser Daten lässt sich sagen, dass (1.) bei Auswahl der Patienten mittels moderner MRT-Bildgebung eine Thrombolyse zumindest bis zu einem Zeitfenster von 6 Stunden sicher und effektiv durchführbar ist, und (2.) auch über Achtzigjährige ohne eine Zunahme der Mortalität oder symptomatischer intrazerebraler Blutungen mittels intravenöser Thrombolyse behandelt werden können. In Anbetracht der Tatsache, dass viele akute Schlaganfallpatienten das Krankenhaus erst außerhalb des 3 Stunden Zeitfensters erreichen, und vor dem Hintergrund der zunehmenden Überalterung der Gesellschaft mit der Folge einer wachsenden Zahl alter und sehr alter Schlaganfallpatienten, bedeutet dies, dass sich die Anzahl der sicher und effektiv mit Thrombolyse behandelbaren Patienten deutlich steigern ließe. Zusammenfassend ist zu empfehlen, an erfahrenen Zentren akute Schlaganfallpatienten auch über ein Alter von 80 Jahren hinaus und nach MRT-Kriterien bis zu 6 Stunden nach Symptombeginn mittels intravenöser Thrombolyse zu behandeln.

Abstract

Intravenous thrombolysis with tPA is the only approved and effective treatment for acute ischemic stroke. The approval, however, is restricted to treatment within 3 hours of stroke onset, and it is not recommended to treat patients beyond 80 years of age. Due to these restrictions, thrombolysis is only given to a small number of acute stroke patients. At the same time there is growing evidence that patients can be treated with thrombolysis safely and effectively even beyond these restrictions. We give an overview over the published data regarding thrombolysis beyond the 3 hour time window and in patients aged 80 or over. Based on these data we conclude that (1.) intravenous thrombolysis in MRI selected patients is safe and effective within an extended time window of up to 6 hours, and (2.) there is no increase in mortality or symptomatic intracerebral bleeding complications in patients aged 80 or over treated with thrombolysis. A great number of acute stroke patients reaches the hospital beyond the 3 hour time window, and there is a growing number of old and very old stroke patients in the western world. Treating patients up to a 6 hour time window and beyond the age of 80 years would clearly increase the number of patients, which might benefit from this effective treatment. To summarize, we recommend experienced stroke centres to treat acute stroke patients with thrombolysis up to 6 hours using MRI criteria for patient selection, and to treat also patients aged 80 years or older.

Schlüsselwörter

Akuter Schlaganfall - intravenöse Thrombolyse - diffusions- und perfusionsgewichtetes MRT - 80 Jahre und älter

Key words

stroke, acute - thrombolytic therapy - diffusion and perfusion weighted MRI - aged, 80 and over

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