Zusammenfassung
Der akute Schlaganfall ist in den westlichen Industrieländern die dritthäufigste Todesursache und führt am häufigsten dauerhaft zur Invalidität . Die ischämische Form entsteht durch kritische Minderperfusion eines Hirnareals (Penumbra) infolge Verschluss des versorgenden Gefäßes . Auf dem Penumbrakonzept basieren alle wesentlichen akuttherapeutischen Ansätze: schnelle anhaltende Wiederherstellung der Gewebeperfusion und Schutz des vom Untergang bedrohten Penumbragewebes durch z. B. Neuroprotektion.
Zum Vorgehen gehören kurze Anamnese, Neurostatus und zum Ausschluss einer ICB die Nativ-CCT oder moderne Schlaganfall-MRT-Sequenzen mit besserer Patientenselektion in erweiterten Zeitfenstern. Die i.v.-Lyse mit rt-PA innerhalb von 3 h ist die einzige zugelassene und effektive Therapie der akuten zerebralen Ischämie mit signifikantem Nutzen für den Patienten. Der Effekt ist kleiner, aber klinisch noch signifikant im Fenster zwischen 3 und 4,5 h und liegt bei Einsatz von Schlaganfall-MRT mit DWI und PWI bis zu 9 h vor. Aggressivere Therapien, wie interventionelle Reperfusion und Hemikraniektomie oder Hypothermie bei malignem Mediainfarkt sind spezialisierten Zentren vorbehalten.
Abstract
Acute stroke is the third most common cause of death and also the most common cause of permanent disability in industrialized countries. Ischemic stroke is caused by occlusion of a cerebral artery leading to a critical reduction in brain perfusion in the respective brain area (penumbra). Most acute stroke treatment strategies are based on the penumbra concept: attaining rapid and persistent reperfusion is followed by the protection of critically ischemic and not yet infarcted (penumbral) tissue by, e.g., neuroprotection.
Examination of the acute stroke patient includes a brief history, neurostatus and imaging (CT or MRI) for the exclusion of intracerebral hemorrhage. The diagnostic standard is CT; modern stroke MRI protocols provide an improved selection in later time windows. Intravenous thrombolysis with rt-PA within 3 h of symptom onset is the only approved therapy with a proven significant benefit for the patient. The effect is smaller but still significant if treatment occurs up to 4.5 h, and may still be present in MRI selected patients up to 9 h. More aggressive forms of therapy include interventional reperfusion techniques and therapy of malignant MCA infarction such as hemicraniectomy and hypothermia, which at present, however, are not routine and are only performed in specialized centers.
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Der korrespondierende Autor weist auf eine Verbindung mit folgender Firma/Firmen hin: PDS und WH haben Honorartätigkeit für die Firma Boehringer Ingelheim (rt-PA, Actilyse®) geleistet.
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Schellinger, P.D., Kollmar, R., Meyding-Lamadé, U.K. et al. Akute zerebrale Durchblutungsstörung. Internist 46, 982–993 (2005). https://doi.org/10.1007/s00108-005-1449-y
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DOI: https://doi.org/10.1007/s00108-005-1449-y