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Gefäßmedizin Scan - Zeitschrift für Angiologie, Gefäßchirurgie, diagnostische und interventionelle Radiologie 2017; 04(02): 129-143
DOI: 10.1055/s-0043-111765
CME-Fortbildung
© Georg Thieme Verlag KG Stuttgart · New York

Rolle der zerebralen Bildgebung für die Therapieentscheidung zur Thrombektomie

Daniel Kaiser
,
Johannes C. Gerber
,
Volker Puetz
Further Information

Publication History

Publication Date:
19 July 2017 (online)

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Der ischämische Schlaganfall, bedingt durch Gefäßverschluss und konsekutive zerebrale Minderperfusion, ist eine potenziell reversible Erkrankung. Unbehandelt kann er jedoch innerhalb kürzester Zeit zu Behinderung oder Tod führen. Dieser Beitrag beschreibt, wie die Behandlung bei Schlaganfall in den letzten 2 Jahrzehnten mit dem Fortschritt in der bildgebenden Diagnostik zur sicheren und hocheffektiven Kausaltherapie weiterentwickelt wurde.
Kernaussagen

  • Sechs aktuelle randomisierte kontrollierte Studien haben einen signifikanten Behandlungseffekt der Thrombektomie auf den klinischen Verlauf bei Patienten mit akutem Schlaganfall aufgrund eines proximalen Gefäßverschlusses im vorderen Stromgebiet gezeigt.

  • Alle Studien bestätigten die entscheidende Rolle einer prätherapeutischen Bildgebung in der Auswahl der Patienten, die von einer endovaskulären Therapie profitieren können. Dabei wurden jedoch unterschiedliche bildgebungsbasierte Ansätze mit Darstellung des behandelbaren Gefäßverschlusses, des Infarktkerns, der arteriellen Kollateralversorgung oder der Penumbra gewählt.

  • Auf Basis der aktuellen Studienlage und Leitlinien [13] wird zur Indikationsstellung für die Thrombektomie empfohlen, dass Patienten mit einem akuten Schlaganfall unverzüglich eine nicht invasive zerebrale Bildgebung erhalten.

  • Bei ischämischer Schlaganfallgenese gilt die Empfehlung, unverzüglich eine Gefäßdarstellung (CTA, MRA [Magnetresonanzangiografie]) durchzuführen, um Patienten für eine Thrombektomie auszuwählen.

  • Die Thrombektomie wird für Patienten mit intrakraniellem Gefäßverschluss im vorderen Stromgebiet (A. carotis interna, M1; eingeschränkt für M2) und bildgebenden Zeichen eines kleinen Infarkts (z. B. ASPECTS > 5) in einem Zeitfenster von bis zu 6 h nach Symptombeginn empfohlen.

  • Patienten im erweiterten Zeitfenster (mehr als 6 h) oder mit größerem Infarkt (z. B. ASPECTS ≤ 5) sind nicht grundsätzlich von einer Thrombektomie auszuschließen. Weitere Bildgebung (Perfusion, Kollateralen) sollte herangezogen werden, um Patienten auszuwählen, deren Hirngewebe noch gerettet werden kann.

  • Patienten mit einem akuten Basilarisverschluss sollten primär mit einer Thrombektomie behandelt oder in randomisierte Studien eingeschlossen werden.

 

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