Therapierelevante Pathophysiologie des akuten ischämischen Schlaganfalls: Was ist gesichert?

Zusammenfassung

Die einzige zugelassene, kausal wirksame Therapie des akuten Schlaganfalls, die rekanalisierende Therapie mittels rtPA, kann derzeit in allenfalls 1 - 2 % aller betroffenen Menschen durchgeführt werden. Für die große Mehrzahl der Patienten bleibt die allgemeine medizinische Behandlung oder auch Basistherapie. Wir wollen anhand tierexperimenteller Untersuchungen vier Aspekte der Basistherapie nach akutem Schlaganfall näher beleuchten. Es handelt sich hierbei um die Behandlung des systemischen Blutdrucks, des Blutzuckers, der Körpertemperatur und von Infektionen. Unter Berücksichtigung vorliegender klinischer Studien bzw. gegenwärtiger Behandlungskonzepte verweisen wir auf die klinische Relevanz tierexperimenteller Ergebnisse und auf mögliche neue therapeutische Optionen. Trotz teilweise noch umstrittener pathophysiologischer Vorstellungen haben letztlich vor allem tierexperimentelle Untersuchungen zur Formulierung der gegenwärtigen Behandlungskonzepte geführt. Klinische Therapiestudien, die diese Konzepte solide stützen, fehlen derzeit. Ungeachtet dessen scheint die konsequente Umsetzung dieser Konzepte auf den spezialisierten Schlaganfallstationen (Stroke Units) zur verbesserten Versorgung der Schlaganfallpatienten beizutragen, wenn auch die Erfolge noch bescheiden bleiben.

Abstract

At present, thrombolytic therapy with rtPA is the only approved pharmacological strategy for the treatment of acute ischemic stroke with demonstrated efficacy. However, due to the narrow time window, only 1 - 2 % of stroke patients do benefit from thrombolysis. For the remaining patients, general measures remain the only option. We review the experimental and clinical evidence for the efficacy of targeting four physiologic variables in the therapy of acute stroke: systemic blood pressure, blood glucose, body temperature, and infections. It will become apparent that while most general measures of stroke are plausible, experimental evidence for their efficacy is not always unequivocal, and clinical evidence in most instances is lacking. As a consequence, additional evidence from controlled clinical studies in acute stroke patients is necessary to provide a solid basis for the manipulation of blood pressure, blood glucose, and body temperature, as well as for the prevention of infections. Since there is little or no incentive for pharmaceutical companies to sponsor such trials, novel funding concepts are desperately needed.

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