Diagnostik und endovaskuläre Therapie intrakranieller arterieller Stenosen

Zusammenfassung

Intrakranielle arterielle Stenosen (IAS) sind abhängig von der ethnischen Herkunft für etwa 6 – 50 % aller ischämischen Schlaganfälle verantwortlich. Patienten mit einer symptomatischen IAS haben trotz medikamentöser Sekundärprophylaxe innerhalb eines Jahres ein hohes Reinsultrisiko (12 %) in dem zugehörigen Gefäßterritorium, bei einem Stenosegrad ≥ 70 % sogar 19 %. Nach wie vor ist die digitale Subtraktionsangiografie der Goldstandard in der Diagnostik einer IAS. Zunehmend werden aber in der initialen Diagnostik nicht invasive Verfahren (MRA und CTA sowie die Doppler/Duplex-Sonografie) eingesetzt. MRA und CTA sind relativ sensitive Methoden, können aber aufgrund der technischen Gegebenheiten zu Fehleinschätzungen des Stenosegrads führen. Andererseits geben diese Verfahren in der klinischen Routine aber auch Zusatzinformationen zum zerebralen Befund. Aktuell wird bei symptomatischen IAS zunächst eine medikamentöse Sekundärprophylaxe mit Acetylsalicylsäure empfohlen. Bei einem unter Thrombozytenfunktionshemmern auftretenden erneuten ischämischen Schlaganfall/TIA im Gefäßterritorium der symptomatischen IAS wird insbesondere bei Stenosen ≥ 70 % eine interventionelle (stentgestützte) Angioplastie in einem spezialisierten Zentrum empfohlen. Die verschiedenen Möglichkeiten der Angioplastie und Stentimplantation werden in diesem Artikel diskutiert. Aktuell liegt die periprozedurale Komplikationsrate zwischen 2 und 7 %, die Re-Stenoseraten zwischen 10 und 40 %, abhängig sowohl von Lokalisation als auch Alter des Patienten. Randomisierte Studien, die die medikamentöse Therapie mit der interventionellen Therapie vergleichen, werden derzeit durchgeführt. Mit Weiterentwicklung der endovaskulären Methodik und Verminderung der Komplikationsraten ist aktuell insbesondere für den hinteren Kreislauf eine Ausweitung der Indikation zur endovaskulären Therapie gegeben.

Abstract

Approximately 6 – 50 % of all ischemic strokes are caused by intracranial arterial stenosis (IAS). Despite medical prevention, patients with symptomatic IAS have a high annual risk for recurrent ischemic stroke of about 12 %, and up to 19 % in the case of high-grade IAS (≥ 70 %). Digital subtraction angiography remains the gold standard for the diagnosis and grading of IAS. However, noninvasive imaging techniques including CT angiography, MR angiography, or transcranial Doppler and duplex ultrasound examinations are used in the clinical routine to provide additional information about the brain structure and hemodynamic. However, for technical reasons, the grading of stenoses is sometimes difficult and inaccurate. To date, aspirin is recommended as the treatment of choice in the prevention of recurrent ischemic stroke in patients with IAS. IAS patients who suffer a recurrent ischemic stroke or transient ischemic attack while taking aspirin can be treated with endovascular stenting or angioplasty in specialized centers. The periprocedural complication rate of these endovascular techniques is about 2 – 7 % at experienced neuro-interventional centers. The rate of re-stenosis is reported between 10 and 40 % depending on patient age and stenosis location. Further randomized studies comparing medical secondary prevention and endovascular therapy are currently being performed. With regard to the improvement of endovascular methods and lower complication rates, the indication for endovascular therapy in IAS could be broadened especially for stenosis in the posterior circulation.

vascular - brain - angioplasty - stents - ischemia/infarction

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