Dtsch Med Wochenschr 2015; 140(21): 1583-1586
DOI: 10.1055/s-0041-106309
Dossier
Schlaganfall / vaskuläre Demenz
© Georg Thieme Verlag KG Stuttgart · New York

Versorgung des akuten ischämischen Schlaganfalls

Management of acute ischemic stroke
Christian Hans Nolte
1   Klinik für Neurologie und Centrum für Schlaganfallforschung Berlin (CSB), Charite, Universitätsmedizin Berlin
,
Heinrich Jakob Audebert
1   Klinik für Neurologie und Centrum für Schlaganfallforschung Berlin (CSB), Charite, Universitätsmedizin Berlin
› Author Affiliations
Further Information

Publication History

Publication Date:
21 October 2015 (online)

Zusammenfassung

Die Akutversorgung des ischämischen Schlaganfalls umfasst Maßnahmen wie Diagnosesicherung, Basismaßnahmen der Erstversorgung und Indikationstellung für spezifische Therapien.

Viele Therapieoptionen sind in ihrem Wirkungsgrad zeitabhängig. Deshalb sind Zeitverzögerungen in der Versorgungskette von Nachteil. Die stationäre Versorgung erfolgt durch das geschulte, multidisziplinäre Personal der spezialisierten Schlaganfallstation (Stroke Unit). Auch technische Möglichkeiten beeinflussen die Therapieoptionen. Eine zentrale Rolle kommt dabei der zerebralen Bildgebung zu.

Evidenzbasiert sind folgende fünf Therapien: Behandlung auf der Stroke Unit, Thrombolyse innerhalb von 4,5 h nach Symptombeginn, mechanische Rekanalisation bei Verschlussnachweis in einem proximalen, intrakraniellen Gefäß, frühe Gabe von ASS sowie die Hemikraniektomie bei Patienten mit sogenannten malignen Infarkten

Im folgenden Beitrag werden die notwendige Akutdiagnostik, sowie die allgemeinen und spezifischen Therapieoptionen dargestellt, welche die Versorgung innerhalb der ersten 72 h bestimmen.

Abstract

Targets of acute ischemic stroke management include verification of clinical diagnosis, start of basic care and decision-making about specific treatments.

Effectiveness of most therapeutic options is time dependent. Time delays within the rescue chain are associated with worse outcome. Trained and multidisciplinary teams on Stroke Unit form the backbone of acute management. Moreover, technical infrastructure influences therapeutic options. Cerebral imaging is pivotal.

The following five therapies are evidence-based: treatment on a stroke unit, thrombolysis within 4.5hrs after symptom onset, mechanical recanalization in patients with occlusion of proximal, intracranial arteries, early administration of Aspirin, and hemicraniectomy in patients with so-called malignant infarction.

This article describes the necessary diagnostic steps and specific as well as non-specific therapeutic options that compose acute management within the first 72 hours.

 
  • Literatur

  • 1 Ahmed N, Dávalos A, Eriksson N et al. Association of admission blood glucose and outcome in patients treated with intravenous thrombolysis: results from the Safe Implementation of Treatments in Stroke International Stroke Thrombolysis Register (SITS-ISTR). Arch Neurol 2010; 67: 1123-1130
  • 2 Audebert H. Telestroke: effective networking. Lancet Neurol 2006; 5: 279-282
  • 3 Audebert HJ, Wimmer ML, Hahn R et al. TEMPIS Group. Can telemedicine contribute to fulfill WHO Helsingborg Declaration of specialized stroke care?. Cerebrovasc Dis 2005; 20: 362-369
  • 4 Audebert HJ, Kukla C, Vatankhah B et al. Comparison of tissue plasminogen activator administration management between Telestroke Network hospitals and academic stroke centers: the Telemedical Pilot Project for Integrative Stroke Care in Bavaria / Germany. Stroke 2006; 37: 1822-1827
  • 5 AVERT Trial Collaboration group. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet 2015; 386: 46-55
  • 6 Dziedzic T, Pera J, Trabka-Janik E et al. The impact of postadmission glycemia on stroke outcome: Glucose normalisation is associated with better survival. Atherosclerosis 2010; 211: 584-588
  • 7 Ebinger M, Winter B, Wendt M et al. STEMO Consortium. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA 2014; 311: 1622-1631
  • 8 Ebinger M, Scheitz JF, Kufner A et al. MRI-based intravenous thrombolysis in stroke patients with unknown time of symptom onset. Eur J Neurol 2012; 19: 348-350
  • 9 Ebinger M, Kunz A, Wendt M et al. Effects of golden hour thrombolysis: a Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke (PHANTOM-S) substudy. JAMA Neurol 2015; 72: 25-30
  • 10 Emberson J, Lees KR, Lyden P et al. Stroke Thrombolysis Trialists‘ Collaborative Group. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014; 384: 1929-1935
  • 11 Erdur H, Scheitz JF, Ebinger M et al. In-hospital stroke recurrence and stroke after transient ischemic attack: frequency and risk factors. Stroke 2015; 46: 1031-1037
  • 12 Fiebach JB, Schellinger PD, Gass A et al. Stroke magnetic resonance imaging is accurate in hyperacute intracerebral hemorrhage: a multicenter study on the validity of stroke imaging. Stroke 2004; 35: 502-506
  • 13 Fjærtoft H, Rohweder G, Indredavik B. Stroke unit care combined with early supported discharge improves 5-year outcome: a randomized controlled trial. Stroke 2011; 42: 1707-1711
  • 14 Gierhake D, Weber JE, Villringer K et al. [Mobile CT: technical aspects of prehospital stroke imaging before intravenous thrombolysis]. Rofo 2013; 185: 55-59
  • 15 European Stroke Organisation (ESO) Executive Committee and ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008; 25: 457-507
  • 16 Haeusler KG, Schmidt WUH, Föhring F et al. Cellular immunodepression preceding infectious complications after acute ischemic stroke in humans. Cerebrovasc Dis 2008; 25: 50-58
  • 17 Huff JS. Stroke mimics and chameleons. Emerg Med Clin North Am 2002; 20: 583-595
  • 18 Jauch EC, Saver JL, Adams HP Jr. American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association / American Stroke Association. Stroke 2013; 44: 870-947
  • 19 Jüttler E, Unterberg A, Woitzik J et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. DESTINY II Investigators. N Engl J Med 2014; 370: 1091-1100
  • 20 Kessler C, Khaw AV, Nabavi DG et al. Standardized prehospital treatment of stroke. Dtsch Arztebl Int 2011; 108: 585-591
  • 21 Krebes S, Ebinger M, Baumann AM et al. Development and validation of a dispatcher identification algorithm for stroke emergencies. Stroke 2012; 43: 776-781
  • 22 Müller-Nordhorn J, Nolte CH, Rossnagel K et al. Knowledge about risk factors for stroke: a population-based survey with 28 090 participants. Stroke 2006; 37: 946-950
  • 23 Müller-Nordhorn J, Wegscheider K, Nolte CH et al. Population-based intervention to reduce prehospital delays in patients with cerebrovascular events. Arch Intern Med 2009; 169: 1484-1490
  • 24 Nabavi DG, Ringelstein EB, Faiss J et al. [Regional and national stroke units in Germany: amended certification criteria]. Nervenarzt 2012; 83: 1039-1052
  • 25 Nolte CH, Müller-Nordhorn J, Jungehülsing GJ et al. [Symptoms, risk factors, and etiology of transient ischemic attack and stroke]. Nervenarzt 2005; 76: 1231-38
  • 26 Nolte CH, Endres M. [Management of acute ischemic stroke]. Internist 2012; 53: 585-592
  • 27 Nolte CH, Doepp F, Schreiber SJ et al. Quantification of Target Population for Ultrasound Enhanced Thrombolysis in Acute Ischemic Stroke. J Neuroimaging 2013; 23: 79-81
  • 28 Nolte CH, Malzahn U, Kühnle Y et al. Improvement of door-to-imaging time in acute stroke patients by implementation of an all-points alarm. Stroke Cerebrovasc Dis 2013; 22: 149-153
  • 29 Nolte CH, Rossnagel K, Jungehuelsing GJ et al. Gender differences in knowledge of stroke in patients with atrial fibrillation. Prev Med 2005; 41: 226-231
  • 30 Nor AM, McAllister C, Louw SJ et al. Agreement between ambulance paramedic- and physician-recorded neurological signs with Face Arm Speech Test (FAST) in acute stroke patients. Stroke 2004; 35: 1355-1359
  • 31 Prabhakaran S, Ruff I, Bernstein RA. Acute stroke intervention: a systematic review. JAMA 2015; 313: 1451-1462
  • 32 Rossnagel K, Jungehülsing GJ, Nolte CH et al. Out-of-hospital delays in patients with acute stroke. Ann Emerg Med 2004; 44: 476-483
  • 33 Sandercock P, Gubitz G, Foley P et al. Antiplatelet therapy for acute ischaemic stroke. Cochrane Database Syst Rev 2003; (02) CD000029
  • 34 Schwab S, Vatankhah B, Kukla C et al. TEMPiS Group. Long-term outcome after thrombolysis in telemedical stroke care. Neurology 2007; 69: 898-903
  • 35 Stroebele N, Müller-Riemenschneider F, Nolte CH et al. Knowledge of risk factors, and warning signs of stroke: a systematic review from a gender perspective. Int J Stroke 2011; 6: 60-66
  • 36 Thomalla G, Audebert HJ, Berger K et al. Bildgebung beim Schlaganfall – eine Übersicht und Empfehlungen des Kompetenznetz Schlaganfall. Aktuelle Neurologie 2009; 36: 354-67
  • 37 Thomalla G, Cheng B, Ebinger M et al. DWI-FLAIR mismatch for the identification of patients with acute ischaemic stroke within 4·5 h of symptom onset (PRE-FLAIR): a multicentre observational study. Lancet Neurol 2011; 10: 978-986
  • 38 Vahedi K, Hofmeijer J, Juettler E et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 2007; 6: 215-222
  • 39 Walter S, Kostopoulos P, Haass A et al. Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial. Lancet Neurol 2012; 11: 397-404
  • 40 Weimar C, Weber R, Schlamann M et al. [Diagnostic and treatment of acute ischemic stroke]. Dtsch Med Wochenschr 2013; 138: 423-436
  • 41 Wendt M, Ebinger M, Kunz A et al. STEMO Consortium. Improved prehospital triage of patients with stroke in a specialized stroke ambulance: results of the pre-hospital acute neurological therapy and optimization of medical care in stroke study. Stroke 2015; 46: 740-745