Optimierte Rate spezifischer revaskularisierender Therapien beim akuten ischämischen Schlaganfall – was ist das Ziel? Erwägungen anhand der Erfahrungen eines tertiären Versorgungszentrums

 

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Zusammenfassung

Hintergrund: Aufgrund des besseren Verlaufes nach Rekanalisierung und vielversprechender interventioneller Verfahren werden derzeit strukturelle Bemühungen unternommen, die Rate dieser Therapien beim Schlaganfall zu verbessern. Unklar ist, wie und auf welchem Niveau dies optimierbar ist.

Patienten und Methode: Retrospektive unizentrische Analyse aller primär zugewiesener, nach einem strukturierten Behandlungspfad mit multimodaler CT Bildgebung spezifisch rekanalisierend behandelter Schlaganfallpatienten eines tertiären Versorgungszentrums im Zeitraum 1/2010 bis 3/2012.

Ergebnisse: 20 % der Patienten wurden lysiert, etwa 20 % hiervon zusätzlich interventionell behandelt. Bei Off-label-Indikation war die Rate spezifischer Perfusionsbefunde signifikant höher als bei On-label-Lysen. Der kurzzeitige klinische Verlauf war hiervon unabhängig.

Schlussfolgerung: Ein strukturierter Behandlungspfad erlaubt eine hohe Rate an Lysen und Interventionen. Anhand der dargestellten Daten kann eine erste Zielsetzung für die allgemeine Versorgungsrealität formuliert werden (20/20 in 2020).

Abstract

Background: Recanalisation favourably influences outcome in acute stroke. Improved endovascular approaches seem to have higher recanalisation rates than systemic thrombolysis. Substantial efforts have been undertaken to increase the proportion of patients to whom these therapies can be applied. It is still unclear what rates can be realised in a clinical setting.

Patients and Methods: This is a retrospective single-centre analysis of patients with acute ischaemic stroke and specific recanalisation therapy primarily admitted to our tertiary care centre from 1/2010 to 3/2012.

Results: 20 % of patients received systemic thrombolysis, 20 % of these additional endovascular strategies. Pathological multimodal CT patterns were more common in patients not fulfilling the inclusion criteria for thrombolysis. Short-term clinical outcomes were similar in on-label and off-label applications.

Conclusion: Structured clinical pathways including multimodal CT imaging are useful in identifying patients likely to profit from revascularisation therapies. Based upon our data, some realistic aims concerning therapy rates in patients with ischaemic stroke treated in everyday practice may be formulated (20/20 in 2020).

• Literatur

• 1 Wardlaw JM, Zoppo G, Yamaguchi T et al. Thrombolysis for acute ischaemic stroke. Cochrane database of systematic reviews (Online) 2003; CD000213
  PubMedGoogle Scholar
• 2 Hacke W, Kaste M, Bluhmki E et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359: 1317-1329
  CrossrefPubMedGoogle Scholar
• 3 Del Zoppo GJ, Saver JL, Jauch EC et al. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke 2009; 40: 2945-2948
  CrossrefPubMedGoogle Scholar
• 4 Furlan A, Higashida R, Wechsler L et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 1999; 282: 2003-2011
  CrossrefPubMedGoogle Scholar
• 5 Saver JL. Intra-arterial thrombolysis. Neurology 2001; 57: S58-S60
  CrossrefPubMedGoogle Scholar
• 6 Janjua N, Brisman JL. Endovascular treatment of acute ischaemic stroke. Lancet Neurol 2007; 6: 1086-1093
  CrossrefPubMedGoogle Scholar
• 7 Nogueira RG, Yoo AJ, Buonanno FS et al. Endovascular approaches to acute stroke, part 2: a comprehensive review of studies and trials. Am J Neuroradiol 2009; 30: 859-875
  CrossrefPubMedGoogle Scholar
• 8 Tarr R, Hsu D, Kulcsar Z et al. The POST trial: initial post-market experience of the Penumbra system: revascularization of large vessel occlusion in acute ischemic stroke in the United States and Europe. J Neurointerv Surg 2010; 2: 341-344
  CrossrefPubMedGoogle Scholar
• 9 Mielke O, Wardlaw J, Liu M. Thrombolysis (different doses, routes of administration and agents) for acute ischaemic stroke. Cochrane database of systematic reviews (Online) 2004; CD000514
  PubMedGoogle Scholar
• 10 Smith EE, Hassan KA, Fang J et al. Do all ischemic stroke subtypes benefit from organized inpatient stroke care?. Neurology 2010; 75: 456-462
  CrossrefPubMedGoogle Scholar
• 11 Rha J, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 2007; 38: 967-973
  CrossrefPubMedGoogle Scholar
• 12 Ueda T, Sakaki S, Kumon Y et al. Multivariable analysis of predictive factors related to outcome at 6 months after intra-arterial thrombolysis for acute ischemic stroke. Stroke 1999; 30: 2360-2365
  CrossrefPubMedGoogle Scholar
• 13 Liebeskind DS. Reperfusion for acute ischemic stroke: arterial revascularization and collateral therapeutics. Curr Opin Neurol 2010; 23: 36-45
  CrossrefPubMedGoogle Scholar
• 14 Rouchaud A, Mazighi M, Labreuche J et al. Outcomes of mechanical endovascular therapy for acute ischemic stroke: a clinical registry study and systematic review. Stroke 2011; 42: 1289-1294
  CrossrefPubMedGoogle Scholar
• 15 Molina CA. Reperfusion therapies for acute ischemic stroke: current pharmacological and mechanical approaches. Stroke 2011; 42: S16-S19
  CrossrefPubMedGoogle Scholar
• 16 Eyding J, Wiebringhaus R, Klein FG et al. Multimodal CT Imaging and Recanalizing Therapy in Acute Ischemic Stroke: Retrospective Analysis of a One-Year Single-Center Experience. Eur Neurol 2012; 67: 193-199
  CrossrefPubMedGoogle Scholar
• 17 Konig M, Klotz E, Heuser L. Zerebrale Perfusions-CT – Theoretische Grundlagen, methodische Realisierung und praktische Erfahrungen in der Diagnostik des ischämischen Hirninfarktes. Fortschr Röntgenstr 2000; 172: 210-218
  Article in Thieme ConnectPubMedGoogle Scholar
• 18 Lui YW, Tang ER, Allmendinger AM et al. Evaluation of CT perfusion in the setting of cerebral ischemia: patterns and pitfalls. Am J Neuroradiol 2010; 31: 1552-1563
  CrossrefPubMedGoogle Scholar
• 19 Heuschmann PU, Biegler MK, Busse O et al. Development and implementation of evidence-based indicators for measuring quality of acute stroke care: the Quality Indicator Board of the German Stroke Registers Study Group (ADSR). Stroke 2006; 37: 2573-2578
  CrossrefPubMedGoogle Scholar
• 20 Lyden PD, Zweifler R, Mahdavi Z et al. A rapid, reliable, and valid method for measuring infarct and brain compartment volumes from computed tomographic scans. Stroke 1994; 25: 2421-2428
  CrossrefPubMedGoogle Scholar
• 21 Eyding J, Kitzrow M, Bartig D et al. Versorgungsrealität von Patienten mit ischämischem Schlaganfall in der Metropolenregion Ruhrgebiet: aktueller Stand und Perspektiven einer fachspezifischen Vernetzung. Nervenarzt 2012; DOI: 10.1007/s00115-012-3613-7.
  PubMedGoogle Scholar
• 22 Boode B, Welzen V, Franke C et al. Estimating the number of stroke patients eligible for thrombolytic treatment if delay could be avoided. Cerebrovasc Dis 2007; 23: 294-298
  CrossrefPubMedGoogle Scholar
• 23 Mazighi M, Serfaty J, Labreuche J et al. Comparison of intravenous alteplase with a combined intravenous-endovascular approach in patients with stroke and confirmed arterial occlusion (RECANALISE study): a prospective cohort study. Lancet Neurol 2009; 8: 802-809
  CrossrefPubMedGoogle Scholar
• 24 Grunwald IQ, Walter S, Papanagiotou P et al. Revascularization in acute ischaemic stroke using the penumbra system: the first single center experience. Eur J Neurol 2009; 16: 1210-1216
  CrossrefPubMedGoogle Scholar
• 25 Wintermark M, Meuli R, Browaeys P et al. Comparison of CT perfusion and angiography and MRI in selecting stroke patients for acute treatment. Neurology 2007; 68: 694-697
  CrossrefPubMedGoogle Scholar
• 26 Thomalla G, Audebert HJ, Berger K et al. Bildgebung beim Schlaganfall – eine Übersicht und Empfehlungen des Kompetenznetzes Schlaganfall. Akt Neurol 2009; 36: 354-367
  Article in Thieme ConnectPubMedGoogle Scholar