Zekerheden en onzekerheden. Behandeling van patienten met een beroerte

Stroke is the third leading cause of death in The Netherlands and the single most important cause of disability. It should be distinguished in haemorrhagic and ischaemic stroke. The most common causes of ischaemic stroke are (cardiac) embolism, atherosclerotic lesion or perfusion disorders. Haemorrhagic stroke includes subarachnoid bleeding or intraparenchymal bleeding. The most common cause of subarachnoid haemorrhage is a ruptured aneurysm, whereas intraparenchymal haemorrhage can be caused by atherosclerotic lesions, arterio-venous malformations, amyloid angiopathy, or more rare causes. Acetylsalicylic acid should be the first choice for secondary prevention of future cardiovascular complication after transient ischaemic attack or minor ischaemic stroke. In patients with atrial fibrillation warfarin is to be preferred. The place of dipyridamole and clopidogrel has to be further established. Carotid endarterectomy should be considered in patients with a high-grade symptomatic stenosis of the internal carotid artery. Treatment of acute ischaemic stroke is uncertain. Alteplase has been proved of value only if it can be administered within three hours after onset of the neurological deficit. Acetylsalicylic acid probably is both safe and useful. Several neuroprotective compounds have been studied, but at this moment none of these drugs has been definitely proved efficient.