Akute Kopfschmerzen in der Notaufnahme

Viele Patienten werden mit Kopfschmerzen in der Notaufnahme vorstellig. Radiologen spielen im Hinblick auf die frühzeitige Diagnose und Therapieentscheidung eine zentrale Rolle. Die Vertrautheit mit subtilen Bildgebungsbefunden, die wegweisend für die Diagnose sein können, ist daher wichtig. Dieser Artikel gibt einen Überblick über die Ätiologie von akuten Kopfschmerzen in der Notaufnahme und die jeweils typischen Bildgebungsbefunde.

Abstract

Acute headache is a common symptom and is reported by approximately 2 % – 4 % of patients who present to the emergency department. Many abnormalities manifest with headache as the first symptom, and it is crucial to obtain a patient’s complete clinical history for correct diagnosis. Headache onset, duration, and severity; risk factors such as hypertension, immunosuppression, or malignancy; and the presence of focal neurologic deficits or systemic symptoms may aid the radiologist in deciding whether imaging is appropriate and which modality to choose. Imaging findings are more likely to be abnormal in patients with a “thunderclap” headache than in those with headaches of lesser severity. The causes of headache in the emergency setting are various. They may manifest at imaging as subarachnoid hemorrhage (ruptured aneurysm, reversible vasoconstriction syndrome, or pituitary apoplexy), parenchymal hemorrhage (hypertension, ruptured arteriovenous malformation, cerebral amyloid angiopathy, dural arteriovenous fistula, or sinus thrombosis), or parenchymal edema (posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome, sinus thrombosis, or encephalitis). Alterations in intracranial pressure that are related to idiopathic intracranial hypertension or spontaneous intracranial hypotension and prior lumbar puncture or epidural injection may manifest with specific imaging findings. With accumulating knowledge of disease pathophysiology, radiologists have started to play a more central role in making the correct diagnosis. This article reviews multiple causes of acute headache and their characteristic appearances at multimodality imaging and familiarizes the reader with current concepts in imaging.

Kernaussagen

• Eine Subarachnoidalblutung im Bereich der Hirnkonvexität ist die früheste Komplikation eines reversiblen zerebralen Vasokonstriktionssyndroms, liegt jedoch lediglich in 20 – 25 % der Fälle vor.

• Angiografische Untersuchungen einschließlich der MR-Angiografie, der CT-Angiografie und der Katheterangiografie können in der ersten Woche nach der klinischen Manifestation eines reversiblen zerebralen Vasokonstriktionssyndroms unauffällig sein. Dies liegt wahrscheinlich am zentripetalen Verlauf der zerebralen Vasokonstriktion, die in kleinen peripheren Arteriolen auftritt und zentral zu den mittelgroßen und großen zerebralen Arterien fortschreitet.

• Die 2-D-Time-of-Flight-MR-Venografie ist die am häufigsten eingesetzte Technik zur Beurteilung einer zerebralen Venenthrombose und verhält sich am sensitivsten gegenüber dem Fluss senkrecht zur Akquisitionsebene.

• Kopfschmerzen sind das früheste Symptom und werden von 68 % der Patienten mit einer spontanen Dissektion der A. carotis interna und von 69 % der Patienten mit einer spontanen Vertebralisdissektion berichtet.

• Bei mehr als 90 % der Patienten mit idiopathischer intrakranieller Hypertonie wurde eine Stenose des Sinus transversus nachgewiesen. Damit kommt als zugrundeliegender pathophysiologischer Mechanismus u. a. eine venöse Abflussobstruktion infrage.

Schlüsselwörter

Akute Kopfschmerzen - Ätiologie - Notaufnahme - Bildgebung

Publication History

Article published online:
07 April 2021

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