Der erhöhte intrakranielle Druck – Multimodales Neuromonitoring – Indikationen und Methoden

Zusammenfassung

Die Behandlung von Patienten mit schwerem Schädelhirntrauma und aneurysmatischer Subarachnoidalblutung zählt zu den anspruchsvollsten Aufgaben der Intensivmedizin. Die Mehrzahl der Patienten benötigt eine Analgosedierung zur Beatmung bei respiratorischem Versagen oder zur Behandlung eines erhöhten intrakraniellen Drucks. Neben der standardgemäßen ICP-Messung existierten mehrere weitere kontinuierliche apparative Überwachungsverfahren am Krankenbett. Der Beitrag diskutiert die 5 gebräuchlichsten Methoden und beleuchtet deren Stellenwert im multimodalen Neuromonitoring.

Abstract:

Managing patients after severe traumatic brain injury and aneurysmal subarachnoid hemorrhage is a challenging task of modern intensive care. Most patients do require sedation for mechanical ventilation due to respiratory distress or treatment of increased intracranial pressure. Besides standard ICP monitoring, a variety of continuous monitoring technologies for bedside use exists. The paper discusses the 5 methods most frequently used and their significance for multimodal neuromonitoring.

Kernaussagen

• Das multimodale Neuromonitoring ist eine sinnvolle Ergänzung des Standard-ICP-Monitorings nach Schädelhirntrauma und aneurysmatischer Subarachnoidalblutung.

• An Verfahren werden derzeit v. a. direkte zerebrale Blutflussmessung (CBF-Messung), Gewebeoxymetrie, zerebrale Mikrodialyse, Nahinfrarotspektroskopie, EEG und die Bestimmung des Status der zerebralen Autoregulation diskutiert.

• Die radiologische Bildgebung mit Nativ- und Perfusions-CT dient zur Überprüfung der korrekten Lage nach Implantation einer Mikrosonde ins Gehirn.

• Die besten Hinweise für eine Verbesserung des neurologischen Behandlungsergebnisses gibt es für die Gewebeoxymetrie. Hier sollte ein Sauerstoffparitaldruck im Hirngewebe (p_brO₂ ) von 15–20 mmHg nicht unterschritten werden.

• Der Status der zerebralen Autoregulation kann über den Pressure Reactivity Index (PRx) bestimmt werden und korreliert signifikant und unabhängig von anderen Faktoren mit dem neurologischen Behandlungsergebnis.

• Ein einfaches 1- oder 2-Kanal-EEG ermöglicht die Steuerung der Sedierungstiefe bei beatmeten Patienten.

• Die direkte CBF-Messung mittels Thermodiffusion und die zerebrale Mikrodialyse sind Verfahren mit hohem wissenschaftlichem Potenzial. Für das Routinemonitoring sind sie aufgrund der derzeitigen Datenlage nur eingeschränkt zu empfehlen.

• Der Einsatz der Nahinfrarotspektroskopie in der neurologischen Intensivmedizin ist bisher noch unzureichend validiert.

• Bei allen Methoden ist der Einsatz von externer Software und Rechnerunterstützung zur Datenvisualisierung sinnvoll.

Schlüsselworte:

Schädelhirntrauma - Subarachnoidalblutung - multimodales Neuromonitoring - Gewebeoxymetrie - EEG

Key words:

traumatic brain injury - subarachnoid hemorrhage - multimodal neuromonitoring - brain tissue oxygenation - EEG

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