Neues in der Behandlung neurologischer Notfälle

Zusammenfassung

Innovationen: Akute neuromuskuläre Erkrankungen: Rituximab führt bei einer therapierefraktären Myasthenie häufig zu einer signifikanten Verbesserung. Studien weisen auf eine mögliche Wirkung von Eculizumab hin. Bei der Behandlung des Guillain-Barré-Syndroms sind Plasmapherese und Immunglobuline gleichwertig, die Immunadsorption eine gute Alternative. Kortikosteroide scheinen die Prognose zu verschlechtern. Ischämische Schlaganfälle: Neuerungen sind positive Studien zur Thrombektomie. Die Destiny-II-Studie wies bei Patienten über dem 70. Lebensjahr mit einem malignen Mediainfarkt eine Senkung der Mortalität durch eine Hemikraniektomie nach. Intrazerebrale Blutungen: Die INTERACT-2-Studie wies keine sichere Überlegenheit einer aggressiven Blutdrucksättigung nach. In der Therapie der intrazerebralen Blutung ist der STICH-II-Trial zur operativen Therapie von Lobärhämatomen abgeschlossen, eine frühe Operation zeigte keinen eindeutigen Vorteil. Die SAIVMs-Studie wies einen Nachteil der operativen Exzision von Kavernomen gegenüber einem konservativen Vorgehen bezüglich des Outcomes nach 5 Jahren nach. Gleiches gilt für unrupturierte arteriovenöse Malformationen. Meningitis und Enzephalitis: Neuere Studien zeigen einen Rückgang der Inzidenz der Meningitis durch Meningokokken und Pneumokokken. Die Dexamethason-Gabe bei bakterieller Meningitis ist nach den aktualisierten DGN-Leitlinien nur noch nach einer nachgewiesenen Pneumokokkenmeningitis empfohlen. Bei anderen bakteriellen Meningitiden sollte jedoch nach mikrobiologischen Resultaten Dexamethason abgesetzt werden. Bezüglich viraler Enzephalitiden ist die zusätzliche Gabe von Valaciclovir nach einer intravenösen Gabe von Aciclovir bei Herpes-simplex-Enzephalitis nicht prognoseverbessernd. In Serbien wurden mehr als 50 Fälle mit einer West-Nil-Virus-Enzephalitis nachgewiesen, ebenso erste Fälle in Österreich, sodass das Virus in die Differenzialdiagnose einbezogen werden muss. Das in Polynesien, Südamerika und in der Karibik endemisch vorkommende Zikah-Virus führt häufig zu einem parainfektiösen Guillain-Barré-Syndrom, seltener zu einer Meningoenzephalitis.

Summary

Innovations: Acute neuromuscular disease: Rituximab significantly improve treatment-refractory Myasthenia gravis. Studies hints at a possible efficacy of eculizumab. Plasmapheresis and i.v. Immunoglobulins appear to have the same efficacy in treatment of acute Guillain-Barré syndrome, immunadsorption is a good alternative. In contrast, corticosteroids impair prognosis in GBS. Ischaemic stroke: Several positive randomized studies proved efficacy of thrombectomy. Thus, thrombectomy with stent retrievers after bridging thrombolysis is evidence based. The Destiny II trial revealed a significant decrease of mortality by hemicraniectomy in patients older than 70 years with malignant stroke in the medial cerebral artery territory. Intracerebral hemorrhage: INTERACT2 trial showed no significant improvement with aggressive treatment of arterial hypertension in comparison to conservative approaches to decrease arterial hypertension in patients with acute intracerebral hemorrhage. STICH-II trial investigated whether early surgical treatment is superior to conservative treatment in patients with lobar haematoma. The trial revealed no difference between both treatment approaches. SAIVMs trial showed a better outcome of conservative vs. surgical treatment in patients with intracranial cavernous after 5 years. A similar result was found for unruptured intracranial arteriovenous malformations. Meningitis and encephalitis: Studies showed a decrease in incidence of meningococcal and pneumococcal meningitis. Administration of dexamethasone in patients with acute bacterial meningitis is recommended only for patients with pneumococcal meningitis according to DGN guidelines. In acute meningitis due to other bacteria it should be withdrawn after microbiological results are received. In herpes simplex virus encephalitis the additional administration of valaciclovir after i.v. aciclovir has no influence on outcome. In Serbia 50 cases of West Nil virus encephalitis have been detected, other cases have been revealed in Austria hinting at inclusion of this virus in the differential diagnosis of encephalitis in Europe. Very recently, the Zikah virus which is endemic in Polynesia, South America and Caribbean regions has been shown to cause parainfectious Guillain-Barré syndrome, rarely meningoencephalitis.

Schlüsselwörter

Maligner Mediainfarkt - intrazerebrale Blutung - bakterielle Meningitis - virale Enzephalitis - Intensivneurologie

Keywords

Malignant brain infarction - intracerebral hemorrhage - bacterial meningitis - viral encephalitis - neurological intensive care medicine

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