Therapie der intrazerebralen und subarachnoidalen Blutung

ZUSAMMENFASSUNG

In den letzten Jahren gab es deutliche Fortschritte in der Akutbehandlung von Patienten mit intrazerebraler Blutung (ICB) und Subarachnoidalblutung (SAB). Allerdings sind die Letalität weiterhin hoch und das funktionelle Outcome der Überlebenden oft stark eingeschränkt. Während bei der ICB aufgrund des Parenchymdefekts häufig motorische Einschränkungen im Vordergrund stehen, leiden SAB-Patienten auch an alltagsrelevanten Folgeschäden wie Kopfschmerzen, Depressionen und kognitiven Einschränkungen. Bei der Behandlung der ICB stehen die Vermeidung einer frühen Blutungsprogression durch Blutdruckmanagement und Hämostase im Vordergrund sowie die Erprobung neuerer minimal-invasiver Techniken zur Blutungsausräumung. Weiterhin eine Herausforderung stellt das Management des Perifokalödems, des Hirndrucks, des Ventrikeleinbruchs und Hydrozephalus sowie die langfristige antithrombotische Therapie dar. Bei der SAB steht die zügige Aneurysmaausschaltung und Hydrozephalusbehandlung im Fokus der Akuttherapie. Neue Aspekte haben sich auch bei der Vermeidung und Behandlung von Vasospamen und sekundären zerebralen Ischämien ergeben. Weitere Forschungsfelder sind das optimale Drainagemanagement, mittels Ventrikel- und Lumbaldrainagen, sowie die intraventrikuläre Fibrinolyse. Die vorliegende Übersichtsarbeit geht auf diese relevanten Themenkomplexe in der Akut- und Langzeittherapie von ICB- und SAB-Patienten ein und gibt einen Überblick zu der aktuellen Datenlage und Kontroversen in diesen Behandlungsfeldern.

ABSTRACT

In recent years there have been significant advances in the acute treatment of patients with intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). However, mortality remains high and functional outcome of surviving patients is often severely impaired. While ICH patients often suffer from motor deficits, SAH patients may be limited in daily activities due to concentration disorders, headaches, depression and cognitive impairment. Treatment of ICH focuses on prevention of early hematoma expansion by blood pressure management and hemostasis. Further, novel minimally invasive techniques for hemorrhage evacuation are currently at trial. The management of perihemorrhagic edema, intracranial pressure, ventricular involvement and hydrocephalus as well as long-term antithrombotic therapy remain challenging. In SAH, acute treatment relies on rapid aneurysm closure and hydrocephalus treatment. New aspects have also emerged in the prevention and treatment of vasospasms and secondary cerebral ischemia. Further research areas are optimal drainage management using ventricular and lumbar drains as well as intraventricular fibrinolysis. This review article deals with these relevant topics in acute and long-term treatment of ICH and SAH patients and provides an overview of current evidence and controversies in these treatment fields.

Schlüsselwörter

Intrazerebrale Blutung - subarachnoidale Blutung - Hämatomvergrößerung - Blutungsausräumung - Vasospamen - Hydrozephalus - Sterblichkeit - Outcome

Key words

Intracerebral hemorrhage - subarachnoid hemorrhage - hematoma enlargement - hematoma evacuation - vasospasm - hydrocephalus - mortality - outcome

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