Zusammenfassung
Die Akutversorgung von Schlaganfallpatienten auf der Stroke Unit erfolgt interdisziplinär
unter anfangs hohem Zeitdruck, um rechtzeitig eine Entscheidung über geeignete Therapieverfahren
treffen zu können. Die traditionsreichen elektrophysiologischen Untersuchungstechniken
haben in der modernen Diagnostik des Hirninfarkts einen Bedeutungswandel erfahren,
nachdem klinisch vermutete Läsionen heute in aller Regel rascher und eindeutiger durch
bildgebende Verfahren lokalisiert werden können. Da evozierte Potenziale und Reflexstudien
die untersuchten Bahnsysteme im Gegensatz zur konventionellen Bildgebung jedoch funktionell
charakterisieren, bleiben die herkömmlichen elektrophysiologischen Verfahren dennoch
für den Kliniker hilfreich. Zu den Anwendungsgebieten gehören die elektrophysiologische
Hirnstammdiagnostik, das Monitoring komatöser oder sedierter Patienten durch multimodale
evozierte Potenziale und die Prognoseabschätzung mittels motorisch evozierter Potenziale.
Weiterhin können neurophysiologische Verfahren in differenzialdiagnostisch schwierigen
Fällen zur topographischen Diagnose beitragen und bei Verdacht auf psychogene Störungen
die Annahme intakter anatomischer Strukturen stützen. Diese Arbeit gibt eine subjektive
Übersicht über in der Praxis der Schlaganfallbehandlung sinnvolle Einsatzmöglichkeiten
von Reflexstudien und evozierten Potenzialen in der Akutbehandlung des Hirninfarkts.
Abstract
The management of patients with acute stroke requires an interdisciplinary approach
and strict time management to enable therapeutic decisions in due time. Neurophysiological
investigations, with their long tradition in neurological medicine, have undergone
a changing role in stroke management since most lesions are now easily and reliably
located by modern imaging studies. However, in contrast to conventional MRI and CT
scans, evoked potential recordings and brain stem reflex studies provide a functional
characterisation of the neural circuits under study and thus remain helpful for the
clinician in many instances. Applications include neurophysiological investigations
of the brain stem with its many closely neighbouring structures, the monitoring of
comatose and sedated patients using multimodal evoked potentials, and studies aiming
at determining the prognosis of functional motor deficits using motor evoked potentials.
Further, neurophysiological investigations may help in clarifying unusual differential
diagnoses and provide additional evidence for normal physiological functioning in
cases of suspected psychogenic deficits. This review summarizes in a subjective manner
applications of evoked potential recordings and reflex studies that are useful in
the management of acute stroke in clinical practice.
Key words
Ischemic stroke - Evoked potential - Clinical neurophysiology - Blink reflex
Literatur
- 1 Stöhr M, Dichgans J, Buettner U W, Hess C W, Altenmüller E. Evozierte Potenziale. Berlin;
Springer 1996
- 2 Lowitzsch K, Hopf H C, Buchner H, Claus D, Jörg J, Rappelsberger P, Tackmann W.
Das EP-Buch. Stuttgart; Thieme 2000
- 3
Chiappa K H, Hill R A.
Evaluation and prognostication in coma.
Electroencephalogr Clin Neurophysiol.
1998;
106
149-155
- 4
Nuwer M R.
Fundamentals of evoked potentials and common clinical applications today.
Electroencephalogr Clin Neurophysiol.
1998;
106
142-148
- 5
Procaccio F, Polo A, Lanteri P, Sala F.
Electrophysiologic monitoring in neurointensive care.
Curr Opin Crit Care.
2001;
7
74-80
- 6
Krieger D, Jauss M, Schwarz S, Hacke W.
Serial somatosensory and brainstem auditory evoked potentials in monitoring of acute
supratentorial mass lesions.
Crit Care Med.
1995;
23
1123-1131
- 7
Steiner T, Schwab S, Hacke W.
Intensivmedizin bei akuter Ischämie.
Therapeutische Umschau.
1996;
53
568-572
- 8
Haupt W F, Erasmi-Korber H, Lanfermann H.
Intraoperative recording of parietal SEP can miss hemodynamic infarction during carotid
endarterectomy: a case study.
Electroencephalogr Clin Neurophysiol.
1994;
92
86-88
- 9
Sleigh J W, Havill J H, Frith R, Kersel D, Marsh N, Ulyatt D.
Somatosensory evoked potentials in severe traumatic brain injury: a blinded study.
J Neurosurg.
1999;
91
577-580
- 10
Madl C, Kramer L, Domanovits H, Woolard R H, Gervais H, Gendo A, Eisenhuber E, Grimm G,
Sterz F.
Improved outcome prediction in unconscious cardiac arrest survivors with sensory evoked
potentials compared with clinical assessment.
Crit Care Med.
2000;
28
721-726
- 11
Haupt W F, Birkmann C, Halber M.
Serial evoked potentials and outcome in cerebrovascular critical care patients.
J Clin Neurophysiol.
2000;
17
326-330
- 12
Schwarz S, Schwab S, Aschoff A, Hacke W.
Favorable recovery from bilateral loss of somatosensory evoked potentials.
Crit Care Med.
1999;
27
182-187
- 13
Krieger D, Adams H P, Hacke W.
Erfahrungen mit lichtblitz-evozierten visuellen Potenzialen bei bewusstseinsgestörten
Patienten auf der neurologischen Intensivstation.
EEG-EMG Z Elektroenzephalogr Elektromyogr Verwandte Geb.
1991;
22
246-253
- 14
Ferbert A, Buchner H.
Evozierte Potenziale in der Diagnostik ischämischer Hirnstammläsionen.
Nervenarzt.
1991;
62
460-466
- 15
Hopf H C.
Topodiagnostic value of brain stem reflexes.
Muscle Nerve.
1994;
17
475-484
- 16
Hopf H C, Deuschl G.
Diagnostische Aussagekraft der Hirnstammreflexe.
Aktuelle Neurologie.
1998;
25
127-132
- 17
Urban P P, Hopf H C, Connemann B, Hundemer H P, Koehler J.
The course of cortico-hypoglossal projections in the human brain stem. Functional
testing using transcranial magnetic stimulation.
Brain.
1996;
119
1031-1038
- 18
Aramideh M, Ongerboer V, de Visser B W, Koelman J H, Majoie C B, Holstege G.
The late blink reflex response abnormality due to lesion of the lateral tegmental
field.
Brain.
1997;
120
1685-1692
- 19
Fitzek S, Fitzek C, Marx J, Speckter H, Urban P P, Thomke F, Stoeter P, Hopf H C.
Blink reflex R2 changes and localisation of lesions in the lower brainstem (Wallenberg's
syndrome): an electrophysiological and MRI study.
J Neurol Neurosurg Psychiatry.
1999;
67
630-636
- 20
Fitzek S, Baumgartner U, Fitzek C, Magerl W, Urban P, Thomke F, Marx J, Treede R D,
Stoeter P, Hopf H C.
Mechanisms and predictors of chronic facial pain in lateral medullary infarction.
Ann Neurol.
2001;
49
493-500
- 21
Marx J J, Thoemke F, Fitzek S, Vucurevic G, Fitzek C, Mika-Gruettner A, Urban P P,
Stoeter P, Hopf H C.
Topodiagnostic value of blink reflex R1 changes: a digital postprocessing MRI correlation
study.
Muscle Nerve.
2001;
24
1327-1331
- 22
Urban P P, Szegedi A, Müller-Forell W, Hopf H C.
Superficial siderosis of the CNS as a rare differential diagnosis of chronic low back
pain.
J Neurol.
1999;
246
980-981
- 23
Urban P P, Wicht S, Vucorevic G, Fitzek S, Marx J, Thomke F, Mika-Gruttner A, Fitzek C,
Stoeter P, Hopf H C.
The course of corticofacial projections in the human brainstem.
Brain.
2001;
124
1866-1876
- 24
Heald A, Bates D, Cartlidge N E, French J M, Miller S.
Longitudinal study of central motor conduction time following stroke. 1. Natural history
of central motor conduction.
Brain.
1993;
116
1355-1370
- 25
Rossini P M, Rossi S.
Clinical applications of motor evoked potentials.
Electroencephalogr Clin Neurophysiol.
1998;
106
180-194
- 26
Heald A, Bates D, Cartlidge N E, French J M, Miller S.
Longitudinal study of central motor conduction time following stroke. 2. Central motor
conduction measured within 72 h after stroke as a predictor of functional outcome
at 12 months.
Brain.
1993;
116
1371-1385
- 27
Pennisi G, Rapisarda G, Bella R, Calabrese V, d Maertens N, Delwaide P J.
Absence of response to early transcranial magnetic stimulation in ischemic stroke
patients: prognostic value for hand motor recovery.
Stroke.
1999;
30
2666-2670
- 28
Vang C, Dunbabin D, Kilpatrick D.
Correlation between functional and electrophysiological recovery in acute ischemic
stroke.
Stroke.
1999;
30
2126-2130
- 29
Escudero J V, Sancho J, Bautista D, Escudero M, Lopez-Trigo J.
Prognostic value of motor evoked potential obtained by transcranial magnetic brain
stimulation in motor function recovery in patients with acute ischemic stroke.
Stroke.
1998;
29
1854-1859
- 30
Feys H, van Hees J, Bruyninckx F, Mercelis R, de Weerdt W.
Value of somatosensory and motor evoked potentials in predicting arm recovery after
a stroke.
J Neurol Neurosurg Psychiatry.
2000;
68
323-331
- 31
Rösler K M, Magistris M R, Glocker F X, Kohler A, Deuschl G, Hess C W.
Electrophysiological characteristics of lesions in facial palsies of different etiologies.
A study using electrical and magnetic stimulation techniques.
Electroencephalogr Clin Neurophysiol.
1995;
97
355-368
- 32
Leis A A, Kronenberg M F, Stetkarova I, Paske W C, Stokic D S.
Spinal motoneuron excitability after acute spinal cord injury in humans.
Neurol.
1996;
47
231-237
- 33
Müllges W, Ferbert A, Buchner H.
Transkranielle Magnetstimulation bei psychogenen Lähmungen.
Nervenarzt.
1991;
62
349-353
- 34
Pillai J J, Markind S, Streletz L J, Field H L, Herbison G.
Motor evoked potentials in psychogenic paralysis.
Neurol.
1992;
42
935-936
PD Dr. Reinhard Kiefer
Klinik und Poliklinik für Neurologie · Universitätsklinikum Münster
48129 Münster
Email: kieferr@uni-muenster.de
