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Intensivmedizinische Therapie intrazerebraler Blutungen

Critical care management of intracerebral hemorrhage

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Zusammenfassung

Hintergrund

Der Anteil spontaner intrazerebraler Blutungen bei akuten Schlaganfällen beträgt bis zu 20 %. Neben einer hohen Mortalität gehen sie oftmals mit schwerwiegenden neurologischen Folgeschäden für die Betroffenen einher.

Zielsetzung

Intensivmedizinische Therapieprinzipien zur Verminderung des durch die Blutung verursachten primären und sekundären neurologischen Schadens werden basierend auf den aktuellen Therapieleitlinien und der Literatur dargestellt.

Ergebnisse

Ein im Rahmen der intrakraniellen Blutung erhöhter arterieller Blutdruck sollte rasch auf Werte unter systolisch 140 mmHg gesenkt werden. Auch in den folgenden Tagen trägt eine strikte Blutdruckkontrolle mit Vermeidung von Blutdruckspitzen und Blutdruckschwankungen zur Prognoseverbesserung der Patienten bei. Eine gestörte plasmatische Blutgerinnung sollte nach Aufnahme so schnell wie möglich normalisiert werden. Bei formal nicht beeinträchtigter Gerinnung wird aber eine zusätzliche darüber hinausgehende hämostatische Behandlung nicht empfohlen. Die Entscheidung zur operativen Hämatomausräumung kann v. a. bei initial bewusstseinsgetrübten Patienten erwogen werden. Zur initialen Thromboseprophylaxe wird eine pneumatische Beinkompression empfohlen. Eine sich im Verlauf entwickelnde intrakranielle Druckerhöhung sollte konsequent therapiert werden. Eine Gabe von Kortikosteroiden ist nicht indiziert.

Schlussfolgerung

Die intensivmedizinische Therapie intrazerebraler Blutungen erfordert ein multimodales abgestuftes Vorgehen zur Reduktion sowohl des primären als auch des sekundären neurologischen Schadens.

Abstract

Background

Intracerebral hemorrhage accounts for up to 20 % percent of all ischemic strokes. In addition to a higher mortality, they are often associated with severe neurological impairment for those affected.

Objectives

Review of the current literature and guidelines addressing the critical care management of spontaneous intracerebral hemorrhage, including treatments to reduce primary and secondary neurological damage.

Results

Acute blood pressure lowering to less than 140 mmHg should be aspired immediately after intensive care admission. During the following days blood pressure variability should be minimized. Preexisting oral anticoagulation should be immediately reversed, while hemostatic therapy not associated with reversal of antithrombotic therapy should not be applied. Surgery for patients with impaired consciousness should be discussed. Use of pneumatic compression in immobile patients is recommended. Developing intracranial hypertension should be treated with combined physical and pharmacological measures in a stepwise approach. Administration of glucocorticoids is currently not recommended.

Conclusions

Critical care management of spontaneous hemorrhage demands a multimodal, graded approach for reduction of both primary and secondary neurological damage.

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  1. Klinik für Anästhesiologie, Klinikum der Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistraße 15, 81377, München, Deutschland

    V. Huge

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Huge, V. Intensivmedizinische Therapie intrazerebraler Blutungen. Med Klin Intensivmed Notfmed 113, 164–173 (2018). https://doi.org/10.1007/s00063-016-0154-z

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