Aktuelle Aspekte in der Intensivtherapie des Schlaganfalls

In Deutschland erleiden jährlich ca. 270000 Patient*innen einen Schlaganfall [1]. Die Invaliditäts- und Mortalitätsraten sind hoch (bis zu 30%) und ein relevanter Anteil der Betroffenen muss auf der Intensivstation behandelt werden. Der Artikel thematisiert intensivmedizinische Behandlungsaspekte des ischämischen Schlaganfalls als häufigste Unterform (85% aller Schlaganfälle).

Abstract

In this review, we provide an update on the intensive care unit (ICU) management of ischemic stroke. Over the last decade, new evidence has led to rapid changes in the early management of patients admitted with acute ischemic stroke. Nevertheless, stroke remains a leading cause of disability. Consequently, a significant number of patients with acute ischemic stroke require ICU level care. The most frequent reasons for ICU admissions are large infarction with potential swelling, reduced level of consciousness, secondary hemorrhagic transformation, acute symptomatic seizures or respiratory failure and stroke-related disorders of the brain–heart interaction. Moreover, there is an increasing number of patients receiving intravenous thrombolysis or mechanical thrombectomy with a subsequent need of ICU monitoring. Several studies have shown that the implementation of specialized neuro-intensive care teams help to improve functional outcome after acute ischemic stroke. The main goal in the ICU management of stroke patients is to prevent secondary brain injury. To this end, a comprehensive approach to optimize systemic physiological homeostasis, control intracranial pressure, cerebral perfusion, hemodynamic and respiratory parameters is needed. Here, we summarize recent advances in invasive and non-invasive neuro-monitoring, decision making in decompressive neurosurgery for large supratentorial or cerebellar infarction, specific cardiorespiratory management, nutrition, temperature management and mobilization strategies in ischemic stroke.

Kernaussagen

• Die Invaliditäts- und Mortalitätsrate des ischämischen Schlaganfalls beträgt bis zu 30%.

• Das funktionelle Outcome nach einem schweren Schlaganfall kann mit einer Betreuung durch spezialisierte Neurointensivmediziner verbessert werden.

• Das übergeordnete Ziel in der Intensivtherapie des Schlaganfalls ist es, einen sekundären Hirnschaden (Secondary Brain Injury) zu vermeiden.

• Die hohe Mortalität des malignen Mediainfarkts (ca. 80%) kann durch eine dekompressive Hemikraniektomie innerhalb von 48 h reduziert werden.

• Die Beatmungstherapie auf der ITS sollte sich an physiologischen Zielparametern orientieren, da sowohl Hypoxämie als auch Hyperkapnie zu einer Secondary Brain Injury führen können.

• Das intensivmedizinische Blutdruckmanagement nach ischämischem Schlaganfall soll die Perfusion der Penumbra optimieren und das Risiko einer sekundären hämorrhagischen Transformation reduzieren.

• Nach einem Schlaganfall sollte innerhalb von 72 h mit der enteralen Ernährung begonnen werden.

• Die Normothermie zählt zu den neuroprotektiven Standardmaßnahmen in der Akutphase des Schlaganfalls; dagegen verbessert eine therapeutische Hypothermie das Outcome nicht.

• Die Mobilisation sollte innerhalb der ersten 2 Tage nach einem Schlaganfall erfolgen.

Schlüsselwörter

Schlaganfall - ischämischer Hirninfarkt - Intensivtherapie

Keywords

stroke - ischemic cerebral infarction - intensive care

Publication History

Article published online:
23 March 2022

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