Aneurysmatische Subarachnoidalblutung – Diagnostik und Therapie zerebraler und systemischer Komplikationen

Zusammenfassung

Das Management der aneurysmatischen Subarachnoidalblutung (SAB) erfordert ein grundlegendes Verständnis der Erkrankung, ihrer Therapieoptionen und Komplikationen. Ziel der präoperativen Therapie ist das Verhindern einer Nachblutung durch Blutdruckkontrolle, die Behandlung von Schmerz und Unruhe sowie die Stabilisierung der Atem– und Kreislaufverhältnisse. Ein symptomatischer Hydrozephalus muss sofort behandelt werden. Die eigentliche Aneurysmatherapie erfolgt entweder durch mikrochirurgisches Clipping oder endovaskuläres Coiling. Das postoperative Ziel liegt neben der Optimierung der Atem– und Kreislaufverhältnisse vor allem in der Prophylaxe, Diagnostik und Therapie SAB–assoziierter zerebraler Komplikationen (zerebraler Vasospasmus, Hydrozephalus, Epilepsie) und systemischer Komplikationen (Elektrolytstörungen, kardiale Dysfunktion). Diese Arbeit gibt einen Überblick über das prä–, peri– und postoperative Management von Patienten mit SAB.

Abstract

The management of patients with aneurysmal subarachnoid hemorrhage (SAH) requires a fundamental knowledge of the disease, its therapeutic options and possible complications. The preoperative goal is to prevent rebleeding by controlling blood pressure and treating pain and anxiety as well as stabilizing cardiopulmonary functions. An acute hydrocephalus has to be treated immediately. Microsurgical clipping or endovascular coiling are the therapeutic options available. The postoperative goal aims at securing cardiopulmonary functions as well as recognizing and treating cerebral (cerebral vasospasm, hydrocephalus, epilepsy) and systemic complications (electrolyte disorder, cardiac dysfunction). This article provides an overview about the pre–, peri– and postoperative management of patients with SAH.

Schlüsselwörter:

Subarachnoidalblutung - Aneurysma - intrakranielle Hypertension - zerebraler Vasospasmus - Hydrozephalus

Key words:

subarachnoid hemorrhage - aneurysm - intracranial hypertension - cerebral vasospasm - hydrocephalus

Kernaussagen

• Aufgrund der Fortschritte mikrochirurgischer und endovaskulärer Techniken sowie erweiterter intensivmedizinischer Möglichkeiten konnte das Outcome von Patienten mit SAB in den letzten Jahrzehnten deutlich verbessert werden.

• Die Erhebung des initialen klinischen und radiologischen Schweregrades (Hunt & Hess, WFNS, Fisher) ist entscheidend für die Prognose und den weiteren Therapieplan.

• Der Blutungsnachweis erfolgt durch eine Computertomografie und muss bei unauffälligem Befund durch eine lumbale Liquorpunktion ergänzt werden.

• Die Lokalisation und Morphologie des Aneurysmas wird durch CT–Angiografie und/oder Panangiografie dargestellt.

• Ziel der präoperativen Phase ist die Verhinderung einer Nachblutung, Therapie eines akuten Hydrozephalus und frühzeitige Aneurysmaausschaltung (< 72 Stunden).

• Die Optionen der Aneurysmaausschaltung mittels mikrochirurgischen Clippings oder endovaskulären Coilings sollten stets interdisziplinär diskutiert werden, um die Behandlung mit dem geringsten Risiko anbieten zu können.

• Etwa jeder 4. Patient leidet an einem chronischen Hydrozephalus mit Indikation für eine permanente Liquorableitung.

• Multimodales Neuromonitoring ist bei Patienten mit erhöhtem Risiko für zerebrale Vasospasmen und/oder intrakranielle Hypertension indiziert, um diese schweren Komplikationen frühzeitig zu erkennen und neuroprotektive Therapieregime in die Wege zu leiten und zu überwachen.

• Systemische Komplikationen mit Einfluss auf die zerebrale Hämodynamik oder den Metabolismus (Hyponatriämie, kardiale Dysfunktion, Hyperthermie, Pneumonie) sind konsequent zu behandeln.

• Ziel der intensivmedizinischen Therapie ist die Prophylaxe, Diagnostik und Therapie krankheitsspezifischer Komplikationen, um sekundäre zerebrale Ischämien zu verhindern und damit das klinisch–funktionelle Ergebnis zu verbessern.

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