Kernaussagen
Die Subarachnoidalblutung (SAB) wird meistens durch eine Aneurysmaruptur verursacht. Die häufigsten Lokalisationen zerebraler Aneurysmen liegt im vorderen Kreislaufabschnitt des Circulus Willisii.
Die spontane aneurysmatische SAB tritt am häufigsten im mittleren Lebensalter (40.–60. Lebensjahr) aus völliger Gesundheit heraus auf. Leitsymptom ist der akut eintretende Vernichtungskopfschmerz sowie oft eine deutliche Nackensteifigkeit (Meningismus). Zur Beschreibung des klinischen Schweregrads der SAB und zur Einschätzung der Prognose werden die Klassifikation nach Hunt & Hess sowie der WFNS‐Score (World Federation of Neurological Surgeons) verwendet.
Bei Verdacht auf eine SAB ist immer eine umgehende Klinikeinweisung und Abklärung indiziert. Die SAB lässt sich gut im CT nachweisen, mit der typischen Blutungsverteilung im Subarachnoidalraum und insbesondere in den basalen Zisternen. Zum weiteren Nachweis der Blutungsquelle und Planung der weiteren Therapie sollte eine CT‐Angiografie oder konventionelle Angiografie erfolgen.
Zu den häufigsten Komplikationen zählen neben der Rezidivblutung die akute und chronische Liquorzirkulationsstörung (Hydrozephalus) sowie der zerebrale Vasospasmus bzw. das verzögertes ischämisches neurologisches Defizit (DIND). Eine Triple-H‐Therapie sollte erst bei nachgewiesenem Vasospasmus erfolgen. Eine prophylaktische Hämodilution und Hypertonie sollte unterlassen werden.
Die Therapie der SAB hat zum Ziel:
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die Ausschaltung der Blutungsquelle und somit der Rezidivblutung,
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die Versorgung möglicher sekundärer Komplikationen wie Hydrozephalus, Vasospasmus, DIND.
Als Therapieoptionen steht neben der neurochirurgischen operativen Aneurysma-Ausschaltung (Clipping) die neuroradiologische endovaskulär-interventionelle Versorgung (Coiling) zur Verfügung. Patienten mit einem guten bis mittleren SAB‐Grad (WFNS1–4, Hunt & Hess I–IV) sollten in den ersten Tagen nach SAB (< 72 Stunden nach SAB) versorgt werden.
Die Versorgung ist abhängig von der anatomischen Lokalisation, Form und Konfiguration des Aneurysmas sowie der Verfügbarkeit der entsprechenden Methoden (chirurgisch/interventionell) und sollte immer interdisziplinär diskutiert und besprochen werden. Faktoren zur Entscheidungsfindung für ein operatives oder interventionelles Therapieverfahren sind: Alter, Komorbidität, Vorhandensein eines intrazerebralen Hämatoms, klinischer Grad der Blutung, Aneurysmalage, ‐konfiguration, ‐größe, Kollateralisierung, fachliche Kompetenz und Verfügbarkeit, Entscheidung des aufgeklärten Patienten und interdisziplinärer Konsens.
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Dr. Carla S. Jung
Neurochirurgische Klinik
Ruprecht Karls-Universität Heidelberg
Im Neuenheimer Feld 400
69120 Heidelberg
Phone: 0 62 21/5 63 96 65
Fax: 0 62 21/56 55 34
Email: Carla.Jung@med.uni-heidelberg.de
