PDF herunterladen
Aktuelle Neurologie 2011; 38(07): 351-361
DOI: 10.1055/s-0031-1291291
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

Raumfordernder Hirninfarkt: Aktuelle Behandlungskonzepte

Space-Occupying Cerebral Infarction: Current Treatment Options
J. Witsch
1   Charité - Universitätsmedizin Berlin, Centrum für Schlaganfallforschung Berlin (CSB), Berlin
,
E. Jüttler
1   Charité - Universitätsmedizin Berlin, Centrum für Schlaganfallforschung Berlin (CSB), Berlin
,
H. Schneider
2   Universitätsklinikum Carl Gustav Carus an der TU Dresden, Klinik und Poliklinik für Neurologie, Dresden
› Institutsangaben
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
14. November 2011 (online)

Auch verfügbar auf
    Lizenzen und Reprints

Zusammenfassung

Große supratentorielle raumfordernde ischämische Schlaganfälle betreffen zu einem besonders großen Anteil jüngere Patienten und sind mit einer sehr hohen frühen Letalität oder, wenn die Akutphase überlebt wird, immer mit einer bleibenden Behinderung behaftet. Pathophysiologisch liegt diesem Infarkttyp ein sehr ausgedehntes und gleichzeitig sich sehr rasch in den ersten Tagen nach dem Ereignis entwickelndes Hirnödem zugrunde. Dies führt durch seine raumfordernde Wirkung zur Kompression von benachbarten und schließlich auch von lebensnotwendigen anderen Gehirnarealen und damit unbehandelt in 80–90% der Fälle meist innerhalb der ersten 2–4 Erkrankungstage zum Tod durch Herniation. Aufgrund dieses unbehandelt raschen, meist fatalen Verlaufs werden diese Infarkte auch als „maligne Mediainfarkte“ bezeichnet. Die hohe Letalität kann auch durch maximale medikamentöse und intensivmedizinische Therapie kaum verringert werden. Der besonders hohe Anteil derjenigen Patienten, die nach Überleben der Akutphase bei Verlassen der Klinik schwer behindert sind, führte bis vor wenigen Jahren häufig zu Fatalismus bei den Ärzten in Bezug auf die Behandlung solcher raumfordernder Hirninfarkte. Innerhalb des letzten Jahrzehnts hat sich diese Einstellung zunehmend geändert, vor allem durch den immer häufigeren Einsatz der Hemikraniektomie als chirurgisches Therapiekonzept, dessen Effektivität zuletzt auch in randomisierten Studien zur Behandlung raumfordernder Hirninfarkte bei jüngeren Patienten belegt werden konnte. Frühzeitig durchgeführt senkt die Hemikraniektomie nicht nur die Letalität, sondern vermindert auch den Grad der bleibenden Behinderung der überlebenden Patienten. Auch der lange Zeit angeführte Hauptkritikpunkt, die Hemikraniektomie führe durch die Senkung der Letalität vor allem zu einem erhöhten Anteil maximal behinderter, dauerhaft pflegebedürftiger und vollständig abhängiger Patienten, konnte durch die randomisierten Studien widerlegt werden. Laufende Studien bei raumfordernden Hirninfarkten beschäftigen sich mit der Übertragbarkeit der Ergebnisse der randomisierten Studien zur Hemikraniektomie auf den klinischen Alltag, mit deren Nutzen für ältere Patienten mit der Versorgung und Lebensqualität der überlebenden Patienten sowie mit dem Nutzen der moderaten Hypothermie als zweitem vielversprechenden Therapieverfahren zur Hirnödembehandlung.

Abstract

Space-occupying supratentorial ischaemic strokes are associated with high lethality and disability, especially in younger patients. This type of stroke is characterised by a large, early increasing brain oedema. Swelling causes secondary injury to other brain regions and subsequent brain herniation and increases in intracranial pressure. If untreated, space-occupying strokes lead to early clinical deterioration and to death in 80–90% of patients. Therefore these strokes are described as “malignant” strokes. The high mortality is only slightly reduced by medical therapies and intensive care treatment. For many years, the high proportion of severely disabled patients surviving large strokes led to therapeutic reluctance by treating physicians. During the last decade this attitude has changed, mainly due to several randomised studies showing the efficiency of hemicraniectomy in younger patients with malignant stroke. Early hemicraniectomy not only increases the number of surviving patients but also reduces the level of disability in surviving patients. Current clinical trials are investigating whether the recent study results for hemicraniectomy can be confirmed under clinical routine conditions. Ongoing studies will also evaluate the quality of life in surviving stroke patients and evaluate their care situation. Another focus of clinical research is the application of therapeutic hypothermia to treat malignant stroke oedema.

Schlüsselwörter

Maligner Hirninfarkt - Hemikraniektomie - Osmotherapie - Hypothermiebehandlung - Schlaganfall

Keywords

space-occupying infarction - decompressive craniectomy - osmotic therapy - induced hypothermia - stroke
 

  • Literatur

  • 1 Simard JM, Kent TA, Chen M et al. Brain oedema in focal ischaemia: molecular pathophysiology and theoretical implications. Lancet Neurol 2007; 6: 258-268
    CrossrefPubMedGoogle Scholar
  • 2 Ropper AH, Shafran B. Brain edema after stroke. Clinical syndrome and intracranial pressure. Arch Neurol 1984; 41: 26-29
    CrossrefPubMedGoogle Scholar
  • 3 Hacke W, Schwab S, Horn M et al. ‘Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol 1996; 53: 309-315
    CrossrefPubMedGoogle Scholar
  • 4 Heinsius T, Bogousslavsky J, Van Melle G. Large infarcts in the middle cerebral artery territory. Etiology and outcome patterns. Neurology 1998; 50: 341-350
    CrossrefPubMedGoogle Scholar
  • 5 Qureshi AI, Suarez JI, Yahia AM et al. Timing of neurologic deterioration in massive middle cerebral artery infarction: a multicenter review. Crit Care Med 2003; 31: 272-277
    CrossrefPubMedGoogle Scholar
  • 6 Poca MA, Benejam B, Sahuquillo J et al. Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful?. J Neurosurg 2010; 112: 648-657
    CrossrefPubMedGoogle Scholar
  • 7 Frank JI. Large hemispheric infarction, deterioration, and intracranial pressure. Neurology 1995; 45: 1286-1290
    CrossrefPubMedGoogle Scholar
  • 8 Hofmeijer J, Algra A, Kappelle LJ et al. Predictors of life-threatening brain edema in middle cerebral artery infarction. Cerebrovasc Dis 2008; 25: 176-184
    CrossrefPubMedGoogle Scholar
  • 9 Juttler E, Schwab S, Schmiedek P et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 2007; 38: 2518-2525
    CrossrefPubMedGoogle Scholar
  • 10 Vahedi K, Hofmeijer J, Juettler E et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 2007; 6: 215-222
    CrossrefPubMedGoogle Scholar
  • 11 Hofmeijer J, Kappelle LJ, Algra A et al. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 2009; 8: 326-333
    CrossrefPubMedGoogle Scholar
  • 12 Krieger DW, Demchuk AM, Kasner SE et al. Early clinical and radiological predictors of fatal brain swelling in ischemic stroke. Stroke 1999; 30: 287-292
    CrossrefPubMedGoogle Scholar
  • 13 Barber PA, Demchuk AM, Zhang J et al. Computed tomographic parameters predicting fatal outcome in large middle cerebral artery infarction. Cerebrovasc Dis 2003; 16: 230-235
    CrossrefPubMedGoogle Scholar
  • 14 Oppenheim C, Samson Y, Manai R et al. Prediction of malignant middle cerebral artery infarction by diffusion-weighted imaging. Stroke 2000; 31: 2175-2181
    CrossrefPubMedGoogle Scholar
  • 15 Thomalla G, Hartmann F, Juettler E et al. Prediction of malignant middle cerebral artery infarction by magnetic resonance imaging within 6 hours of symptom onset: A prospective multicenter observational study. Ann Neurol 2010; 68: 435-445
    CrossrefPubMedGoogle Scholar
  • 16 Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol 2009; 8: 949-958
    CrossrefPubMedGoogle Scholar
  • 17 Juttler E, Schellinger PD, Aschoff A et al. Clinical review: Therapy for refractory intracranial hypertension in ischaemic stroke. Crit Care 2007; 11: 231
    CrossrefPubMedGoogle Scholar
  • 18 Bardutzky J, Schwab S. Antiedema therapy in ischemic stroke. Stroke 2007; 38: 3084-3094
    CrossrefPubMedGoogle Scholar
  • 19 Diedler J, Sykora M, Juttler E et al. Intensive care management of acute stroke: general management. Int J Stroke 2009; 4: 365-378
    CrossrefPubMedGoogle Scholar
  • 20 Jüttler E, Köhrmann M, Aschoff A et al. Hemicraniectomy for space-occupying supratentorial ischemic stroke. Future Neurology 2008; 3: 251-264
    CrossrefPubMedGoogle Scholar
  • 21 Schwarz S, Georgiadis D, Aschoff A et al. Effects of body position on intracranial pressure and cerebral perfusion in patients with large hemispheric stroke. Stroke 2002; 33: 497-501
    CrossrefPubMedGoogle Scholar
  • 22 Diedler J, Sykora M, Blatow M et al. Decompressive surgery for severe brain edema. J Intensive Care Med 2009; 24: 168-178
    CrossrefPubMedGoogle Scholar
  • 23 Drakulovic MB, Torres A, Bauer TT et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999; 354: 1851-1858
    CrossrefPubMedGoogle Scholar
  • 24 Hofmeijer J, van der Worp HB, Kappelle LJ. Treatment of space-occupying cerebral infarction. Crit Care Med 2003; 31: 617-625
    CrossrefPubMedGoogle Scholar
  • 25 Schwarz S, Georgiadis D, Aschoff A et al. Effects of hypertonic (10%) saline in patients with raised intracranial pressure after stroke. Stroke 2002; 33: 136-140
    CrossrefPubMedGoogle Scholar
  • 26 Schwarz S, Schwab S, Bertram M et al. Effects of hypertonic saline hydroxyethyl starch solution and mannitol in patients with increased intracranial pressure after stroke. Stroke 1998; 29: 1550-1555
    CrossrefPubMedGoogle Scholar
  • 27 Videen TO, Zazulia AR, Manno EM et al. Mannitol bolus preferentially shrinks non-infarcted brain in patients with ischemic stroke. Neurology 2001; 57: 2120-2122
    CrossrefPubMedGoogle Scholar
  • 28 Muizelaar JP, Marmarou A, Ward JD et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg 1991; 75: 731-739
    CrossrefPubMedGoogle Scholar
  • 29 Carmona Suazo JA, Maas AI, van den Brink WA et al. CO2 reactivity and brain oxygen pressure monitoring in severe head injury. Crit Care Med 2000; 28: 3268-3274
    CrossrefPubMedGoogle Scholar
  • 30 Marion DW, Puccio A, Wisniewski SR et al. Effect of hyperventilation on extracellular concentrations of glutamate, lactate, pyruvate, and local cerebral blood flow in patients with severe traumatic brain injury. Crit Care Med 2002; 30: 2619-2625
    CrossrefPubMedGoogle Scholar
  • 31 Paulson OB, Olesen J, Christensen MS. Restoration of autoregulation of cerebral blood flow by hypocapnia. Neurology 1972; 22: 286-293
    CrossrefPubMedGoogle Scholar
  • 32 Simard D, Paulson OB. Artifical hyperventilation in stroke. Trans Am Neurol Assoc 1973; 98: 309-310
    PubMedGoogle Scholar
  • 33 Schwab S, Spranger M, Schwarz S et al. Barbiturate coma in severe hemispheric stroke: useful or obsolete?. Neurology 1997; 48: 1608-1613
    CrossrefPubMedGoogle Scholar
  • 34 Schwarz S, Bertram M, Aschoff A et al. Indomethacin for brain edema following stroke. Cerebrovasc Dis 1999; 9: 248-250
    CrossrefPubMedGoogle Scholar
  • 35 Qizilbash N, Lewington SL, Lopez-Arrieta JM. Corticosteroids for acute ischaemic stroke. Cochrane Database Syst Rev 2002; CD000064
    PubMedGoogle Scholar
  • 36 Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002; 346: 549-556
    CrossrefPubMedGoogle Scholar
  • 37 Bernard SA, Gray TW, Buist MD et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002; 346: 557-563
    CrossrefPubMedGoogle Scholar
  • 38 Schwab S, Georgiadis D, Berrouschot J et al. Feasibility and safety of moderate hypothermia after massive hemispheric infarction. Stroke 2001; 32: 2033-2035
    CrossrefPubMedGoogle Scholar
  • 39 Georgiadis D, Schwarz S, Kollmar R et al. Endovascular cooling for moderate hypothermia in patients with acute stroke: first results of a novel approach. Stroke 2001; 32: 2550-2553
    CrossrefPubMedGoogle Scholar
  • 40 Georgiadis D, Schwarz S, Aschoff A et al. Hemicraniectomy and moderate hypothermia in patients with severe ischemic stroke. Stroke 2002; 33: 1584-1588
    CrossrefPubMedGoogle Scholar
  • 41 Milhaud D, Thouvenot E, Heroum C et al. Prolonged moderate hypothermia in massive hemispheric infarction: clinical experience. J Neurosurg Anesthesiol 2005; 17: 49-53
    PubMedGoogle Scholar
  • 42 Els T, Oehm E, Voigt S et al. Safety and therapeutical benefit of hemicraniectomy combined with mild hypothermia in comparison with hemicraniectomy alone in patients with malignant ischemic stroke. Cerebrovasc Dis 2006; 21: 79-85
    CrossrefPubMedGoogle Scholar
  • 43 Schwab S, Schwarz S, Spranger M et al. Moderate hypothermia in the treatment of patients with severe middle cerebral artery infarction. Stroke 1998; 29: 2461-2466
    CrossrefPubMedGoogle Scholar
  • 44 Steiner T, Friede T, Aschoff A et al. Effect and feasibility of controlled rewarming after moderate hypothermia in stroke patients with malignant infarction of the middle cerebral artery. Stroke 2001; 32: 2833-2835
    CrossrefPubMedGoogle Scholar
  • 45 Schwab S, Aschoff A, Spranger M et al. The value of intracranial pressure monitoring in acute hemispheric stroke. Neurology 1996; 47: 393-398
    CrossrefPubMedGoogle Scholar
  • 46 Unterberg A, Juettler E. The role of surgery in ischemic stroke: decompressive surgery. Curr Opin Crit Care 2007; 13: 175-179
    PubMedGoogle Scholar
  • 47 Quinn TM, Taylor JJ, Magarik JA et al. Decompressive craniectomy: technical note. Acta Neurol Scand 2011; 123: 239-244
    CrossrefPubMedGoogle Scholar
  • 48 Sykora M, Diedler J, Juttler E et al. Intensive care management of acute stroke: surgical treatment. Int J Stroke 2010; 5: 170-177
    CrossrefPubMedGoogle Scholar
  • 49 Vahedi K, Vicaut E, Mateo J et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 2007; 38: 2506-2517
    CrossrefPubMedGoogle Scholar
  • 50 Adeoye O, Hornung R, Khatri P et al. The Rate of Hemicraniectomy for Acute Ischemic Stroke is Increasing in the United States. J Stroke Cerebrovasc Dis 2011; 20: 251-254
    CrossrefPubMedGoogle Scholar
  • 51 Sarov M, Guichard JP, Chibarro S et al. Sinking skin flap syndrome and paradoxical herniation after hemicraniectomy for malignant hemispheric infarction. Stroke 2010; 41: 560-562
    CrossrefPubMedGoogle Scholar
  • 52 Schwab S, Schwarz S, Aschoff A et al. Moderate hypothermia and brain temperature in patients with severe middle cerebral artery infarction. Acta Neurochir Suppl 1998; 71: 131-134
    PubMedGoogle Scholar
  • 53 Uhl E, Kreth FW, Elias B et al. Outcome and prognostic factors of hemicraniectomy for space occupying cerebral infarction. J Neurol Neurosurg Psychiatry 2004; 75: 270-274
    PubMedGoogle Scholar
  • 54 Holtkamp M, Buchheim K, Unterberg A et al. Hemicraniectomy in elderly patients with space occupying media infarction: improved survival but poor functional outcome. J Neurol Neurosurg Psychiatry 2001; 70: 226-228
    CrossrefPubMedGoogle Scholar
  • 55 Leonhardt G, Wilhelm H, Doerfler A et al. Clinical outcome and neuropsychological deficits after right decompressive hemicraniectomy in MCA infarction. J Neurol 2002; 249: 1433-1440
    CrossrefPubMedGoogle Scholar
  • 56 Arac A, Blanchard V, Lee M et al. Assessment of outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 60 years of age. Neurosurg Focus 2009; 26: E3
    PubMedGoogle Scholar
  • 57 Puetz V, Campos CR, Eliasziw M et al. Assessing the benefits of hemicraniectomy: what is a favourable outcome?. Lancet Neurol 2007; 6: 580 author reply -1
    PubMedGoogle Scholar
  • 58 Nakagawa K, Bianchi MT, Nakagawa SS et al. Aggressive care after a massive stroke in young patients: is that what they want?. Neurocrit Care 2010; 13: 118-122
    CrossrefPubMedGoogle Scholar
  • 59 Samsa GP, Matchar DB, Goldstein L et al. Utilities for major stroke: results from a survey of preferences among persons at increased risk for stroke. Am Heart J 1998; 136: 703-713
    CrossrefPubMedGoogle Scholar
  • 60 Walz B, Zimmermann C, Bottger S et al. Prognosis of patients after hemicraniectomy in malignant middle cerebral artery infarction. J Neurol 2002; 249: 1183-1190
    CrossrefPubMedGoogle Scholar
  • 61 Woertgen C, Erban P, Rothoerl RD et al. Quality of life after decompressive craniectomy in patients suffering from supratentorial brain ischemia. Acta Neurochir (Wien) 2004; 146: 691-695
    PubMedGoogle Scholar
  • 62 Skoglund TS, Eriksson-Ritzen C, Sorbo A et al. Health status and life satisfaction after decompressive craniectomy for malignant middle cerebral artery infarction. Acta Neurol Scand 2008; 117: 305-310
    CrossrefPubMedGoogle Scholar
  • 63 Benejam B, Sahuquillo J, Poca MA et al. Quality of life and neurobehavioral changes in survivors of malignant middle cerebral artery infarction. J Neurol 2009; 256: 1126-1133
    CrossrefPubMedGoogle Scholar
  • 64 Foerch C, Lang JM, Krause J et al. Functional impairment, disability, and quality of life outcome after decompressive hemicraniectomy in malignant middle cerebral artery infarction. J Neurosurg 2004; 101: 248-254
    CrossrefPubMedGoogle Scholar
  • 65 de Haan RJ, Limburg M, Van der Meulen JH et al. Quality of life after stroke. Impact of stroke type and lesion location. Stroke 1995; 26: 402-408
    CrossrefPubMedGoogle Scholar
  • 66 Carter BS, Ogilvy CS, Candia GJ et al. One-year outcome after decompressive surgery for massive nondominant hemispheric infarction. Neurosurgery 1997; 40: 1168-1175 discussion 75-76
    CrossrefPubMedGoogle Scholar
  • 67 Curry Jr WT, Sethi MK, Ogilvy CS et al. Factors associated with outcome after hemicraniectomy for large middle cerebral artery territory infarction. Neurosurgery 2005; 56: 681-692 discussion-92
    CrossrefPubMedGoogle Scholar
  • 68 Erban P, Woertgen C, Luerding R et al. Long-term outcome after hemicraniectomy for space occupying right hemispheric MCA infarction. Clin Neurol Neurosurg 2006; 108: 384-387
    CrossrefPubMedGoogle Scholar
  • 69 Vahedi K, Benoist L, Kurtz A et al. Quality of life after decompressive craniectomy for malignant middle cerebral artery infarction. J Neurol Neurosurg Psychiatry 2005; 76: 1181-1182
    CrossrefPubMedGoogle Scholar
  • 70 Kastrau F, Wolter M, Huber W et al. Recovery from aphasia after hemicraniectomy for infarction of the speech-dominant hemisphere. Stroke 2005; 36: 825-829
    CrossrefPubMedGoogle Scholar
  • 71 Berrouschot J, Sterker M, Bettin S et al. Mortality of space-occupying (‘malignant’) middle cerebral artery infarction under conservative intensive care. Intensive Care Med 1998; 24: 620-623
    CrossrefPubMedGoogle Scholar