Blutdruckmanagement beim akuten Schlaganfall (Ischämie, Blutung, SAB)

Ziel dieses Übersichtsartikels ist es, die aktuelle Datenlage zur Blutdruckbehandlung im Rahmen eines akuten Schlaganfalls – ischämischer Schlaganfall, intrazerebrale Blutung und Subarachnoidalblutung – darzustellen sowie Herausforderungen und Probleme zu diskutieren und mögliche Therapiestrategien aufzuzeigen.

Kernaussagen

• Im Allgemeinen gilt es, bei Schlaganfallpatienten eine Hypotension (systolischer Blutdruck < 120 mmHg) und eine hohe Blutdruckvariabilität zu vermeiden.

• Die Qualität der Evidenz ist überwiegend niedrig, es besteht ein hoher Forschungsbedarf, um optimale Blutdruckintervalle und vorteilhafte Medikamente zu identifizieren.

• Grundsätzlich sollte der systolische Blutdruck zwischen 120 mmHg und 180 mmHg liegen, aber je nach individuellen Patientencharakteristika und Therapie sollte eine spezifischere Anpassung erfolgen:

  • Patienten mit ischämischem Schlaganfall ohne Indikation für revaskularisierende Therapien:

    • systolische Blutdrucksenkung um 15% bei Werten über 220 mmHg empfohlen;

    • eine moderate Blutdrucksenkung frühzeitig (< 6 Stunden) nach Ereignis ist möglicherweise vorteilhaft.

  • Patienten mit ischämischem Schlaganfall und einer Indikation für eine intravenöse Lysetherapie:

    • Blutdrucksenkung vor Beginn der Lysetherapie, Ziel < 185 mmHg (systolisch),

    • anschließend < 180 mmHg.

  • Patienten mit ischämischem Schlaganfall und Indikation für eine mechanische Rekanalisation:

    • systolische Blutdruckwerte über 185 mmHg vermeiden, Ziel < 160 mmHg;

    • nach erfolgreicher Rekanalisation (TICI 2b+3) ohne Stenosen systolisches Blutdruckziel zwischen 120 mmHg und 140 mmHg.

  • Patienten mit intrazerebraler Blutung:

    • aggressive Blutdrucksenkung auf einen systolischen Zielwert von 140 mmHg ist sicher und mit einer reduzierten Nachblutungsrate assoziiert.

    • Patienten mit aneurysmatischer subarachnoidaler Blutung:

      • vor Versorgung des Aneurysmas systolischer Blutdruck < 160 mmHg;

      • nach Versorgung des Aneurysmas:
        ohne Vasospasmen Normotension anstreben,
        bei manifesten Vasospasmen je nach Ausprägung konsekutive Erhöhung des MAD (> 100 mmHg),
        bei schweren Vasospasmen ggf. auch deutlich höher.

Schlüsselwörter

Blutdruck - ischämischer Schlaganfall - intrazerebrale Blutung - Subarachnoidalblutung - ischämischer Insult - Apoplex - Hirnschlag - Gehirninfarkt

• Literatur

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