Neurochirurgisches Management bei Schädel-Hirn-Trauma

Bei einem Schädel-Hirn-Trauma (SHT) spielen neurochirurgische Therapieentscheidungen eine zentrale Rolle, um das akute Überleben zu sichern sowie um sekundäre Hirnschädigungen, die einen großen Einfluss auf die weitere Lebensqualität der Patient*innen haben, abzumildern. Dieser Beitrag beschreibt das neurochirurgische Management bei SHT, das auf umsichtigen und entschlossenen klinischen Entscheidungen basiert und schnelle chirurgische Interventionen erfordern kann.

Abstract

The neurosurgical management of traumatic brain injury (TBI) plays a critical role in ensuring acute survival and mitigating secondary brain damage, which significantly impacts patients’ quality of life. TBI is defined as an external force impacting the skull, leading to brain injuries and subsequent functional impairments. It is a leading cause of mortality and morbidity, particularly among young individuals. The initial clinical examination is crucial, with external signs like scalp injuries, hematomas, nasal fluid leakage, skull deformities, and neurological deficits providing important clues to injury patterns. Pupil examination is particularly critical, as mydriasis coupled with reduced consciousness may indicate an acute life-threatening increase in intracranial pressure (ICP), necessitating immediate neurosurgical intervention. TBI assessment often utilizes the Glasgow Coma Scale (GCS), classifying injuries as mild (GCS 13–15), moderate (GCS 9–12), or severe (GCS < 9). Even mild TBI can lead to long-term complications. TBI should be viewed as a disease process rather than a singular event. Primary brain damage results from shearing forces on the parenchyma, manifesting as contusions, hematomas, or diffuse axonal injury. Secondary brain damage is driven by mechanisms such as inflammation and spreading depolarizations. Treatment aims not only to secure immediate survival but also to reduce secondary injuries, with ICP management being crucial. Neurosurgical interventions are guided by cranial pathologies, with options including ICP monitoring, burr hole trepanation, craniotomy. In severe TBI cases with refractory ICP elevation, decompressive craniectomy may be performed as a last resort, significantly reducing mortality but often resulting in high morbidity and vegetative states, necessitating careful consideration of indications.

Kernaussagen

• Das schwere Schädel-Hirn-Trauma (SHT) hat eine schlechte Prognose mit einer Mortalität von bis zu 40%, auch initial leichte und mittelschwere SHT sollten nicht unterschätzt werden.

• Das SHT führt zu primären und sekundären Hirnschädigungen.

• Nicht beurteilbare Patient*innen mit einer intrakraniellen Pathologie benötigen eine Hirndrucksonde zur Überwachung.

• Die Konsistenz eines akuten Subduralhämatoms ist „marmeladenähnlich“, sodass bei einer chirurgischen Versorgung immer eine Kraniotomie notwendig ist. Ein chronisches Subduralhämatom ist flüssig und kann daher auch über eine weniger invasive Bohrlochtrepanation entlastet werden.

• Eine Mydriasis bei Vigilanzminderung kann auf eine Einklemmung hindeuten und ist als absolute Notfallsituation zu werten.

• Dekompressive Kraniektomien senken die Mortalität, gehen jedoch mit einer hohen Morbidität einher.

Schlüsselwörter

Schädel-Hirn-Trauma - Kraniotomie - Kraniektomie - Neurochirurgie

Keywords

traumatic brain injury - craniotomy - craniectomy - neurosurgery

Publication History

Article published online:
29 July 2024

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