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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
› Author Affiliations
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Publication History

Publication Date:
14 November 2011 (online)

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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
 

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