Der erhöhte intrakranielle Druck – Therapiemaßnahmen

Zusammenfassung

Ein erhöhter intrakranieller Druck kann die Folge verschiedener intrakranieller Pathologien sein. Persistierend hohe Werte über 20–25 mmHg führen eigenständig durch Perfusionsstörungen oder direkten Druck zu einer weiteren Schädigung des Gehirns führen. Dies kann für das neurologische Behandlungsergebnis und damit für das weitere Leben des Betroffenen katastrophale Folgen haben. Ein zentrales Krankheitsbild, das mit einer vital bedrohlichen intrakraniellen Druckerhöhung einhergehen kann, ist das Schädelhirntrauma. Die hieran entwickelten und zum Teil auch auf andere Pathologien mit erhöhtem intrakraniellen Druck übertragenen Behandlungsansätze basieren auf Basistherapiemaßnahmen, die um Eskalationsstufen ergänzt sind. Trotz der enormen gesellschaftlichen, medizinischen und ökonomischen Bedeutung einer effektiven Therapie des erhöhten intrakraniellen Druckes besteht aktuell nur wenig Evidenz für viele der auch in Leitlinien empfohlenen Therapiemaßnahmen.

Summary

Increased intracranial pressure can be the result of different intracranial pathologies. Sustained intracranial pressure above 20–25 mmHg may cause secondary brain injury by impaired cerebral perfusion or direct pressure with neuronal injury, with in consequence deterioration of neurological outcome. A main cause of critically increased intracranial pressure is traumatic brain injury. Most treatment strategies for increased intracranial pressure were developed and studied on these patients. Most of them were transferred to other pathologies with increased intracranial pressure.

Treatment is based on general measures, which can be escalated for medical and surgical options in case of failure to sufficiently decrease intracranial pressure below the established threshold. Despite its enormous medical and socio-economical relevance, the evidence for most treatment strategies of intracranial hypertension, though published in guidelines, is weak.

Kernaussagen

• Ein erhöhter intrakranieller Druck ist der wichtigste Prädiktor für Mortalität und Morbidität nach Schädelhirntrauma.

• Die Prinzipien der neurotraumatologischen Intensivmedizin sind auf die Verhinderung eines Anstiegs des intrakraniellen Drucks sowie die effektive Behandlung erhöhter Werte ausgerichtet.

• Unterschieden wird zwischen Basismaßnahmen, Therapien der 1. Wahl und fakultativen Therapiemöglichkeiten.

• Bei Patienten mit einem Schädelhirntrauma mit intrakranieller Läsion und einem Wert von 3–8 auf der Glasgow-Coma-Scale besteht eine Indikation zur Messung des intrakraniellen Drucks. Die alleinige Beurteilung im CT ist nicht ausreichend.

• Der intrakranielle Druck kann über eine externe Ventrikeldrainage oder eine Parenchymsonde gemessen werden.

• Eine suffiziente Analgosedierung und die Oberkörperhochlagerung sind Basismaßnahmen der Therapie bei Patienten mit Schädelhirntrauma.

• Der zerebrale Perfusionsdruck entspricht der Differenz von mittlerem arteriellen Druck und intrakraniellem Druck und sollte um 60 mmHg bis max. 70 mmHg betragen.

• Auch bei erhöhtem intrakraniellem Druck wird eine Normoventilation mit einem arteriellen pCO₂ nicht <35 mmHg angestrebt.

• Die Liquordrainage über eine externe Ventrikeldrainage ist die schnellste Möglichkeit, einen erhöhten intrakraniellen Druck zu senken.

• Mannitol und hypertone NaCl-Lösung stehen als gleichwertige Alternativen zur Osmotherapie zur Verfügung. Neue Studien zeigen möglicherweise einen leichten klinischen Vorteil für NaCl, wobei die Evidenzlage noch niedrig ist.

• Als fakultative Therapiemöglichkeiten eines erhöhten intrakraniellen Drucks können individuell diskutiert werden

  • eine therapeutische Hypothermie von 32–35°C Körpertemperatur,

  • eine Dekompressionskraniektomie,

  • eine lumbale Liquordrainage oder

  • eine EEG-gesteuerte Barbiturat-Narkose.

Schlüsselwörter:

intrakranieller Druck - Therapiemaßnahmen - Schädelhirntrauma - Evidenz

Keywords:

intracranial hypertension - therapy - traumatic brain injury - evidence

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