Empfehlungen zum Management der aneurysmatischen Subarachnoidalblutung

 

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Zusammenfassung

Die aneurysmatische Subarachnoidalblutung ist ein Krankheitsbild, das durch häufige primäre und sekundäre Komplikationen gekennzeichnet ist, die neurochirurgischen Interventionen bedürfen, um eine sekundäre Hirnschädigung zu vermeiden. Es ist Ziel der vorliegenden Arbeit, den aktuellen Stand der Datenlage für die einzelnen Therapiemodalitäten der Subarachnoidalblutung wiederzugeben, die im Rahmen des stationären Managements zur Anwendung kommen. Soweit möglich, erfolgt dabei eine Abstufung der Therapieempfehlungen entsprechend der Kriterien der evidenzbasierten Medizin. Die vorliegenden Empfehlungen wurden gemeinsam von der Sektion vaskuläre Neurochirurgie der Deutschen Gesellschaft für Neurochirurgie und dem Wissenschaftlichen Arbeitskreis Neuroanästhesie der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin erarbeitet.

Abstract

After SAH, primary and secondary complications are frequent and often require neurosurgical interventions to avoid secondary brain damage. The authors of the present paper have summarized the available data about the treatment modalities often used for patients with SAH. The present recommendations have been developed as a neurosurgical and neuroanestesiological consensus. Evidence from prospective, randomized, double blind, placebo-controlled studies support grade A recommendations (standard) for the prophylaxis and treatment of cerebral vasospasm with oral Nimodipine in good grade patients. For intravenous Nimodipine or for oral nimodipine treatment in poor grade patients, available data only support grade C recommendations (options). Despite the lack of data supporting standards (grade A) or guidelines (grade B), avoidance and rigorous treatment of hypotension and hypovolemia remains the mainstay in the prophylaxis and treatment of a delayed ischemic neurological deficit (DIND). Prophylactic hypervolemia or prophylactic hypertension and hypervolemia was shown to be ineffective in reducing symptomatic vasospasm and improving outcome (grade B). Therapeutic hypertensive hypervolemic hemodilution is recommended as a treatment of symptomatic vasospasm but no prospective studies are available (grade C recommendation). Suggested target values for moderate triple-H-therapy are CPP 80- 120 mmHg (MAP 90-130), CVP > 7 mmHg and Hk 0.25-0.40. Balloon angioplasty should be considered for treatment of DIND cause by focal, proximal cerebral vasospasm. There is no evidence supporting the routine use of antifibrinolytica, steroids or anticonvulsive prophylaxis. Clinical data indicate that current prophylaxis and treatment of cerebral vasospasm is still insufficient and aggressive triple-H-therapy is associated with an increased incidence of complications.

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Prof. Dr. med. Andreas Raabe

Klinik und Poliklinik für Neurochirurgie · Johann-Wolfgang-Goethe-Universität

Schleusenweg 2-16

60528 Frankfurt am Main

Germany

Phone: +49/69/63 01 59 39

Fax: +49/69/63 01 71 75

Email: A.Raabe@em.uni-frankfurt.de