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Der Nervenarzt

, Volume 86, Issue 8, pp 1018–1030 | Cite as

Intensivtherapie des raumfordernden ischämischen Hemisphäreninfarkts

Zusammenfassung der NCS/DGNI-Leitlinie
  • J. BöselEmail author
  • S. Schönenberger
  • C. Dohmen
  • E. Jüttler
  • D. Staykov
  • K. Zweckberger
  • W. Hacke
  • S. Schwab
  • M.T. Torbey
  • H.B. Huttner
  • stellvertretend für die Teilnehmer der „International Consensus Conference on Critical Care Management of Patients Following Large Hemispheric Infarct“ der NCS und DGNI)
Konsensuspapiere

Zusammenfassung

Der große ischämische Hemisphäreninfarkt („large hemispheric infarction“, LHI, Synonym maligner Mediainfarkt, MMI) ist eine schwerwiegende neurologische Erkrankung mit hoher Mortalität und Morbidität. Sowohl behandelnde Ärzte als auch Angehörige sehen sich insbesondere hinsichtlich konservativer Therapiemaßnahmen mit einer schwachen Datenlange konfrontiert. Aktuelle Leitlinien zur allgemeinen Schlaganfallbehandlung legen den Hauptfokus auf Risikofaktoren, Prävention und das akute Rekanalisierungsmanagement, beinhalten aber nur sehr limitierte Empfehlungen zur ggf. folgenden spezifischen intensivmedizinischen Behandlung. Um diese Lücke zu füllen, wurde kürzlich eine interdisziplinäre Konsensus-Konferenz der Neurocritical Care Society (NCS) und der Deutschen Gesellschaft für NeuroIntensiv- und Notfallmedizin (DGNI) zum intensivmedizinischen Management des MMI organisiert. Experten aus Neurologie, Neurointensivmedizin, Neurochirurgie, Neuroradiologie und Neuroanästhesie aus Europa und Nordamerika wurden auf Basis ihrer Expertise und ihrer Forschungsschwerpunkte ausgewählt. Arbeitsgruppen zu einzelnen Schwerpunktthemen erarbeiteten eine Reihe zentraler klinischer Fragestellungen zu diesem Thema und erstellten auf dem Boden der aktuellen Datenlage nach dem System Grading of Recommendation Assessment, Development and Evaluation (GRADE) Empfehlungen. Dies ist eine kommentierte Kurzfassung derselben.

Schlüsselwörter

Hemikraniektomie Zerebrales Ödem Schlaganfall Mediainfarkt Empfehlungen 

Intensive care therapy of space-occupying large hemispheric infarction

Summary of the NCS/DGNI guidelines

Summary

Large hemispheric infarction (LHI), synonymously called malignant middle cerebral artery (MCA) infarction, is a severe neurological disease with a high mortality and morbidity. Treating physicians as well as relatives are often faced with few and low quality data when attempting to apply optimal treatment to these patients and make decisions. While current stroke treatment guidelines focus on risk factors, prevention and acute management, they include only limited recommendations concerning intensive care management of LHI. The Neurocritical Care Society (NCS) and the German Society for Neurocritical and Emergency Medicine (DGNI) organized an interdisciplinary consensus conference on intensive care management of LHI to meet this demand. European and American experts in neurology, neurocritical care, neurosurgery, neuroradiology and neuroanesthesiology were selected based on their expertise and research focus. Subgroups for several main topics elaborated a number of central clinical questions concerning this topic and evaluated the quality of the currently available data according to the grading of recommendation assessment, development and evaluation (GRADE) guideline system. Subsequently, evidence-based recommendations were compiled after weighing the advantages against the disadvantages of certain management options. This is a commented abridged version of the results of the consensus conference.

Keywords

Cerebral edema Hemicraniectomy Stroke Middle cerebral artery Infarction Recommendations 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt. J. Bösel, S. Schönenberger, C. Dohmen, E. Jüttler, D. Staykov, K. Zweckberger, W. Hacke, S. Schwab, M.T. Torbey und H.B. Huttner geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

Literatur

  1. 1.
    Hacke W, Schwab S, Horn M et al (1996) „Malignant“ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol 53:309–315PubMedCrossRefGoogle Scholar
  2. 2.
    Morgenstern LB, Hemphill JC III, Anderson C et al (2010) Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 41:2108–2129PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Jauch EC, Saver JL, Adams HP Jr et al (2013) Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 44:870–947PubMedCrossRefGoogle Scholar
  4. 4.
    Wijdicks EF, Sheth KN, Carter BS et al (2014) Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 45:1222–1238PubMedCrossRefGoogle Scholar
  5. 5.
    Diener HC, Weimar C, Berlit P et al; Kommission „Leitlinien“ der Deutschen Gesellschaft für Neurologie (DGN) (2012) Leitlinien für Diagnostik und Therapie in der Neurologie der Deutschen Gesellschaft für Neurologie, 5. Aufl. Thieme, StuttgartGoogle Scholar
  6. 6.
    Guyatt G, Oxman AD, Akl EA et al (2011) GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 64:383–394PubMedCrossRefGoogle Scholar
  7. 7.
    Torbey MT, Bösel J, Rhoney DH et al (2015) Evidence-based guidelines for the management of large hemispheric infarction: a statement for health care professionals from the neurocritical care society and the german society for neuro-intensive care and emergency medicine. Neurocrit Care 22(1):146–164PubMedCrossRefGoogle Scholar
  8. 8.
    Zha AM, Sari M, Torbey MT (2015) Recommendations for management of large hemispheric infarction. Curr Opin Crit Care 21:91–98PubMedCrossRefGoogle Scholar
  9. 9.
    Zweckberger K, Juettler E, Bösel J, Unterberg WA (2014) Surgical aspects of decompression craniectomy in malignant stroke: review. Cerebrovasc Dis 38:313–323PubMedCrossRefGoogle Scholar
  10. 10.
    Kummer R von, Meyding-Lamade U, Forsting M et al (1994) Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk. AJNR Am J Neuroradiol 15:9–15Google Scholar
  11. 11.
    Krieger DW, Demchuk AM, Kasner SE et al (1999) Early clinical and radiological predictors of fatal brain swelling in ischemic stroke. Stroke 30:287–292PubMedCrossRefGoogle Scholar
  12. 12.
    Bösel J, Schiller P, Hook Y et al (2013) Stroke-related Early Tracheostomy versus Prolonged Orotracheal Intubation in Neurocritical Care Trial (SETPOINT): a randomized pilot trial. Stroke 44:21–28PubMedCrossRefGoogle Scholar
  13. 13.
    CLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration, Dennis M, Sandercock P et al (2013) Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet 382:516–524CrossRefGoogle Scholar
  14. 14.
    Sandercock PA, Belt AG van den, Lindley RI, Slattery J (1993) Antithrombotic therapy in acute ischaemic stroke: an overview of the completed randomised trials. J Neurol Neurosurg Psychiatry 56:17–25PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Berge E, Abdelnoor M, Nakstad PH, Sandset PM (2000) Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study. HAEST Study Group. Heparin in Acute Embolic Stroke Trial. Lancet 355:1205–1210PubMedCrossRefGoogle Scholar
  16. 16.
    Kuramatsu JB, Gerner ST, Schellinger PD et al (2015) Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage. JAMA 313:824–836PubMedCrossRefGoogle Scholar
  17. 17.
    Sandercock PA, Soane T (2011) Corticosteroids for acute ischaemic stroke. Cochrane Database Syst Rev CD000064Google Scholar
  18. 18.
    Els T, Oehm E, Voigt S et al (2006) Safety and therapeutical benefit of hemicraniectomy combined with mild hypothermia in comparison with hemicraniectomy alone in patients with malignant ischemic stroke. Cerebrovasc Dis 21:79–85PubMedCrossRefGoogle Scholar
  19. 19.
    Neugebauer H, Kollmar R, Niesen WD et al (2013) DEcompressive surgery Plus hypoTHermia for Space-Occupying Stroke (DEPTH-SOS): a protocol of a multicenter randomized controlled clinical trial and a literature review. Int J Stroke 8:383–387PubMedCrossRefGoogle Scholar
  20. 20.
    Frank JI, Schumm LP, Wroblewski K et al (2014) Hemicraniectomy and durotomy upon deterioration from infarction-related swelling trial: randomized pilot clinical trial. Stroke 45:781–787PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Hofmeijer J, Kappelle LJ, Algra A et al (2009) Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 8:326–333PubMedCrossRefGoogle Scholar
  22. 22.
    Jüttler E, Schwab S, Schmiedek P et al (2007) Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 38:2518–2525PubMedCrossRefGoogle Scholar
  23. 23.
    Vahedi K, Vicaut E, Mateo J et al (2007) Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 38:2506–2517PubMedCrossRefGoogle Scholar
  24. 24.
    Vahedi K, Hofmeijer J, Juettler E et al (2007) Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 6:215–222PubMedCrossRefGoogle Scholar
  25. 25.
    Rincon F, Mayer SA (2007) Decompressive surgery in malignant infarction of the middle cerebral artery. Curr Neurol Neurosci Rep 7:511–512PubMedCrossRefGoogle Scholar
  26. 26.
    Jüttler E, Unterberg A, Woitzik J et al (2014) Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 370:1091–1100PubMedCrossRefGoogle Scholar
  27. 27.
    Jüttler E, Bösel J, Amiri H et al (2011) DESTINY II: DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY II. Int J Stroke 6:79–86PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • J. Bösel
    • 1
    Email author
  • S. Schönenberger
    • 1
  • C. Dohmen
    • 2
  • E. Jüttler
    • 3
  • D. Staykov
    • 4
  • K. Zweckberger
    • 5
  • W. Hacke
    • 1
  • S. Schwab
    • 6
  • M.T. Torbey
    • 7
  • H.B. Huttner
    • 6
  • stellvertretend für die Teilnehmer der „International Consensus Conference on Critical Care Management of Patients Following Large Hemispheric Infarct“ der NCS und DGNI)
  1. 1.Neurologische KlinikUniversitätsklinikum HeidelbergHeidelbergDeutschland
  2. 2.Klinik und Poliklinik für NeurologieUniklinik KölnKölnDeutschland
  3. 3.Neurologische KlinikOstalb-KlinikumAalenDeutschland
  4. 4.Abteilung für NeurologieBarmherzige Brüder, Krankenhaus EisenstadtEisenstadtÖsterreich
  5. 5.Neurochirurgische KlinikUniversitätsklinikum HeidelbergHeidelbergDeutschland
  6. 6.Neurologische KlinikUniversitätsklinikum ErlangenErlangenDeutschland
  7. 7.Department of Neurology and NeurosurgeryWexner Center, Ohio State UniversityColumbus, OHUSA

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