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Die Sinnhaftigkeit der Papillenbeurteilung durch den Augenarzt vor Lumbalpunktion

The usefulness of optic disc examination by the ophthalmologist before lumbar puncture

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Zusammenfassung

Tod durch cerebrale Einklemmung nach Lumbaipunktion — der Albtraum eines jeden Neurologen. Kann die Beurteilung der Papille durch den Ophthalmologen eine Aussage über die herrschenden intrakraniellen Druckverhältnisse machen und damit zu Risikominimierung beitragen? Mittels dieses Literaturüberblicks versuchen wir, die klinische Relevanz der Papillenbeurteilung zu bewerten.

Bei der Diagnose einer akuten Meningitis ist die Stauungspapille einer von vielen klinischen Parametern, die auf einen erhöhten Hirndruck hinweisen können, tritt jedoch nur in 1% der Fälle und dann erst nach 24 h auf, was beim fulminanten Verlauf einer Meningitis ein langer Zeitraum ist.

Bei intracerebralen Tumoren kann es in bis zu 60% der Fälle irgendwann im Verlauf der Erkrankung zum Auftreten einer Stauungspapille kommen. In der Ära von CT und MRT hat die Lumbalpunktion für die Diagnostik von Tumoren jedoch lediglich ergänzenden Wert.

Eine akute Subarachnoidalblutung kann verlässlich durch eine CCT nachgewiesen werden, zur Diagnose einer älteren Blutung kann die Lumbaipunktion hilfreich sein.

Die Liquordiagnostik bei Verdacht auf Multiple Sklerose hat sicherlich einen hohen diagnostischen Stellenwert, eine Papillenbeurteilung erfolgt hier routinegemäß beim ophthalmologischen Konsil im Rahmen der Durchuntersuchung.

Der Pseudotumor cerebri definiert sich durch einen erhöhten intrakraniellen Druck mit Stauungspapille, ohne pathologisches Korrelat für die Druckerhöhung. Obwohl die Stauungspapille traditionsgemäß als absolute Kontraindikation für eine Lumbaipunktion gilt, hat bei diesem Krankheitsbild die Lumbaipunktion sogar einen therapeutischen Wert.

Zusammenfassend ist die Papillenbeurteilung durch den Augenarzt vor Lumbaipunktion nur mehr auf wenige Indikationen beschränkt.

Summary

Death following lumbar puncture — the nightmare of every neurologist. Is the optic disc exam by the ophthalmologist useful in verifying intracranial hypertension and hereby reduce the risk of herniation? This literature review tries to evaluate the clinical relevance of the optic disc examination.

Papilledema is one of several clinical parameters of an acute meningitis indicating increased intracranial pressure. Presence of papilledema is only found in 1% of meningitis cases and appears not earlier than 24 h after onset of the disease, which is a long gap in a potential fulminant course of meningitis.

Overall 60% of patients with cerebral tumours have papilledema sometimes during the course of illness. In the era of CT and MRI, the lumbar puncture as diagnostic tool for intracranial tumours is merely of additional value.

Suspicion of acute subarachnoid haemorrhage can be verified reliably by CCT. In the diagnostic of subarachnoid haemorrhage a lumbar puncture might be helpful.

Cerebrospinal fluid analysis has a profound diagnostic sensitivity in suspected Multiple Sclerosis. Ophthalmologic and optic disc examination is performed routinely in the general check up.

Idiopathic intracranial hypertension (pseudotumor cerebri) is characterised by raised intracranial pressure of unknown etiology with papilledema without finding a pathological correlation for the pressure increase. Although papilledema is traditionally seen as contraindication for lumbar puncture in pseudotumor cerebri the lumbar puncture is even of therapeutical value.

In conclusion the optic disc examination performed by an ophthalmologist is limited to a few indications.

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Authors and Affiliations

  1. Augenabteilung KH Lainz, Wolkersbergenstraße 1, 1130, Wien, Österreich

    B. Weingessel

  2. Universitätsklinik für Augenheilkunde und Optometrie, Medizinische Universität Wien, Österreich

    S. Sacu, S. Richter-Müksch, U. Schmidt-Erfurth & P. V. Vécsei-Marlovits

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  1. B. Weingessel
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  2. S. Sacu
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  4. U. Schmidt-Erfurth
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  5. P. V. Vécsei-Marlovits
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Correspondence to B. Weingessel.

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Weingessel, B., Sacu, S., Richter-Müksch, S. et al. Die Sinnhaftigkeit der Papillenbeurteilung durch den Augenarzt vor Lumbalpunktion. Spektrum Augeheilkd 19, 237–241 (2005). https://doi.org/10.1007/BF03163405

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