Advertisement

Intensivmedizinische Therapie intrazerebraler Blutungen

Übersichten

Zusammenfassung

Hintergrund

Der Anteil spontaner intrazerebraler Blutungen bei akuten Schlaganfällen beträgt bis zu 20 %. Neben einer hohen Mortalität gehen sie oftmals mit schwerwiegenden neurologischen Folgeschäden für die Betroffenen einher.

Zielsetzung

Intensivmedizinische Therapieprinzipien zur Verminderung des durch die Blutung verursachten primären und sekundären neurologischen Schadens werden basierend auf den aktuellen Therapieleitlinien und der Literatur dargestellt.

Ergebnisse

Ein im Rahmen der intrakraniellen Blutung erhöhter arterieller Blutdruck sollte rasch auf Werte unter systolisch 140 mmHg gesenkt werden. Auch in den folgenden Tagen trägt eine strikte Blutdruckkontrolle mit Vermeidung von Blutdruckspitzen und Blutdruckschwankungen zur Prognoseverbesserung der Patienten bei. Eine gestörte plasmatische Blutgerinnung sollte nach Aufnahme so schnell wie möglich normalisiert werden. Bei formal nicht beeinträchtigter Gerinnung wird aber eine zusätzliche darüber hinausgehende hämostatische Behandlung nicht empfohlen. Die Entscheidung zur operativen Hämatomausräumung kann v. a. bei initial bewusstseinsgetrübten Patienten erwogen werden. Zur initialen Thromboseprophylaxe wird eine pneumatische Beinkompression empfohlen. Eine sich im Verlauf entwickelnde intrakranielle Druckerhöhung sollte konsequent therapiert werden. Eine Gabe von Kortikosteroiden ist nicht indiziert.

Schlussfolgerung

Die intensivmedizinische Therapie intrazerebraler Blutungen erfordert ein multimodales abgestuftes Vorgehen zur Reduktion sowohl des primären als auch des sekundären neurologischen Schadens.

Schlüsselwörter

Intrazerebrale Blutung Intrakranielle Druckerhöhung Intensivmedizin Blutdrucksenkung Review 

Critical care management of intracerebral hemorrhage

Abstract

Background

Intracerebral hemorrhage accounts for up to 20 % percent of all ischemic strokes. In addition to a higher mortality, they are often associated with severe neurological impairment for those affected.

Objectives

Review of the current literature and guidelines addressing the critical care management of spontaneous intracerebral hemorrhage, including treatments to reduce primary and secondary neurological damage.

Results

Acute blood pressure lowering to less than 140 mmHg should be aspired immediately after intensive care admission. During the following days blood pressure variability should be minimized. Preexisting oral anticoagulation should be immediately reversed, while hemostatic therapy not associated with reversal of antithrombotic therapy should not be applied. Surgery for patients with impaired consciousness should be discussed. Use of pneumatic compression in immobile patients is recommended. Developing intracranial hypertension should be treated with combined physical and pharmacological measures in a stepwise approach. Administration of glucocorticoids is currently not recommended.

Conclusions

Critical care management of spontaneous hemorrhage demands a multimodal, graded approach for reduction of both primary and secondary neurological damage.

Keywords

Intracerebral hemorrhage Intracranial hypertension Critical care Blood pressure lowering Review 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

V. Huge gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine vom Autor durchgeführten Studien an Menschen oder Tieren.

Literatur

  1. 1.
    Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, Lindley R, Robinson T, Lavados P, Neal B, Hata J, Arima H, Parsons M, Li Y, Wang J, Heritier S, Li Q, Woodward M, Simes RJ, Davis SM, Chalmers J, Investigators I (2013) Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med 368:2355–2365CrossRefPubMedGoogle Scholar
  2. 2.
    Andrews PJ, Sinclair HL, Rodriguez A, Harris BA, Battison CG, Rhodes JK, Murray GD, Eurotherm Trial C (2015) Hypothermia for Intracranial hypertension after traumatic brain injury. N Engl J Med 373:2403CrossRefPubMedGoogle Scholar
  3. 3.
    Barnes B, Hanley DF, Carhuapoma JR (2014) Minimally invasive surgery for intracerebral haemorrhage. Curr Opin Crit Care 20:148–152CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Caldeira D, Rodrigues FB, Barra M, Santos AT, de Abreu D, Goncalves N, Pinto FJ, Ferreira JJ, Costa J (2015) Non-vitamin K antagonist oral anticoagulants and major bleeding-related fatality in patients with atrial fibrillation and venous thromboembolism: a systematic review and meta-analysis. Heart 101:1204–1211CrossRefPubMedGoogle Scholar
  5. 5.
    Chacko B, Peter JV, Tharyan P, John G, Jeyaseelan L (2015) Pressure-controlled versus volume-controlled ventilation for acute respiratory failure due to acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). Cochrane Database Syst Rev 1:CD008807PubMedGoogle Scholar
  6. 6.
    Coles JP, Fryer TD, Coleman MR, Smielewski P, Gupta AK, Minhas PS, Aigbirhio F, Chatfield DA, Williams GB, Boniface S, Carpenter TA, Clark JC, Pickard JD, Menon DK (2007) Hyperventilation following head injury: effect on ischemic burden and cerebral oxidative metabolism. Crit Care Med 35:568–578CrossRefPubMedGoogle Scholar
  7. 7.
    de Herdt V, Dumont F, Henon H, Derambure P, Vonck K, Leys D, Cordonnier C (2011) Early seizures in intracerebral hemorrhage: incidence, associated factors, and outcome. Neurology 77:1794–1800CrossRefPubMedGoogle Scholar
  8. 8.
    Elmer J, Hou P, Wilcox SR, Chang Y, Schreiber H, Okechukwu I, Pontes-Neto O, Bajwa E, Hess DR, Avery L, Duran-Mendicuti MA, Camargo CA Jr., Greenberg SM, Rosand J, Pallin DJ, Goldstein JN (2013) Acute respiratory distress syndrome after spontaneous intracerebral hemorrhage. Crit Care Med 41:1992–2001CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, Moran AE, Sacco RL, Anderson L, Truelsen T, O’Donnell M, Venketasubramanian N, Barker-Collo S, Lawes CM, Wang W, Shinohara Y, Witt E, Ezzati M, Naghavi M, Murray C, Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), GBD Stroke Experts Group (2014) Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet 383:245–254CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Fogelholm R, Murros K, Rissanen A, Avikainen S (2005) Admission blood glucose and short term survival in primary intracerebral haemorrhage: a population based study. J Neurol Neurosurg Psychiatr 76:349–353CrossRefGoogle Scholar
  11. 11.
    Garrett MC, Komotar RJ, Starke RM, Merkow MB, Otten ML, Connolly ES (2009) Predictors of seizure onset after intracerebral hemorrhage and the role of long-term antiepileptic therapy. J Crit Care 24:335–339CrossRefPubMedGoogle Scholar
  12. 12.
    Gioia LC, Kate M, Dowlatshahi D, Hill MD, Butcher K (2015) Blood pressure management in acute intracerebral hemorrhage: current evidence and ongoing controversies. Curr Opin Crit Care 21:99–106CrossRefPubMedGoogle Scholar
  13. 13.
    Greer DM, Funk SE, Reaven NL, Ouzounelli M, Uman GC (2008) Impact of fever on outcome in patients with stroke and neurologic injury: a comprehensive meta-analysis. Stroke 39:3029–3035CrossRefPubMedGoogle Scholar
  14. 14.
    Hertle DN, Dreier JP, Woitzik J, Hartings JA, Bullock R, Okonkwo DO, Shutter LA, Vidgeon S, Strong AJ, Kowoll C, Dohmen C, Diedler J, Veltkamp R, Bruckner T, Unterberg AW, Sakowitz OW, Cooperative Study of Brain Injury D (2012) Effect of analgesics and sedatives on the occurrence of spreading depolarizations accompanying acute brain injury. Brain 135:2390–2398CrossRefPubMedGoogle Scholar
  15. 15.
    Kramer AH, Roberts DJ, Zygun DA (2012) Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis. Crit Care 16:R203CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Kuramatsu JB, Gerner ST, Schellinger PD, Glahn J, Endres M, Sobesky J, Flechsenhar J, Neugebauer H, Juttler E, Grau A, Palm F, Rother J, Michels P, Hamann GF, Huwel J, Hagemann G, Barber B, Terborg C, Trostdorf F, Bazner H, Roth A, Wohrle J, Keller M, Schwarz M, Reimann G, Volkmann J, Mullges W, Kraft P, Classen J, Hobohm C, Horn M, Milewski A, Reichmann H, Schneider H, Schimmel E, Fink GR, Dohmen C, Stetefeld H, Witte O, Gunther A, Neumann-Haefelin T, Racs AE, Nueckel M, Erbguth F, Kloska SP, Dorfler A, Kohrmann M, Schwab S, Huttner HB (2015) Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage. JAMA 313:824–836CrossRefPubMedGoogle Scholar
  17. 17.
    Liliang PC, Liang CL, Lu CH, Chang HW, Cheng CH, Lee TC, Chen HJ (2001) Hypertensive caudate hemorrhage prognostic predictor, outcome, and role of external ventricular drainage. Stroke 32:1195–1200CrossRefPubMedGoogle Scholar
  18. 18.
    Lord AS, Karinja S, Lantigua H, Carpenter A, Schmidt JM, Claassen J, Agarwal S, Connolly ES, Mayer SA, Badjatia N (2014) Therapeutic temperature modulation for fever after intracerebral hemorrhage. Neurocrit Care 21:200–206CrossRefPubMedGoogle Scholar
  19. 19.
    Manning L, Hirakawa Y, Arima H, Wang X, Chalmers J, Wang J, Lindley R, Heeley E, Delcourt C, Neal B, Lavados P, Davis SM, Tzourio C, Huang Y, Stapf C, Woodward M, Rothwell PM, Robinson TG, Anderson CS (2014) Blood pressure variability and outcome after acute intracerebral haemorrhage: a post-hoc analysis of INTERACT2, a randomised controlled trial. Lancet Neurol 13:364–373CrossRefPubMedGoogle Scholar
  20. 20.
    Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM (2013) Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet 382:397–408CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Messe SR, Sansing LH, Cucchiara BL, Herman ST, Lyden PD, Kasner SE (2009) Prophylactic antiepileptic drug use is associated with poor outcome following ICH. Neurocrit Care 11:38–44CrossRefPubMedGoogle Scholar
  22. 22.
    Misra UK, Kalita J, Ranjan P, Mandal SK (2005) Mannitol in intracerebral hemorrhage: a randomized controlled study. J Neurol Sci 234:41–45CrossRefPubMedGoogle Scholar
  23. 23.
    Morgenstern LB, Hemphill JC 3rd, Anderson C, Becker K, Broderick JP, Connolly ES Jr., Greenberg SM, Huang JN, MacDonald RL, Messe SR, Mitchell PH, Selim M, Tamargo RJ, American Heart Association Stroke Council, Council on Cardiovascular Nursing (2010) Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Heart 41:2108–2129Google Scholar
  24. 24.
    Naidech AM, Maas MB, Levasseur-Franklin KE, Liotta EM, Guth JC, Berman M, Rosenow JM, Lindholm PF, Bendok BR, Prabhakaran S, Bernstein RA, Kwaan HC (2014) Desmopressin improves platelet activity in acute intracerebral hemorrhage. Stroke 45:2451–2453CrossRefPubMedGoogle Scholar
  25. 25.
    Pollack CV, Reilly PA, Eikelboom J, Glund S, Verhamme P, Bernstein RA, Dubiel R, Huisman MV, Hylek EM, Kamphuisen PW, Kreuzer J, Levy JH, Sellke FW, Stangier J, Steiner T, Wang B, Kam CW, Weitz JI (2015) Idarucizumab for Dabigatran reversal. N Engl J Med 373:511–520CrossRefPubMedGoogle Scholar
  26. 26.
    Poungvarin N, Bhoopat W, Viriyavejakul A, Rodprasert P, Buranasiri P, Sukondhabhant S, Hensley MJ, Strom BL (1987) Effects of dexamethasone in primary supratentorial intracerebral hemorrhage. N Engl J Med 316:1229–1233CrossRefPubMedGoogle Scholar
  27. 27.
    Qureshi AI, Ezzeddine MA, Nasar A, Suri MF, Kirmani JF, Hussein HM, Divani AA, Reddi AS (2007) Prevalence of elevated blood pressure in 563,704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med 25:32–38CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF (2001) Spontaneous intracerebral hemorrhage. N Engl J Med 344:1450–1460CrossRefPubMedGoogle Scholar
  29. 29.
    Reuter DA, Kirchner A, Felbinger TW, Weis FC, Kilger E, Lamm P, Goetz AE (2003) Usefulness of left ventricular stroke volume variation to assess fluid responsiveness in patients with reduced cardiac function. Crit Care Med 31:1399–1404CrossRefPubMedGoogle Scholar
  30. 30.
    Rincon F, Mayer SA (2008) Clinical review: Critical care management of spontaneous intracerebral hemorrhage. Crit Care 12:237CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Roberts I, Yates D, Sandercock P, Farrell B, Wasserberg J, Lomas G, Cottingham R, Svoboda P, Brayley N, Mazairac G, Laloe V, Munoz-Sanchez A, Arango M, Hartzenberg B, Khamis H, Yutthakasemsunt S, Komolafe E, Olldashi F, Yadav Y, Murillo-Cabezas F, Shakur H, Edwards P, CRASH Trial Collaborators. (2004) Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet 364:1321–1328CrossRefPubMedGoogle Scholar
  32. 32.
    Sprigg N, Renton CJ, Dineen RA, Kwong Y, Bath PM (2014) Tranexamic acid for spontaneous intracerebral hemorrhage: a randomized controlled pilot trial (ISRCTN50867461). J Stroke Cerebrovasc Dis 23:1312–1318CrossRefPubMedGoogle Scholar
  33. 33.
    Staykov D, Huttner HB, Schwab S (2012) New treatment strategies for intraventricular hemorrhage. Med Klin Intensivmed Notfmed 107:192–196CrossRefPubMedGoogle Scholar
  34. 34.
    Steiner T, Al-Shahi SR, Beer R, Christensen H, Cordonnier C, Csiba L, Forsting M, Harnof S, Klijn CJ, Krieger D, Mendelow AD, Molina C, Montaner J, Overgaard K, Petersson J, Roine RO, Schmutzhard E, Schwerdtfeger K, Stapf C, Tatlisumak T, Thomas BM, Toni D, Unterberg A, Wagner M, European Stroke Organisation (2014) European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke 9:840–855CrossRefPubMedGoogle Scholar
  35. 35.
    Steiner T, Bohm M, Dichgans M, Diener HC, Ell C, Endres M, Epple C, Grond M, Laufs U, Nickenig G, Riess H, Rother J, Schellinger PD, Spannagl M, Veltkamp R (2013) Recommendations for the emergency management of complications associated with the new direct oral anticoagulants (DOACs), apixaban, dabigatran and rivaroxaban. Clin Res Cardiol 102:399–412CrossRefPubMedGoogle Scholar
  36. 36.
    Stocchetti N, Maas AI (2014) Traumatic intracranial hypertension. N Engl J Med 370:2121–2130CrossRefPubMedGoogle Scholar
  37. 37.
    van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ (2010) Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol 9:167–176CrossRefPubMedGoogle Scholar
  38. 38.
    Wagner I, Hauer EM, Staykov D, Volbers B, Dorfler A, Schwab S, Bardutzky J (2011) Effects of continuous hypertonic saline infusion on perihemorrhagic edema evolution. Stroke 42:1540–1545CrossRefPubMedGoogle Scholar
  39. 39.
    Yuan Q, Wu X, Sun Y, Yu J, Li Z, Du Z, Mao Y, Zhou L, Hu J (2015) Impact of intracranial pressure monitoring on mortality in patients with traumatic brain injury: a systematic review and meta-analysis. J Neurosurg 122:574–587CrossRefPubMedGoogle Scholar
  40. 40.
    Yuan ZH, Jiang JK, Huang WD, Pan J, Zhu JY, Wang JZ (2010) A meta-analysis of the efficacy and safety of recombinant activated factor VII for patients with acute intracerebral hemorrhage without hemophilia. J Clin Neurosci 17:685–693CrossRefPubMedGoogle Scholar
  41. 41.
    Zeiler FA, Teitelbaum J, Gillman LM, West M (2014) THAM for control of ICP. Neurocrit Care 21:332–344CrossRefPubMedGoogle Scholar
  42. 42.
    Zeiler FA, Teitelbaum J, West M, Gillman LM (2014) The ketamine effect on intracranial pressure in nontraumatic neurological illness. J Crit Care 29:1096–1106CrossRefPubMedGoogle Scholar
  43. 43.
    Zhou Y, Wang Y, Wang J, Stetler AR, Yang QW (2014) Inflammation in intracerebral hemorrhage: from mechanisms to clinical translation. Prog Neurobiol 115:25–44CrossRefPubMedGoogle Scholar
  44. 44.
    Ziai WC (2013) Hematology and inflammatory signaling of intracerebral hemorrhage. Stroke 44:S74–78CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  1. 1.Klinik für AnästhesiologieKlinikum der Ludwig-Maximilians-Universität München, Campus GroßhadernMünchenDeutschland

Personalised recommendations