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Aktuelle Therapieziele bei intrazerebralen Blutungen

Current treatment concepts in intracerebral hemorrhage

Zusammenfassung

Hintergrund und Ziel der Arbeit

In den letzten Jahren wurden diverse hochwertige Studien zur Behandlung einer intrazerebralen Blutung (ICB) veröffentlicht, die bislang noch nicht in Leitlinien eingeflossen sind. Die wesentlichen Ergebnisse dieser Studien werden hier zusammengefasst und in bestehende Behandlungskonzepte integriert.

Material und Methoden

Es erfolgte die Identifikation der aktuellen und qualitativ hochwertigen Arbeiten basierend auf einer ausführlichen Literaturrecherche und nach Kenntnis der Autoren.

Ergebnisse und Diskussion

Randomisierte Daten und Metaanalysen zeigen, dass eine aggressive Blutdrucksenkung (systolischer Blutdruck <140 mm Hg) sicher erscheint und die Hämatomprogression reduziert. ICB-Patienten unter Vitamin-K-Antagonisten müssen sofort mit Prothrombinkomplexkonzentraten (PPSB) und Vitamin K antagonisiert werden, mindestens auf einen Zielwert der International Normalized Ratio von 1,3 bzw. 1,2. Für ICB unter Dabigatran steht mit Idarucizumab ein Antidot zur Verfügung; jedoch existiert für Blutungen unter Faktor-Xa-Inhibitoren keine Evidenz. Es sollte aber eine hoch dosierte Antagonisierung (50 I.E./kgKG PPSB) erfolgen. Eine operative Versorgung mittels Hämatomevakuation kann als Routinemaßnahme nicht empfohlen werden, doch minimal-invasive Strategien zeigen vielversprechende Ergebnisse. Patienten mit akutem Verschlusshydrozephalus benötigen eine externe Ventrikeldrainage. Eine intraventrikuläre Lysetherapie erscheint sicher, reduziert die Sterblichkeit und ist mit einem besseren Outcome assoziiert. Eine zusätzliche lumbale Drainage reduziert die permanente Shuntabhängigkeit. Die Summe der Maßnahmen und die spezialisierte Therapie an Zentren mit hoher Expertise ist von wesentlichem Vorteil für Patienten mit ICB.

Abstract

Background and objective

In recent years, various important studies investigating the management of intracerebral hemorrhage (ICH) have been published. However, these have not entered guideline recommendations yet. Therefore, essential results are summarized here and the findings are integrated into current treatment concepts.

Materials and methods

Based on a dedicated literature review and the authors’ experience, up-to-date and high-quality investigations were identified.

Results and discussion

Randomized data and meta-analyses provide evidence that aggressive blood-pressure reduction (targeting a systolic blood pressure <140 mm Hg) appears safe and reduces hematoma enlargement. ICH associated with intake of vitamin K antagonists should be reversed immediately using prothrombin complex concentrates (PCC) and vitamin K, targeting at least international normalized ratio levels below 1.3. For dabigatran-related ICH, an antidote (idarucizumab) is available for reversal, but in ICH under the use of factor Xa inhibitors evidence is poor. However, reversal should be carried out using high-dosed PCC (50 IU/kg PCC). Routine hematoma evacuation surgery cannot be advocated, yet new minimally invasive strategies provide promising results. In patients with acute occlusive hydrocephalus, an external ventricular drain should be placed and utilizing intraventricular lysis appears safe, reduces mortality, and is associated with improved functional outcome. Adding lumbar drainage to this treatment strategy may reduce permanent shunt dependency. The sum of treatment measures and specialized care at high-volume centers improves outcome in patients with ICH.

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Correspondence to H. B. Huttner.

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Interessenkonflikt

H. B. Huttner und J. B. Kuramatsu geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Redaktion

S. Schwab, Erlangen

M. Köhrmann, Essen

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Huttner, H.B., Kuramatsu, J.B. Aktuelle Therapieziele bei intrazerebralen Blutungen. Med Klin Intensivmed Notfmed 112, 695–702 (2017). https://doi.org/10.1007/s00063-017-0361-2

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  • DOI: https://doi.org/10.1007/s00063-017-0361-2

Schlüsselwörter

  • Hirnblutung
  • Verschlusshydrozephalus
  • Antikoagulanzien
  • Hämostatika
  • Blutdruckmonitoring

Keywords

  • Brain hemorrhage
  • Obstructive hydrocephalus
  • Anticoagulant agents
  • Hemostatics
  • Blood pressure monitoring