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Akutbehandlung der intrazerebralen Blutung

Acute treatment of intracerebral hemorrhage

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Zusammenfassung

Hintergrund

Die intrazerebrale Blutung (ICB) ist eine der schwersten Schlaganfallformen und vergesellschaftet mit einer hohen Morbidität sowie Mortalität. Allerdings gibt es bislang keine effektiven Therapiestrategien, die den funktionellen Zustand nachhaltig verbessern.

Ziel der Arbeit

Dieser Übersichtsbeitrag evaluiert aktuelle Entwicklungen der Akutbehandlung einer ICB.

Material und Methoden

Bewertung und Interpretation der aktuellen Evidenzlage zur ICB-Therapie mit Schwerpunkt auf bedeutenden Studien der letzten 3 Jahre.

Ergebnisse

Die Rate der Hämatomprogression – des vielleicht wichtigsten Prognosefaktors – kann mithilfe eines aggressiven Blutdruckmanagements (systolischer Zieldruck 140 mm Hg) reduziert werden. Bei ICB unter oraler Antikoagulation muss sofort die Gerinnungshemmung antagonisiert werden: Vitamin-K-Antagonisten mittels Prothrombinkomplexkonzentraten, Dabigatran mittels Idarucizumab, Faktor-Xa-Inhibitoren mittels Andexanet, sofern verfügbar, oder mit hoch dosiertem Prothrombinkomplexkonzentrat. Die chirurgische Hämatomevakuation, sowohl offen als auch minimal-invasiv, kann aktuell nicht routinemäßig empfohlen werden. Bei Patienten mit ICB und einem Ventrikeleinbruch stellt die intraventrikuläre Fibrinolyse mit oder ohne zusätzliche lumbale Drainage eine vielversprechende Therapieoption dar.

Schlussfolgerung

Mehrere randomisierte und große Beobachtungsstudien haben in den letzten Jahren eine robuste Evidenz zur Behandlung der ICB generiert. Allerdings fehlt noch immer die eine durchgreifende Therapiestrategie, die den funktionellen Zustand signifikant verbessert. Dennoch hat möglicherweise die Summe verschiedener miteinander interagierender Behandlungskonzepte das Potenzial, das Outcome von Patienten mit ICB günstig zu beeinflussen.

Abstract

Background

Intracerebral hemorrhage (ICH) represents one of the most severe forms of stroke with high morbidity and mortality; however, effective treatment options to significantly improve patient outcome do not exist so far.

Objective

This review article evaluates the most recent developments in acute ICH treatment.

Material and methods

Analysis and interpretation of currently available evidence regarding ICH treatment, focusing on the most important studies from the last 3 years.

Results

Hematoma enlargement, perhaps the most important prognostic factor, should be counteracted by aggressive blood pressure management (targeted systolic pressure 140 mm Hg). In cases of ICH under oral anticoagulation, inhibition of coagulation must be immediately antagonized: vitamin K antagonists with prothrombin complex concentrates (PCC), idarucizumab for dabigatran and andexanet if available or high-dose PCC for factor Xa inhibitors. Currently, surgical treatment strategies, both open and minimally invasive, to evacuate the hematoma can currently not be routinely recommended. In patients with intraventricular ICH, treatment with intraventricular fibrinolysis with or without additional lumbar drainage represents a promising treatment option.

Conclusion

In recent years, several randomized controlled and observational studies have generated robust evidence regarding ICH treatment; however, there is still no single breakthrough intervention, which significantly improves patient functional outcome. Nevertheless, the sum of various, possibly interacting treatment concepts may potentially improve outcome after ICH.

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Abb. 1

Abbreviations

CT:

Computertomographie

GFP:

Gefrorenes Frischplasma

HP:

Hämatomprogression

ICB:

Intrazerebrale Blutung

INR:

International Normalized Ratio

IVB:

Intraventrikuläre Blutung

KI:

Konfidenzintervall

mRS:

Modifizierte Rankin-Skala

NOAK:

Nicht-Vitamin-K-abhängige orale Antikoagulanzien

OAK:

Orale Antikoagulation

OR:

Odds Ratio

PPSB:

Prothrombinkomplexkonzentrat

rFVIIa:

Rekombinanter Faktor VIIa

RR:

Relatives Risiko

TAH:

Thrombozytenaggregationshemmer

TXA:

Tranexamsäure

VKA:

Vitamin-K-Antagonisten

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Authors and Affiliations

  1. Klinik für Neurologie, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054, Erlangen, Deutschland

    J. A. Sembill &  J. B. Kuramatsu

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  1. J. A. Sembill
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  2. J. B. Kuramatsu
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Corresponding author

Correspondence to J. B. Kuramatsu.

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Interessenkonflikt

J.A. Sembill und J.B. Kuramatsu geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Redaktion

F.J. Erbguth, Nürnberg

M. Grond, Siegen

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Sembill, J.A., Kuramatsu, J.B. Akutbehandlung der intrazerebralen Blutung. Med Klin Intensivmed Notfmed 114, 613–619 (2019). https://doi.org/10.1007/s00063-019-00607-9

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