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Aneurysmatisch bedingte Subarachnoidalblutung

Aneurysmal subarachnoid hemorrhage

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Zusammenfassung

Die akute Subarachnoidalblutung (SAB) ist eine schwerwiegende und akut vital bedrohliche zerebrovaskuläre Erkrankung. Etwa 80% aller nichttraumatisch bedingten SAB resultieren aus der Ruptur eines Aneurysmas der Hirnarterien. Trotz Fortschritten in Diagnostik und Therapie bestehen weiterhin eine hohe Morbidität und Mortalität. Hierfür sind, abgesehen von der primären zerebralen Schädigung, auch sekundäre Komplikationen, wie Vasospasmus, Rezidivblutung, Hirnödem oder Hydrozephalus, verantwortlich. Für die adäquate Therapie ist das Verständnis der komplexen Pathophysiologie, der Diagnostik- und Therapieoptionen sowie Komplikationen der Erkrankung essenziell. Der Anästhesist ist in der Phase der primären und der sekundären Schädigung entscheidend an der Therapie und konsekutiv am Outcome des Patienten beteiligt. Diese Arbeit gibt einen Überblick über das perioperative und intensivmedizinische Management von Patienten mit SAB.

Abstract

Acute subarachnoid hemorrhage (SAH) is a severe and acute life-threatening cerebrovascular disease. Approximately 80% of all acute non-traumatic SAHs are the result of a ruptured cerebrovascular aneurysm. Despite advances in diagnosis and treatment a high morbidity and mortality still exists. Apart from the primary cerebral damage there are also secondary complications, such as vasospasm, rebleeding, hydrocephalus, cerebral edema or hydrocephalus. For an appropriate therapy an understanding of the extensive pathophysiology, the options in diagnostics and therapy and the complications of the disease are essential. Anesthesiologists are decisively involved in the therapy of the primary and secondary damages and subsequently in the outcome as well. This article provides an overview of the perioperative and intensive care management of patients with SAH.

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Abbreviations

ADH:

antidiuretisches Hormon

ANP:

atriales natriuretisches Peptid

ASS:

Acetylsalicylsäure

AWMF:

Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften

BNP:

„brain natriuretic peptide“

CBF:

zerebraler Blutfluss („cerebral blood flow“)

CBV:

zerebrales Blutvolumen („cerebral blood volume“)

cCT:

kraniale Computertomographie

CMR:

zerebrale Metabolisierungsrate

CMRO2 :

zerebraler Sauerstoffverbrauch („cerebral metabolic rate of oxygenation“)

CPP:

zerebraler Perfusionsdruck („cerebral perfusion pressure“)

CSWS:

zerebrales Salzverlustsyndrom („cerebral salt-wasting syndrome“)

CVR:

zerebraler vaskulärer Widerstand („cerebrovascular resistance“)

CVS:

zerebraler Vasospasmus

DajvO2 :

arteriojugularvenöse Sauerstoffdifferenz

DIND:

„delayed cerebral ischemic deficit“

DSA:

digitale Subtraktionsangiographie

EVD:

externe Ventrikeldrainage

GCS:

Glasgow Coma Scale

HMH:

hochmolekulares Heparin

ICB:

intrakranielle Blutung

ICP:

intrakranieller Druck („intracranial pressure“)

ISAT:

International Subarachnoid Aneurysm Trial

ITS:

Intensivstation

LOS:

„length of stay“

MAC:

minimale alveoläre Konzentration („minimum alveolar concentration“)

MAP:

mittlerer arterieller Blutdruck („mean arterial pressure“)

mRS:

„Modified Rankin Scale“

MRT:

Magnetresonanztomographie

NMH:

niedermolekulares Heparin

NNT:

„number needed to treat“

NSAR:

nichtsteroidale Antirheumatika

NSM:

neurogenbedingte Kardiomyopathie („neurogenic stunned myocardium“)

NSMA:

N-Methyl-D-Aspartat

nPED:

neurogenbedingtes Lungenödem („neurogenic pulmonary edema“)

paCO2 :

arterieller Kohlenstoffdioxidpartialdruck

paO2 :

arterieller Sauerstoffpartialdruck

ptiO2 :

zerebraler Gewebesauerstoffpartialdruck („tissue O2 partial pressure“)

ROI:

„region of interest“

RR:

relatives Risiko

rtPa:

„recombinant tissue plasminogen activator“

SAB:

Subarachnoidalblutung

SaO2 :

arterielle Sauerstoffsättigung

SD:

„spreading depression“

SIADH:

Syndrom der inadäquaten Sekretion des antidiuretischen Hormons

SIRS:

systemisches inflammatorisches Response-Syndrom („systemic inflammatory response syndrome“)

SjvO2 :

jugularvenöse Sauerstoffsättigung

SSRI:

selektiver Serotonin-Wiederaufnahmehemmer („selective serotonin reuptake inhibitor“)

TCD:

transkranielle Dopplersonographie („transcranial Doppler“)

VDD:

Ventrikeldauerdrainage

Vmean :

mittlere Flussgeschwindigkeit

WFNS:

World Federation of Neurological Surgeons

ZVD:

zentraler Venendruck

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Interessenkonflikt

Der korrespondierende Autor weist für sich und seine Koautoren auf folgende Beziehungen hin: PD Dr. J. Soukup hat für wissenschaftliche Vorträge zum Thema Analgosedierung Honorarzahlungen der Firmen Abbott GmbH & Co, SedanaMedical AB (Schweden), Baxter Deutschland GmbH und GlaxoSmithKline GmbH & Co KG erhalten. Alle weiteren Autoren geben an, dass kein Interessenkonflikt besteht.

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  1. Klinik für Anästhesiologie und operative Intensivmedizin, Martin-Luther-Universität, Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle a.d. Saale, Deutschland

    P. Kellner, M. Bucher & C. Raspé

  2. Universitätsklinik und Poliklinik für Diagnostische Radiologie, Martin-Luther-Universität, Halle-Wittenberg, Halle a.d. Saale, Deutschland

    D. Stoevesandt

  3. Klinik für Anästhesiologie, Intensivtherapie und Palliativmedizin, Carl-Thiem-Klinikum, Cottbus, Deutschland

    J. Soukup

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Kellner, P., Stoevesandt, D., Soukup, J. et al. Aneurysmatisch bedingte Subarachnoidalblutung. Anaesthesist 61, 792–814 (2012). https://doi.org/10.1007/s00101-012-2077-2

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